Factors Influencing Athletic Trainers' Professional Development Through Continuing Education

Participants

Participants were solicited using purposive sampling³² through CAATE-accredited programs and colleagues in the field. We chose to use CAATE-accredited programs as a mechanism to reach ATs because they are educating students, and their opinions and thoughts regarding professional development and CE are important to understand; however, participants did not need to be a preceptor to participate in the study. Participants who were not BOC certified were excluded from participation. Fourteen ATs voluntarily participated in the study; individual participant demographics are included in Table 1. Self-selection bias is possible in a study like this (view the “Limitations” section for additional information). In our case, we achieved saturation of responses without having a sample representative of all athletic training settings. As such, the findings may be skewed toward the opinions and experiences of ATs in the secondary schools and collegiate settings. Program faculty, preceptors, and postprofessional athletic training students affiliated with Indiana State University were also excluded in an effort to decrease bias due to their professional relationships with members of the research team.

Table 1 Participant Demographics

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Instrumentation

We established a semistructured interview protocol (Table 2) regarding motivators, barriers, and application of CE. The primary investigator established the interview protocol based on the research questions and previous CE literature (L.E.E., unpublished data, 2017).^10–12 The primary investigator reviewed available and relevant literature within CE and professional development across health care professions to develop an understanding of the empirical findings, which served as the foundation for the development of the interview protocol.³³ The semistructured interview protocol was then provided to the research team for revision in an effort to reduce bias that may have been introduced by the primary investigator. The research team provided minor modifications to the protocol. The primary investigator then performed 1 pilot interview.³³ We did not make any changes to the interview protocol following the pilot interview. The primary investigator also asked probing questions due to the semistructured nature of the interview protocol to clarify participant responses when necessary.

Table 2 Semistructured Interview Protocol

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Procedures

We contacted CAATE-accredited program administrators and ATs within the profession detailing the study purpose, participant involvement, potential benefits/risks, and a link for interested participants. We asked those who received our e-mail to identify and forward the e-mail to potential participants. The potential participants could then click on the link in the e-mail, which included the informed consent document, basic demographic questions, and a request for a phone number and e-mail address if they chose to participate. Upon receiving this information, the primary investigator contacted each participant to schedule a phone interview. At the onset of each interview, the participant reaffirmed consent to participate verbally and provided a pseudonym to de-identify their data. Each interview lasted approximately 15–20 minutes. Interviews were recorded via speakerphone in a private room to ensure response validity in transcription. Data collection continued until the research team confirmed data saturation following 14 interviews.

Data Analysis

The primary investigator transcribed the audio-recorded file verbatim and removed all identifying information. Data were analyzed using a consensual qualitative research approach as described by Hill et al³³ to complete data analysis. The 2 team members read all transcripts to develop a general understanding of participant responses. They then discussed general themes (code domains) within the transcripts, followed by individual coding of 3 transcripts to identify core ideas. The researchers then met to discuss the core ideas to reach consensus. Next, both researchers coded the remaining transcripts, placing all data into each appropriate code domain, creating a codebook representative of the data. A third investigator served as an external auditor to verify the code domains and core ideas. External review also confirmed data saturation and thus the discontinuation of interviews.

Data Creditability

Three methods were used to establish credibility of the data: (1) member checks, (2) intercoder agreement, and (3) peer review. Member checking was completed by sending each participant their transcript via e-mail where they had the opportunity to add or clarify any of their statements by adding comments to the document. We also asked that they confirmed the accuracy of the transcription.³⁴ Five participants responded to the member checking e-mail. Four participants confirmed the accuracy of their transcript, while the fifth participant provided additional context to some of her responses. Second, intercoder agreement was established through multiple rounds of coding and discussion to ensure agreement on the final codebook prior to sharing the document with the external auditor.³³ Lastly, we used an external auditor who is an expert in qualitative research. We provided the external auditor with the purpose of the study, data analysis procedures, the transcripts, and the codebook. The external auditor reviewed the transcripts and codebook and confirmed the codebook was representative of the data.^33,34

Perceived Benefits of Continuing Education

The first theme that emerged was the perceived benefits of CE, which describes how participants positively viewed CE in regard to their clinical practice. Participants typically placed value on CE to advance their knowledge, ensure they were integrating best practices based on the evidence, and keep them up to date as a clinician. Overall, participants were positive in their views of CE. May stated, “It's a chance for us to always be at the forefront of evidence-based medicine,” while Olive discussed the benefits of the EBP CE sessions:

Also, it's hard when you're working full time as an [AT] to read research and to stay on top of research. So, a lot of times these courses, for me, are kind of a refresh on what's new. Someone else has already read a lot of the research and kind of giving me the bullet points of what is important and then providing the resources to look into it further if necessary.

The BOC's EBP format requires that CE deliverers complete a specific application that includes evidence to support the topic of the presentation, learning objectives, and clinical application of the content.³⁵ Throughout the completion of this process, the presenters are compiling data for the presentation from numerous sources, which makes the EBP session format helpful for practicing clinicians because the presenter has done the synthesis of the literature, much as Olive discussed. Participants also highlighted the benefit of staying current with new evidence and techniques that would ultimately improve their patient care. Lee said, “I just think it's really good that we make sure that we are staying up to date with everything that we are doing,” while Brian stated:

It's important for us to continue to develop as professionals to continue to provide the best care that we can for our patients. Going forwards, what I typically tell people, if I'm not learning something new every day, if I'm in this profession 20 years down the road and I'm still not learning something new anymore, then it's safe to say that I shouldn't be in this profession anymore.

Some participants stated that CE sessions allowed them a chance to refresh themselves on information that they had not used for a period. Research specific to skill decay suggests that practicing clinicians experience skill degradation and knowledge decay as soon as 6 weeks after learning the content.⁹ Mya said CE helps to “remind you of things that maybe have gotten lost within the years and years and years of experience.”

David believed that much of CE reinforces content from professional education rather than improving knowledge beyond entry level:

I do think that much of what we do have in regard to [CE] is directly useful for reiterating those basic skills that surround the BOC exam and not necessarily for expanding an [AT's] scope of knowledge.

One may consider CE builds on the entry-level knowledge by expanding upon areas in which professional students typically find difficult or challenging during their professional education. Advancing and improving knowledge were also addressed as a perceived benefit of CE. Mya commented, “I think it's really important because everything is always constantly changing in the profession, and new research is coming out all the time, so to stay up to date and increase your knowledge.” Some clinicians also described how CE is valuable and led to actual changes in their practice. Rachel discussed a recent CE course that she attended and how the information she learned is going to guide changes at her institution:

By attending another [course], we are implementing a new skills session for our coaches who are [cardiopulmonary resuscitation] and [automated external defibrillator] certified, and we are going to be making them do extra hands-on skills sessions just based off of 1 of the presentations.

Participants also cited postprofessional education as a mechanism for obtaining CEUs and advancing their knowledge. Emily commented on the importance of postprofessional degree programs helping her understand the most current research:

For me, [CE] has been kind of a big deal because I went ahead and got my master's in athletic training, and I'm getting my doctorate in athletic training, so I've really seen over the years the research moves in such different directions that, if I didn't continue my education, I didn't continue to learn the top research, then I'm missing out so much on helping my patients.

Lastly, participants also discussed how CE was important to help them address a weakness within their clinical practice. David discussed:

I think the first part to that answer is realizing the areas in which maybe an [AT] is deficient. Specifically for myself, I know there are 2 specific areas that I would pursue [CE] in because it's been a long time since I have been able to review those areas, and that would be nutrition and strength and conditioning.

This mechanism of choosing CE has been commonly reported in the literature. Overall, the participants discussed the importance of CE to maintain EBP, stay current with new or changing information, and to improve their knowledge or skills on topics they do not use as often.

Factors Influencing Continuing Education Selection

The next theme that emerged focused on how participants selected conferences and session to attend. This theme contains 2 subthemes centered on specific selection factors of sessions and selection factors for conferences. Participants discussed mechanisms for choosing sessions and conferences that were clinician driven, meaning they discussed their own perceived needs and/or area of weakness, what they believed would benefit their patient population, and sessions specifically related to their current practice setting when choosing sessions. Participants primarily discussed barriers such as cost, travel distance, and time when choosing conferences.

Improving Continuing Education

The improving CE theme focused on participants' perceptions of systematic changes that would improve their CE experiences. A few participants felt that the current structure is working and nothing should be changed; however, many participants provided suggestions that they believe could be integrated to improve professional development through CE. Specifically, some participants highlighted the need for more hands-on and interactive sessions, which better aligns with the hands-on patient care ATs provide daily. Ann discussed her belief that hands-on and interactive sessions would be more beneficial:

I would say a lot of times the courses that are offered to us are all either prerecorded from a conference or PowerPoint presentations that you're watching online, and I think it's sometimes difficult to take that information and implement it because you're not having that hands-on portion of it, and I think as [ATs] a lot of us thrive off of that hands-on approach to things with labs and things like that, and if there was more of that, it would be a little easier for us to take these new concepts and implement them.

Emily also identified hands-on and interactive sessions as her optimal CE session format because she would be able to receive feedback from the presenters, which she believed would be beneficial:

Most of my [CE] has been online classes or something similar, so I think sometimes a hands-on [course] would be easier. We have used videos in classes and kind of talked about them, but sometimes having somebody watch you do the exercise or see them supervise a patient and be able to ask questions in the moment might be a little bit more helpful.

Another mechanism to improve CE would be to recognize and communicate the barriers to implementation within the presentation. David stated:

I think that 1 way we could do this is potentially by allowing, or attempting to identify, as part of our [CE] courses, you know, some of the most salient barriers for [ATs], or if we are going to potentially conduct a course, potentially maybe just doing a small survey prior to the course that would actually assess perceived barriers for implementation and/or things that the [AT] would potentially see as difficulties, that way those things can be addressed as part of the session.

Some barriers such as financial resources may not be resolved by highlighting them during the presentation, but barriers such as time, policy requirements, or systems level barriers could be addressed in the presentation to provide ATs with a framework for overcoming these challenges within their clinical practice.

Some participants would like to have a physical resource to look back on at the conclusion of a session. Olive said:

You know, in continuing ed[ucation], something to walk away with, if I go to a course, I like to walk away with something as a reference to put on myself so that I can go back and look at it.

As previously stated, speakers who have BOC-approved EBP presentations have already synthesized the literature to compile the evidence for their application and presentation.³⁶ Creating a short handout of key points could be a helpful mechanism to help [ATs] remember the content from the session. Additionally, other participants believed that centralized resources or individualized resources would be helpful to integrate new knowledge and skills. Emily specifically discussed how centralized resources would be helpful:

I think sometimes it's overwhelming how many different types of patient-reported outcome measurements there are. So sometimes if things were all put in 1 place, it would be a lot easier.

Mya would like to see specific resources that help guide implementation following a CE session:

Some courses that I‘ve gone to from the [National Athletic Trainers' Association], I know they have online Web sites and stuff, but there is always so much information there that kind of gets lost in the translation, and maybe you get to it, and maybe you don't get to it. I think, if it was more interactive or something like that, like an online tool to build your own plan and print it out and give it to your athletes, they could go online and do something like that or check off that they could do it each day.

Some participants also cited the importance of socializing students to the CE process prior to graduation to help with the transition. John commented, “It would also give the [professional students] a chance to see what a seminar might be like to kind of introduce them to that.” Considering a mechanism for socializing students to CE prior to the completion of their professional program may better prepare them for the expectations to maintain their credential.

Implementation of Continuing Education Learning into Clinical Practice

The last major theme that emerged from the data highlights implementation of knowledge and skills into clinical practice. Within this theme, 3 subthemes were identified including barriers to implementation, practitioner confidence, and patient response to the new technique.

Perceived Benefits of Continuing Education

Participants discussed the perceived benefits of CE in advancing their knowledge, helping them to practice based on the evidence, keeping them up to date with new research and trends, recovering lost knowledge over time, and to address their self-identified weaknesses. Overall, participants were positive regarding their views on how CE is valuable to them as health care professionals. This is supported by previous research suggesting ATs have positive attitudes toward CE.¹² However, a positive attitude towards CE is not equivalent to learning or applying new knowledge, as is expected by the BOC, state legislatures, and patients. Welch et al²⁰ explored ATs' knowledge of EBP following a modular online CE session. The research team found that knowledge improved following the 10-module course; however, during a follow-up interview, some participants commented that their clinical practice had not changed following the intervention.^20,31 This finding is consistent in occupational therapy as well.¹⁹ While clinicians from various health professions view CE as important, research has suggested clinicians may not be integrating knowledge and skills into their clinical practice.^19,31

Continuing education also serves as a mechanism to ensure high-quality patient care. Health care professionals who do not actively engage in the continual learning process pose a possible danger to the patients they are treating, as research has demonstrated knowledge and skill decay occur over time.^2–9 Therefore, it is imperative that health care professionals engage in development, specifically CE, to maintain competency within their scope of professional practice. Some disciplines currently use or have proposed a mechanism of recertification to ensure competency.^39,40 However, cognitive assessment is the lowest level of determining competence and should not be used as a standalone mechanism to determining a clinician's areas of weakness.⁴¹ In 2016, the American Medical Association released a statement opposing the use of recertification exams for specialty certifications within medicine.⁴² Within physician practice, the maintenance of certification process includes self-assessment, lifelong learning activities to assess current clinical practice, and measurement of improvements in patient care. Shifting the assessment of CE to focus on improved patient care and identifying changes in patient outcomes is likely to increase the direct benefits of CE when compared to the current method of assessing clinicians' perceptions of learning following a session.

Currently, ATs are evaluated on completion of CE sessions, where assessment may only include the learners' perceptions of how well the presentation met the learning objectives. Moreover, those delivering the course materials are only responsible for summarizing the effectiveness of the delivery, not quantifying the learning that occurred.³⁵ This may be dangerous to patients in that ATs are not expected to demonstrate knowledge gain and competency in skill performance prior to application with a patient. Shifting the mechanism of CE to a focus on continued competence and maintaining knowledge within the domains of athletic training would likely prove beneficial to ATs and the patients they are treating. Research on family practice physicians demonstrated the importance of maintaining a broader scope of knowledge to maintain certification.⁴³ Family practice physicians with a broad scope of knowledge performed better on an assessment of competence compared to those with a narrower focus within a specific specialty or patient population.⁴³ This finding supports the notion that ATs should maintain their professional skills within the domains of athletic training, using an assessment of actual knowledge, skill performance, and clinical practice outcome data to guide their professional development and quality improvement. Theoretically, this would improve their patient care across the domains of athletic training and ensure continued competence within professional practice.

Factors Influencing Continuing Education Selection

Participants discussed how they chose conferences/clinical symposia and specific CE sessions. When discussing specific sessions, they typically addressed their preferences for session format and content, whereas when asked about conferences, they discussed barriers to attendance. The barriers to selecting CE opportunities (time, cost, and travel distance) likely have a negative impact on the learners' ability to select sessions because they are bound by the sessions available at the conference they select. Participants' selection of sessions centered on their perceived needs, convenience, current patient population, clinical practice setting, and expertise of the speaker, which aligns with previous research regarding CE motivators.¹¹ Cost of attendance and amount of travel required were the 2 most commonly cited barriers to attending conferences. Athletic trainers have consistently reported both time and cost as barriers to participation in CE (L.E.E., unpublished data, 2017).^10,11

When selecting specific sessions, participants discussed choosing sessions based on areas of weakness and/or areas of interest. Self-directed learning theory supports the notion that ATs would choose to learn more about topics they are already interested in.¹³ Hughes¹² previously concluded that ATs with more experience placed higher emphasis on the content of the course compared to those with less experience. However, Hughes¹² was unable to conclude the underlying rationale for this finding. One potential explanation could be that clinicians with more years of experience have specific areas of interest in which they pursue CE, whereas clinicians with less experience have not had the time to develop this area of interest and therefore have less concern about the course content. Only developing knowledge within a specific area of interest is potentially dangerous to patients and may expose ATs to increased liability because ATs are expected to maintain their knowledge and skills within all domains of professional practice.¹ Providing ATs with external feedback and input regarding their areas of weakness may stimulate the self-management process of self-directed learning and cause ATs to reflect on the knowledge they are lacking, which in turn would intrinsically motivate them to pursue CE in that area.²⁷

An alternative explanation to the findings from Hughes¹² could be attributed to more experienced clinicians better understanding their areas of weakness and selecting to attend sessions to mitigate their knowledge gap, whereas less experienced clinicians struggle to identify their knowledge gaps and/or recognize their need to continue learning in many areas, leading them to rank course relevancy lower on a preference scale because they perceive they have much to learn. However, researchers have demonstrated health care professionals' inability to identify their knowledge gaps and needs for CE, regardless of age or experience (J.R.E., unpublished data, 2017).^27–30 These findings within the literature, although not explicitly, suggest that health care professionals need an alternative mechanism of choosing CE opportunities other than perceived need and/or areas of weakness. One mechanism to better facilitate CE is a method of guided CE, whereby participants engage in quality improvement activities such as a low-stakes assessment of knowledge and review of patient outcomes (L.E.E., unpublished data, 2017). This assessment would determine specific areas of weakness and guide clinicians to seek CE in those areas, eliminating selection by preference or perceived need. Although personal factors will likely always influence CE selection, other mechanisms focused on self-reflective clinical practice, including low stakes knowledge assessment and chart review, could be used to guide CE and maintenance of competence initiatives. Additionally, this information would give ATs a foundation from which to select available sessions that fit within the options that are available to them based on time, cost, and travel.

Improving Continuing Education

Participants also provided suggestions for the improvement of CE including communication of implementation barriers in advance, increased number of hands-on or interactive sessions, physical resources to reference following the CE session, and centralized resources for clinical tools such as patient-reported outcome measures. Continuing education is predominately delivered in a didactic lecture format, whether it is face-to-face or online synchronously or asynchronously.⁴⁴ Participants suggested shifting the format of CE sessions into a more hands-on or interactive session that resembles current clinical practice. Bandura's⁴⁵ social learning theory supports the shift from lecture-based to interactive CE sessions because ATs would learn how to perform the skills by doing them in real time with feedback from the instructor rather than observing someone perform the skill and attempting to replicate the skill after an undefined period of time. Additionally, ATs have demonstrated that they prefer clinical workshops and small group discussions to large group lectures (L.E.E., unpublished data, 2017).¹⁰ A recent Cochrane review suggested that mixed methods sessions that incorporate both didactic and interactive learning had the greatest impact on improving patient outcomes.⁴⁴

Participants also suggested that speakers should communicate or address potential barriers to implementation during the CE session. Research in physician practice suggests numerous barriers such as time, cost, personnel, and the health care system itself prevent clinicians from implementing new knowledge and skills into their patient care.³⁸ Athletic trainers have also identified similar barriers to implementation of patient-reported outcome measures.⁴⁶ Addressing specific barriers during a CE session may allow ATs to develop a framework that will work in their clinical setting to overcome the likely barriers. Speakers and/or facilitators of CE sessions can integrate interactive learning into this portion of the session by asking attendees to share their perceived barriers and allowing others to comment on experiences and strategies to mitigate challenges. This format would allow for the integration of interactive and social learning.

Lastly, participants commented about their desire to have a physical resource to refer to and centralized resources for them to use following a session. The National Athletic Trainers' Association (NATA) and district meetings expect speakers to provide an abstract or summary of their presentation to be posted on the Web site for attendees to reference before, during, and after the session. More recently, these have included a list of relevant references that will guide the sessions. Session coordinators could ask speakers to create an infographic depicting the key points of their presentation. This document would serve as something attendees could take home and reference when integrating new knowledge and skills and use as a reminder of the new content learned during the session. This practice is becoming more and more common, whereby the NATA News and Journal of Athletic Training are using this visual pedagogy to help with developing its professionals in athletic training. Additionally, much of the content taught in CE sessions, specifically the EBP sessions, combines evidence and highlights key pieces for attendees. Creating a centralized location for these resources that helps guide clinicians to use the evidence, as well as improving the ease at which to update this information, would be helpful to clinicians.

Implementation of Continuing Education Learning into Clinical Practice

When asked about implementation of CE, participants discussed the barriers to implementation, how confident they were in the process, and the patient's response to the new knowledge or skills the participant was implementing. Participants highlighted time and financial resources most often when asked about barriers to implementation. This aligns with research in physician practice where physicians identified time, described as actual time, appointment time, and learning time for the new skill(s), as a barrier 25.78% of the time.³⁸ Physicians also cited organization, defined as systems design and policy, equipment and supplies, cost of care, and infrastructure, as a barrier 11.79% of the time.³³ Our participants similarly commented on the time they had to treat the patient due to patient load, the patient needing to get to practice, and not having one-on-one time with the patient. They also commonly cited cost in terms of the resources and equipment needed to integrate some of the information into their clinical practice. Participants also identified coaches and colleagues as barriers, but unlike the findings of Price et al,³⁸ we did not identify the patients as a barrier to changes in the care they provided because of the rapport the ATs built with their patients.

Participants also discussed their confidence providing care using the new skills following a CE session. Interestingly, when participants attended a session focused on a topic they had previous foundational knowledge of, but did not feel comfortable applying that knowledge prior to the session, they stated that their confidence improved following the CE session. However, the participants who had attended a session where they learned new information and had no prior experience with it, they stated they felt less confident and wanted more time to practice the skills on a peer or colleague prior to implementation with a patient. When considering this finding in the context of meaningful learning,⁴⁷ it makes sense that participants were more confident in their learning when they had previous knowledge on the subject because they were able to integrate that information into their previous knowledge. Conversely, when they had no prior knowledge on the topic, they did not possess an anchor to connect the new content, and as such, they had to create a new schema to organize the information.⁴⁷

Participants discussed their method of integrating small pieces of content they learned immediately following the CE session. This allowed participants to improve their confidence with smaller pieces and add to their skillset as they became more comfortable with the skills they were performing. Essentially, the participants were using the scaffolding method to progressively develop their knowledge, skillset, and improve their confidence.⁴⁸ While many participants spoke at length about their increased confidence in integrating new content into their clinical practice, it is important to highlight that they were not using objective measures to determine the efficacy of the changes in patient care.

When asked about their patients' responses to the change in treatment, participants described the subjective positive feedback their patients provided. Patient-centered care is one of the Institutes of Medicine's (IOM's) core competencies.⁴⁹ The IOM core competencies define the foundational behaviors that all professionals should demonstrate across all health care professions.⁴⁹ Patient-centered care places the patient at the center of their own health care with the emphasis on high-quality care of the whole person, shifting the focus away from the disability.⁴⁹ Our participants demonstrated clinician-centered care when asking the patients for their perceptions of the treatment performed by the clinician. We suggest shifting towards patient-centered care through the use of objective measurements that provide consistent data on patients' perceptions of their improvement. Objective measures, such as patient satisfaction surveys, patients-reported outcomes, and clinician-reported outcomes, provide data that can be compared objectively across patient cases to provide a clearer picture on the care provided and allow for analysis of changes in care following professional development through CE.

Limitations

One limitation of this study was the lack of representation of ATs from the emerging and clinic/rehabilitation settings. Participants primarily worked in the college/university or in a secondary school; only 1 participant was employed full time in physician practice. However, this participant did express that CE sessions specifically for ATs within physician practice had been limited, based on her experiences. This may have led to self-selection bias, where ATs from settings other than the secondary schools and college/university choose not to participate. Participants primarily discussed their experiences when attending conferences affiliated with the state, regional, and national membership organizations; few participants discussed other focused workshops they had attended. This suggests the need for further research into the types of conferences or workshops and their impact on clinical practice. Another limitation of this study is the inability to determine if participants were integrating information from CE sessions into their clinical practice. Some participants were able to give very specific examples of skills and/or knowledge they had integrated recently, while others provided broad generalizations. This inability to recall specific examples suggests that the participants may not have integrated anything from CE sessions recently and/or may not integrate much information from CE sessions into clinical practice, both of which are concerning findings. Lastly, the interview protocol focused on changes directly associated with application of knowledge and skills to patient care. We did not ask participants if attending CE sessions initiated changes to policies or procedures that may have a direct or indirect impact on patient care.