Preceptors' Frequency and Supervision of Athletic Training Students' Medical Documentation During Clinical Education

Design

The research team used a cross-sectional survey design with open-ended questions to determine if ATs serving as a preceptor allowed athletic training students to document patient care, why they allowed or did not allow athletic training students to document, and, if they did allow athletic training students to document, how they supervised the documentation. Before its distribution, the Indiana State University Institutional Review Board deemed this study exempt.

Participants

We recruited ATs who are credentialed members of the National Athletic Trainers' Association in good standing. A random selection of 9578 e-mails was purchased from the membership directory that included ATs in all districts and job settings. A total of 1150 of 9578 participants accessed our survey (12.0% access rate), 1053 completed at least 1 portion, and 904 completed the survey in its entirety (85.8% completion rate). The purpose for this selection was to review only the responses of those who were actively serving as a preceptor for athletic training students, and 385 out of 1150 respondents (33.5%) met this criterion. We gained informed consent at the start of the survey, and respondents were able to skip any questions they did not wish to answer and could withdraw at any point by simply clicking out of the Web link.

Instrumentation

For the purpose of this study, we used preceptor-related questions from a larger study that had been created to evaluate medical documentation behaviors of ATs.^11,12 Three questions were used to determine whether the preceptor allowed the athletic training student to document patient care, the rationale for this decision, and, if the preceptor did allow the athletic training student to document, how the activity was supervised (Table 1). We used a panel of experts (N = 4; 3 women and 1 man) for content validation of the survey. The experts had 14 ± 4 years of clinical experience, and 2 of the experts had 11 ± 1 years of survey research experience. Experts indicated if items were “sufficient as written” or “required modifications.” When indicating that modifications were required, the experts were asked to provide comments to help make revisions. We synthesized the feedback and made changes to the survey where appropriate; no changes were made to these specific items.

Table 1 Preceptor-Related Questions

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Procedures

We recruited potential participants via e-mail through a Web-based survey platform (Qualtrics, Provo, UT). A follow-up e-mail was sent every week for 4 weeks to those who had not responded. Data were collected for 5 weeks during the spring of 2017 (March and April). The initial e-mail was sent on a Wednesday morning at 7:30 am EDT and each subsequent reminder was sent on a Wednesday morning at 7:30 am EDT. The survey was closed 1 week and 2 days after the last reminder at 11:59 pm EDT. All data were stored securely in Qualtrics.

Data Analysis and Management

A qualitative approach was used in this study and was guided by the consensual qualitative research (CQR) tradition, which included a 3-person data analysis team (E.R.N., C.W.B., L.E.E.) to reach consensus.^12,13 The additional 2 research team members served as content experts for the survey validation and auditors. Consensual qualitative research allows for multiple perspectives from the various members of the data analysis team to check for accuracy within the codes.^13,14 By using this approach, the ideas and opinions of the respondents can be better represented. Table 2 provides additional information on the research team. Quantitative data and categorical data were analyzed using frequency counts and percentages (Excel; Microsoft, Redmond, WA).

Table 2 Descriptions of the Research Team

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A codebook was created with domains, categories, and subcategories as outlined by best practice for CQR. Initially, we established consistency by allowing the data analysis team to consider multiple perspectives to reach consensus on the coding. The use of the data analysis team helped to reduce the amount of bias that might have occurred with a single coder. The first 50 responses were analyzed by the data analysis team, with ideas compared until consensus was reached and a codebook was created.^13,14 At this point, the principal investigator coded the remaining responses based on the codebook. Once the principal investigator had completed the coding in its entirety, the information was sent to the data analysis team. The other members of the data analysis team then determined if they agreed upon the coding that was performed by the principal investigator. Upon completion, the data analysis team convened for a consensus meeting. If there was a disagreement on the coding, the majority decision (2 of 3) was conferred and the codes were finalized. A total of 17 responses were deemed unrelated to the questions and were discarded from review. Each response was individually coded per respondent and could be coded under multiple categories during analysis. When the data analysis team concluded its work, the survey questions, consensus codebook, and coded response document were shared with the other 2 members of the research team for auditing. Saturation of the data was ensured and trustworthiness was established by the use of multiple researchers and internal auditing.

The final stage of analysis consisted of frequency counting, which allowed the team to determine the frequency of each category across the whole sample.¹⁴ Categories were assigned as general if identified in more than 359 cases. Categories were deemed typical if identified in 193 to 358 cases and variant if identified in 77 to 192 cases. We classified a category as rare if identified in 76 cases or fewer.

Intention for Student Involvement

The domain intention for student involvement comprised the reasons why preceptors allowed their athletic training students to complete medical documentation, including responses such as the need for skill preparation, feedback to the athletic training student, and any issues that would hinder an ideal situation for an athletic training student to learn medical documentation. The learning and knowledge category was used to identify both positive and negative responses that focused on the goal of learning or increasing knowledge, whereas the practice and experience category was used when preceptors indicated they wanted their students to practice the skill and gain experience. The deterrents category was used when preceptors indicated there were challenges that prohibited them from effectively involving their athletic training student in medical documentation.

Mentorship for Student Documentation

The domain mentorship for student documentation focused specifically on the ways preceptors allow athletic training students to perform the skill of medical documentation and the subsequent supervision. The logistics category focused on the “who, what, when, why, and how” approach for determining what actually occurred during documentation by an athletic training student. The category for degree of oversight was used to describe the amount of supervision that the preceptor provided to the athletic training student and if it was done directly or indirectly. Direct supervision was defined as times that the athletic training student and the preceptor completed the medical documentation together or reviewed the materials before submission together. Indirect supervision was chosen when the respondent did not review the athletic training student's materials or did not review the medical documentation with the student present.

Intention for Student Involvement

The purpose of clinical education is for the athletic training student to take the didactic curriculum, integrate the knowledge gained, and apply it to real-life patient encounters through clinical education and experiences. This curricular model allows for experiential learning to occur and has been a historic approach to health care education for over a century. Ideally a preceptor would facilitate this learning by engaging the athletic training student in concrete experiences with medical documentation and then encouraging the athletic training student reflection on the experience and what learning has occurred.

Then, in the final stage of experiential learning, the athletic training student will have the opportunity to experiment and try again.¹⁶ Our respondents indicated that they wanted learning to occur so that the athletic training students could develop knowledge in medical documentation. Many shared that they were active facilitators of the learning, specifically assisting with feedback and revision through the process of documentation. They also described progressive opportunities, where students at different stages of their education were provided more autonomy to document patient care. These preceptors were engaging the athletic training students in experiential learning to facilitate competence.

The NATA Best Practice Guidelines for Athletic Training Documentation¹⁷ state that every patient encounter, including communication, must be documented. Based on this premise, every clinical site must be frequently engaged in medical documentation, and preceptors should provide athletic training students with opportunities to increase knowledge in medical documentation. Previous research identified that 10% to 15% of assigned clinical experiences are unengaged waiting time.¹⁸ Rather than having athletic training students fill unengaged waiting time with extra managerial tasks, such as cleaning the facility or restocking supplies, preceptors should consider allocating unengaged time for guided learning and experiences with medical documentation.¹⁴ A coordinator of clinical education (or athletic training program administrator) should purposefully select preceptors who model best practice and provide sufficient opportunities of real-time medical documentation. If this is not occurring, we suggest that preceptors and sites should be deselected and that these skills be seamlessly integrated with standardized patient encounters or other forms of simulation.^19,20

Previously, the notion existed that in order for someone to develop expertise, they must complete a task for 10 000 hours.²¹ Although we believe this premise is flawed, both in the principle (expertise is aspirational)²² and execution (unlikely for learners to have that many opportunities in professional education),²³ it is imperative that athletic training students be given as many opportunities as possible to increase their knowledge in clinical skills, including documentation. Simply allowing students to perform a task once will not allow them to improve on their skills and abilities. Instead, preceptors should provide opportunity and feedback that transitions an athletic training student from interdependence to independence. In health care, these kinds of day-to-day activities are referred to as entrustable professional activities, whereby residents are permitted to engage in activities without direct oversight or supervision throughout their training.²⁴ Because medical documentation requires a cosignature of the supervising AT, it is possible that this kind of activity can be done with independence, but also complemented with feedback and consultation.

Respondents within our study noted several reasons for not allowing athletic training students to complete medical documentation, including a perceived lack of ability by the student, restrictions by the AT's employer, and the additional time burden of teaching athletic training students. Previous researchers have indicated that ATs surpass 40-hour work weeks,²⁵ and this time burden is noted as the primary reason that medical documentation does not occur, specifically within the secondary school setting.³ Additionally, ATs have stated they are required to spend their working hours covering practices and competitions at their place of employment rather than performing tasks related to organization and administration.³ This role conflict and required prioritization has led to a decreased time for new patient injury evaluations and medical documentation.³

Within our research, we noticed that several ATs were engaged in double documentation, where they or their athletic training student completed multiple drafts or forms of the same set of documentation. An example of this phenomenon is having a student write the medical documentation on a piece of paper or a separate document and then having either the student or the AT redo the documentation for the actual patient record. Preceptors should consider methods such as directly typing into an EMR without saving the information or working alongside athletic training students who still require interdependence to complete the medical documentation. Alternatives may also decrease potential patient privacy violations while also managing the time associated with mentoring students.

Another concern with double documentation is legal in nature. It may be imperative that, if the initial documentation occurred on paper, it be properly disposed of, as it may contain protected health information.²⁶ Examples of proper disposal include shredding the papers that were used or both deleting the document and clearing the recycling bin if the document was saved electronically.²⁶ Failure to comply with the strict methods protecting patients through the Health Insurance Portability and Accountability Act²⁷ and the Family Educational Rights and Privacy Act²⁸ can result in steep financial fines, as well as possible imprisonment for the supervising AT if a report is filed by a patient. To provide a learning opportunity without legal risks and privacy concerns, preceptors can create a test patient in an EMR system for athletic training students to practice on as a low-stakes learning task.²⁹

Mentorship

According to the NATA Best Practice Guidelines for Athletic Training Documentation,¹⁷ ATs should be performing initial injury evaluations for every patient encounter. If an AT is modeling best practice for an athletic training student, the students will have the opportunity to practice patient care documentation.⁷ Medical documentation should occur either during or immediately after a patient encounter for the purposes of accuracy and congruity.¹⁷ Following best-practice guidelines, the preceptor should review the medical documentation with the student and make any adjustments that are necessary to accurately reflect the patient care experience. Both the signature of the athletic training student and the preceptor should be included within the medical documentation.

In order to have effective mentoring and role modeling, the role of preceptor is one that requires time, dedication, and altruism.³⁰ Respondents indicated that additional time is required to provide the athletic training student with a quality clinical experience. Clinical experiences require instruction and assessment for real-time patient encounters.¹⁵ In terms of medical documentation, students should be given opportunities to complete medical documentation after patient encounters. Direct supervision includes the ability for the preceptor to intervene on the behalf of both the student and the patient.¹⁵ Because medical documentation does not involve any direct risk of harm to the patient, preceptors can allow autonomy with supervision and mentorship occurring as a result of cosigning the record. By being near and available for the athletic training student, the preceptor is able to address any questions or concerns that may arise while completing the medical documentation.^10,31 We advise that preceptors allow students to first practice and work through any complications they may have with medical documentation, followed by the preceptor immediately reviewing the document with the student and providing feedback.

The concept of social learning denotes that a person learns through observation, imitation, and modeling of the behaviors, actions, and skills.³² Bandura,³² who is credited with describing social learning theory, denotes 4 parts of the theory: attention, retention, reproduction, and motivation. Athletic training students will continue to mimic the behaviors that they are shown within their clinical experience, and therefore it is important that preceptors model proper documentation habits.

Many of the responses from this survey were seemingly related to a lack of knowledge from the preceptors on both Commission on Accreditation of Athletic Training Education standards for the athletic training student they supervise and a gap in the best practices for training professional students. A few of the respondents within the survey noted that athletic training students could not complete the documentation or would not allow for them to begin practicing these skills until they were at the end of their educational career. To model best practice, preceptors should be up to date on standards for medical documentation and how to integrate athletic training students into their practice.