Supervising Athletic Trainers' Perceptions of Graduate Assistant Athletic Trainers' Professional Preparation

Academic Preparation

Academic preparation includes the didactic and clinical knowledge obtained during professional education. The participants consistently reported that the academic preparation of the GAs is strong and that many GAs are more prepared than they have ever been before. However, the supervisors reported that the GAs need more clinical experience and that their preparation may also be dependent on the professional program from which they graduated. Mort stated, “The GAs have good preparation and are technically very sound. They just need more experience.” Although the participants reported current GAs are better prepared academically, some participants reported that past GAs were more ready to handle clinical duties. Steve commented,

GAs come out knowing more about the ins and outs of athletic training; however, the ability to interact and disseminate information properly has changed. The experiential learning occurs in their first year of graduate school, whereas 7 or 8 years ago [it occurred in professional preparation]. A first-year GA student right now, 2012, is [comparable to] a junior or senior 2003.

While some participants think the clinical preparation is not as strong as it was in the past, Wayne feels that since the academic preparation is so strong, it outweighs some of the weaknesses in clinical preparation. He states,

Without a doubt the academic preparation of our students today is far superior to the internship route. The internship route developed “how-to” clinicians. The strength of graduates from curriculum programs is they know why. The “how to” suffers a little bit, but if I had to choose, I would rather have them know why than how.

Some participants indicated that a number of GAs were better prepared than others because they took ownership of their academic preparation and continued their education by obtaining internships or attending conferences.

Gaps in Preparation

Although the participants reported that GAs were prepared academically, many reported gaps in the preparation in areas such as independent experience, traveling with a team, rehabilitation, and organization and administration. Many participants reported that many GAs are not completely prepared to provide patient care independently and that some GAs came from programs where they were never allowed to talk to a coach or to touch an athlete. Participants felt that the lack of autonomous experience in professional programs minimized their success. Franklin suggests that the GAs do not get the clinical practice experience they used to get. He stated,

These kids are coming out of their undergraduate experience not having any real-life AT experience. They have no idea how to pack for a road game, what it's like to deal with coaches, or what it's like to make these decisions on their own because they have their preceptors holding their hands all the time.

Many participants believe GAs are not ready for their roles because they lack experience, especially in implementing and progressing athletes through rehabilitation or with administration skills. Franklin commented, “These GAs coming out don't know how to talk to insurance companies. I haven't heard one [professional] student talk to an insurance company with a $2000 claim on the line.” Other participants expressed that new GAs are not prepared for the amount of hours required to be a GA, and they do not have a true understanding of the job requirements. Maggie commented,

Time management is a problem because they are coming from CAATE [Commission on Accreditation of Athletic Training Education] programs only allowing 20 hours a week, so they are not quite prepared to ‘work' the hours needed of GAs.

Tobias disagreed, stating,

Those people criticizing the undergrads for not being prepared are the ones abusing GAs and using them as full-time staff. You can't go to school full time and work full time as a health care provider and make everything work.

A number of supervisors believe some institutions have ATPs to access cheaper labor pools, instead of focusing on educational preparation.

Professional Communication

Professional communication emerged as a shortcoming for GAs and includes the ability to speak with athletes, coaches, physicians, supervisors, and peers at the appropriate level and with adequate respect. Many participants have been supervising GAs for many years, and they all agree that interpersonal communication has degenerated. Participants noted that new GAs are less mature in dealing with interpersonal relationships, communication, and conflict management. Adelaide reflected,

Students need to understand that [texting] is a quick way of communicating, but it is not the most professional way. If you want to get a job you need to emulate a level of professionalism so that people have confidence in you that you can get the job done.

Participants also reported GAs have trouble communicating professionally with coaches, physicians, and athletes at the appropriate level. Although participants reported that professional communication has declined since the internship route to certification was eliminated, some participants think it might be attributed to generational differences, not a difference in preparation (ie, internship route versus curricular route).

Role Execution

Another area of shortcomings that emerged from the data was role execution, which is the GA's ability to complete the patient care aspects of their role. While the participants reported that GAs were prepared academically, they noted that many had trouble performing their clinical duties. Michael stated, “The diagnostic testing—they are like politicians—they sure can talk about it but when it boils down to doing it, it is a different story.” Graduate assistants lack time-management skills but often this improves with experience. Graduate assistants are also not very efficient with evaluations; they are either too thorough and inefficient, or too fast and miss things. Stefan commented, “It takes them about a year to decide not to run off every shoulder test they have when the athlete has hurt their shoulder. The ability to determine which tests are appropriate is lacking.” Lindsey reported that they could conduct evaluations, but the decision-making process was lacking. She stated,

A lot of them are not really comfortable doing evaluations and making decisions because they are still in student mode. They have never had to put their foot down. Making decisions is where they need help.

Personality

The final shortcoming subtheme that emerged from the data was personality. Many participants reported that some of the GAs' biggest problems have been because of personal characteristics. Gary stated, “Their problems are rarely skills. It is their personality and character.” Most participants reported that GAs come across as entitled, cocky, or as know-it-alls. Participants found that GAs who are unwilling to adapt to policies and procedures are not going to be successful in their roles. Maggie commented, “I have kids that aren't adapting well. They want to be a dominating figure [with coaches] when they can't be; that is not their role. They are not willing to conform to our policies.” Some GAs are unable to accept constructive criticism to help improve their skills. Other personal shortcomings noted as hindering a GA's success were not being open minded, inattention to detail, and being afraid to fail. Tobias commented about some GAs, “They are afraid to be wrong, and they are not as open-minded as a health care provider should be. They are set in their ways even at a young age.” Participants reported the main reason they ever dismissed a GA was a personality issue, and not related to role execution.

Academic Preparation

We found participants consistently reported the academic preparation of GAs is better than it has ever been in the history of the profession. Athletic training education has evolved greatly since its inception, progressing from the internship model to the curricular model.¹⁷ Since the educational reform that eliminated the internship route in 2004, there have been anecdotal reports of newly credentialed ATs not being as prepared as they once were. Through eliminating the internship route, professional programs gained standardized competencies to ensure that all ATs have mastered certain proficiencies prior to certification.¹⁷ With the internship model, students were often left unsupervised and may not have had the opportunity to gain the depth of knowledge needed to be ATs. Through curricular programs, the CAATE aimed to improve both the technical knowledge and the practical skills to produce highly qualified health care professionals.⁷ Our participants conveyed that previously, through the internship model, students learned how to perform certain technical skills but did not always comprehend why they were performing them. They noted that students now graduating from ATPs may not have gained extensive independent practice performing technical skills, but they have a greater understanding of the skills and the profession. Recent debate regarding the appropriate level of professional education (ie, baccalaureate versus post baccalaureate) has ensued, and many ATs believe educational preparation would be most effective at the postgraduate level.^18,19 Further research should examine the preparation of newly credentialed ATs graduating from both bachelor's and graduate professional programs.

While supervisors noted that the professional preparation of GAs was stronger than it has ever been, some acknowledged that this was dependent on the program. Despite having standardized requirements for education, some programs have had difficulties ensuring students are obtaining adequate clinical experience and skills required for clinical practice.⁷ Massie et al⁷ surveyed employers of entry-level ATs and found that 90% of respondents considered the employees were prepared to fulfill their responsibilities both academically and clinically. While there were some areas in which the new employees were unprepared, the majority of employers believed that some aspects of employment can only be learned in the workplace. Our findings reveal that supervisors think GAs are overall well prepared academically, but that they would benefit from more clinical experience. In addition, supervisors believe that there are some aspects of the GA role that can only be learned through experience.

Gaps in Preparation

While academic preparation is good, participants reported shortcomings in areas such as autonomous practice, traveling with a team, rehabilitation, and organization and administration. Participants reported that new GAs are unable to practice completely autonomously; however, many of our participants understood that these GAs were new clinicians and that being independent was a new experience for them; therefore they needed more practice as they transitioned from student to AT. Similar to Carr and Volberding's⁶ study of AT employers and new employees, many saw that the new ATs had the skills but struggled with decision making and clinical procedures, which is common during transition to practice. Many supervisors understand that GAs need support and development throughout the assistantship.¹¹ One way to provide support is through mentored independence, in which there is a balance between independence and the need for assistance.²⁰ As new clinicians gain more experience, they gain more independence.

An area of weakness reported by our participants was the GAs' lack of experience in developing and progressing rehabilitation plans. This was not a deficiency found in prior studies examining the preparation of new ATs,^6–7,21,22 but many ATs and employers report the importance of rehabilitation.²³ Our participants reported students are moved between clinical experiences too quickly, which often prevents them from gaining experience in the entire rehabilitation process. Additionally, participants noted that students do not gain experience with postoperative rehabilitation. To gain more experience in this area, preceptors could include students in creating, implementing, and progressing athletes through the entire rehabilitation process, including postoperative rehabilitation, regardless of their clinical education assignment.

Our participants also felt GAs had weak organizational and administrative skills. Employers in the study by Massie et al⁷ rated new employees' competence with organization and administration as lower than any other content area. New AT employees also rated administrative skills as area with which they felt uncomfortable.⁶ New ATs in the clinic setting reported feeling least prepared in the areas of communication and insurance, primarily documentation for evaluations, treatments, and third-party reimbursement.²¹ ATs in the clinic setting recommended more education in areas such as documentation and communication with third-party payers and the billing industry. These areas of weakness are not new in athletic training. A study in 1992 reported 4 areas that needed to be improved upon: rehabilitation, organization and administration, counseling of athletes, and education of athletes, parents, and coaches.²⁴ Over 20 years later, supervisors are still citing these as areas of weakness. Because of this continued deficiency in new ATs, supervisors may want to reevaluate expectations of newly credentialed ATs. Some supervisors demonstrate unrealistic expectations of the skill level of new ATs.¹¹ In addition, ATPs should continue developing innovative ways to educate students in these areas. For example, utilizing business meetings complete with round-table discussions and meeting briefs to teach organization and administration topics²⁵ or using standardized patients (SPs) to create realistic learning experiences for uncommon injuries, conditions, or situations.²⁶ Standardized patients can be used to gain experience in psychosocial intervention and referral²⁷ or in simulating phone calls to insurance companies. There are many strategies that are used to promote critical thinking in athletic training education such as questioning tactics to promote interpretation, analysis, and conclusions; encouraging students to find answers independently; classroom discussions and debates; and assignments in which students develop their own decisions based on evidence.²⁸ Other pedagogic strategies that can enhance athletic training education to further prepare GAs are brain-based learning principles,²⁹ case-based analogic reasoning,^30,31 and problem-based learning,^32,33 which stimulate critical thinking skills by engaging students in clinical decision making by providing ill-structured cases in which students must perform evaluations and reach a diagnosis. Immediate feedback and debriefing sessions allow students to solve problems and create neural pathways for future evaluations.^29–33 Regardless of the educational methods used, programs and supervisors could explore ways to provide further education for students and newly credentialed ATs, respectively.

Although our participants understood that GAs were new practitioners, a few thought that the GAs would be more prepared if they had more independent experience during their professional programs. Anecdotal claims^34,35 and a few participants blame the educational model and supervision guidelines for the new AT's lack of independent practice immediately after graduation. Some participants observed that independent, autonomous practice during professional preparation allowed for higher confidence levels and enhanced decision-making skills and believe students should have time to practice without supervision prior to certification; however, unsupervised practice by students may violate state practice acts, is unethical³⁶ and unprofessional, and it is unknown how patient care could be affected. Patient care decisions should be made by appropriately credentialed health care professionals (eg, AT, physician)³⁷; allowing students to be unsupervised violates best practice principles. This practice also implies that students can replace certified, licensed ATs and sends the wrong message for the profession. Many participants believed students should gain travel experience prior to becoming GAs. To gain travel experience, students could potentially travel with their preceptor, but the preceptor would encourage the student to be autonomous. This could allow for some rich discussion between the preceptor and the student regarding what the student learned while traveling. In addition, some participants were apprehensive about having new GAs travel independently; therefore a seasoned AT could initially travel with the GA to help mentor and support them.

In addition to violating best practice, unsupervised practice means the students are not being mentored or guided.³⁴ While confidence may be higher, unsupervised clinical practice could lead to making incorrect decisions and may not provide adequate time for reflection with preceptors.³⁸ Students can still make decisions while being supervised, but supervision allows them to be mentored and to receive feedback from preceptors. Independent decision making need not happen in isolation. Throughout clinical education, there are ways to allow for independent decision making and reflection based on the level of the learner. One proposed model is the situational supervision model, which recognizes different levels of development as students evolve from eager novices to autonomous learners.³⁹ Preceptors can use this model to diagnose the learner and adjust their level of supervision and feedback as the student advances. Similar to the situational supervision model, the supervision, questioning, and feedback model⁴⁰ provides guidelines for asking questions, providing feedback, and stimulating critical thinking for students based on their developmental level.^40–41 Questioning should be strategically planned to reinforce a student's knowledge and promote comprehension and application, and questions should progress from recall questions to confirm knowledge, comprehension, and application, and finally to develop critical thinking skills. Feedback is vital to correct skills or guide students to refine skills. Another model for clinical education is Scriber and Trowbridge's³⁸ model of modified direct supervision, which allows for autonomy while being supervised. Students are able to make independent clinical decisions through conducting evaluations while the preceptor is mentally invested in the decision-making process. Regardless of clinical education model, feedback is an immensely valuable tool in clinical education and can improve clinical performance.^40,42 As the preceptor allows for students to perform skills and make decisions, the preceptor should supervise student performance and provide immediate and detailed feedback to help the student to improve.⁴²

Professional Communication

One of the biggest shortcomings reported was interpersonal communication. Employers expect ATs to communicate professionally with coaches, physicians, parents, and supervising ATs.^6,11,21 Although professional communication is vital, AT supervisors in this study and employers in other studies reported that interpersonal communication is lacking in new AT graduates.^6,7,11 Poor communication skills in new health care professionals are not limited to athletic training. Employers and new health care employees (physiotherapists, physical therapists, physicians, and nurses) have reported poor communication with novice clinicians.^21,43 One of the foundational behaviors of professional practice for athletic training students is to demonstrate effective interpersonal communication skills.⁴⁴ Despite the importance of communication as a foundational behavior, our findings reveal that many GAs never had the opportunity to communicate with coaches, physicians, or parents. In a recent study exploring the psychosocial intervention and referral preparation of newly credentialed ATs, most new ATs reported they felt underprepared for communication with physicians, coaches, and parents.⁴⁵

Effective communication enhances patient satisfaction, compliance with instructions, and improves health outcomes.⁴³ Despite the importance of good communication skills, these skills are often not learned in the professional academic preparation for health professionals. In addition, increased technical competency (eg, taping an ankle, applying modality) has actually been shown to reduce relational skills. Communication skills are specifically taught in some medical schools, and in the programs who teach communication, their students have shown improvement in confidence, interpersonal skills, relationship building, organization, time management, patient assessment, and patient outcomes.^46–50 To improve communication of new clinicians, preceptors should aim to increase the amount of interactions and communication experiences that students have with coaches, physicians, and parents.⁷ Communication skills can also be evaluated via direct observation and feedback, checklists, patient surveys, and review of videotaped experiences to provide feedback and discuss effective communication strategies.^51,52 Students can also participate in SP experiences to enhance their communication skills.^43,52

In addition to inadequate experience communicating with coaches and physicians, many supervisors acknowledged the prevalence of emerging media, and they indicated that text messaging or e-mail may not be the most professional mode of communication. However, some supervisors noted that communication style is changing and text messaging is becoming a common way to communicate. Of anecdotal note, coaches and athletes communicate with ATs via text messages, therefore ATs need to know how to communicate professionally through emerging media, such as text messages and e-mails. Our findings show GAs tend to communicate frequently via text message or e-mail; however, their text messages and e-mails often use short-hand or casual, unprofessional language (eg, “u” instead of “you” or “L8” instead of “late”). Supervisors should understand that text messaging and e-mail can be a viable way to communicate but should also educate GAs and students about using appropriate language in text messages and e-mails.

Role Execution

Although our findings reveal that GAs are prepared for their roles, they occasionally have difficulty executing various aspects of their job. Some AT employers and new employees in Carr and Volberding's⁶ study reported understanding information, but not always knowing how to proceed or apply knowledge. Our findings reveal that GAs often have trouble with time management, whether they are completing an evaluation and selecting appropriate tests or determining how to manage the amount of time they have with multiple responsibilities. New ATs⁶ and new nurses⁵³ struggle with being organized and anticipating the amount of time a certain task will take. Learning how to prioritize patient care responsibilities takes practice.⁵³ Our participants reported GAs are not learning time management during their professional preparation. A few participants felt current GAs struggle more with time management than prior GAs, attributing this struggle to the time limits placed on clinical education during professional programs.

Our findings also revealed GAs have trouble making decisions independently. Many supervisors reported that GAs have clinical skills but that making clinical decisions is a new experience. Carr and Volberding⁶ reported similar findings in which decision making was a deficit reported by new ATs and employers. Despite the importance of making decisions in patient care, supervisors perceive that GAs are not getting enough experience making decisions in their professional preparation. In a study examining postprofessional athletic training students, Neibert⁵⁴ found that GAs considered the graduate level as the appropriate level to synthesize the evidence to make informed decisions because they have displayed mastery of the information. While students may not have mastered enough information to make independent decisions, preceptors should strive to involve students in the decision-making process for patient care. As students progress and gain more knowledge, they could be more involved in making decisions. Although they may not be able to make decisions independently, involving students in the decision-making process may increase confidence and better prepare them to make independent decisions when they are in their first professional position. Problem-based learning,³² classroom discussion and debates to promote critical thinking,²⁸ and use of simulations⁵⁵ and SPs^56,57 are other ways to practice decision-making skills during professional preparation. Preceptors could also discuss their own decision-making process regarding their approach to patient care as well as their communication with coaches, parents, and administrators.

Personality

Our findings reveal that personal characteristics are the biggest shortcomings of GAs. Personal characteristics are vitally important in hiring.⁵⁸ Some of the most important hiring criteria are communication skills, enthusiasm, initiative, maturity, personal appearance, and confidence. Our findings also show the importance of these personal attributes and that many of these attributes are lacking in GAs. Supervisors of GAs in the collegiate setting cite personal characteristics and the ability to adapt to new roles as key in GA success.¹¹ Our findings reveal that the biggest problems the participants had with GAs were owing to personal characteristics, not preparation, and that GAs were only released from their positions because of personal characteristics (eg, unwillingness to adapt to their role).

One of the most vital personal characteristics that supervisors noted as lacking in the GAs was confidence. Confidence is important for many new clinicians regardless of setting. A study examining preceptors' expectations of new physical therapists found that confidence is very important for new physical therapists.²⁰ Regardless of a physical therapist's knowledge, if they did not display confidence, the patients would “pick up on” that and were less likely to listen to the physical therapist's recommendations than when a physical therapist displayed confidence. Similar to our findings, Carr and Volberding⁶ found that confidence was a deficiency reported by new ATs. Although new ATs felt confidence might be lacking, those who employ new ATs believe confidence comes with practice. Our findings show that supervisors expect GAs to gain confidence as they gain experience. Neibert⁵⁴ found that students in postprofessional ATPs discovered that making mistakes in a controlled, low-pressure environment such as a graduate assistantship helped develop confidence. While our findings showed that supervisors acknowledged that GAs developed confidence throughout their assistantship, they believed confidence was vital to patient care and could be further developed in professional preparation. In a study examining pedagogic strategies for athletic training students, Mensch and Ennis⁵⁹ found student's confidence increased when instructors fostered autonomy and decision making and designed activities to allow students to build upon their knowledge.

Generational Differences

While there are many factors that contribute to the shortcomings of GAs, a few supervisors acknowledged that some shortcomings are generational differences more so than differences in the educational model. The majority of current GAs are “Millennials,” individuals born after 1982.⁶⁰ There are many characteristics of Millennials that supervisors considered to be shortcomings, such as a need for immediate feedback, a high level of confidence (or cockiness), a feeling of entitlement, the inability to think critically or to manage time, discomfort while working independently, not being intimidated by senior individuals, and challenging authority.⁶¹ These characteristics, or perceived shortcomings, are common across many fields and may cause workplace conflicts as multiple generations of workers merge.⁶² Communication across generations and extensive organizational socialization may help bridge the generational gap.⁶¹ Graduate assistants and supervisors should meet to discuss expectations regarding feedback and communication. Millennial students are likely to succeed if they receive clearly outlined expectations, regular feedback, and have open access to supervisors.⁶⁰ Many supervisors of GAs already aim to have open-door policies for GAs and will provide feedback whenever possible.¹¹ Supervisors identified many shortcomings in GAs that are characteristic of Millennials; however, despite these predispositions, GAs can work to modify these traits.