Socialization Experiences of Athletic Training Preceptors

Design

We used qualitative focus groups with indicative coding from the phenomenological tradition to examine participants' lived experienced as preceptors.¹⁰ Before the beginning of the study, the Indiana State University Institutional Review Board approved this study.

Participants

We used criterion sampling through the National Athletic Trainers' Association (NATA) to recruit participants who serve as preceptors across all NATA districts and job settings throughout the United States. Seven focus groups were conducted; however, 1 focus group did not meet the required minimum of 3 participants and was excluded from analysis, resulting in 6 focus groups for analysis. A total of 18 participants attended a focus group (age = 32 ± 9; men 5/18 [27.7%], women = 13/18 [72.2%]; Tables 1 and 2). Participants were mostly educated and eligible for certification through an accredited baccalaureate program, had a master's degree, and worked in the college or university setting.

Table 1 Participant Demographics

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Table 2 Participant Characteristics

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Instrumentation

The questions for the focus group were developed on the basis of existing literature related to preceptor training and socialization.^2,11 The goal was to provide questions that would encourage discussion among participants. An initial script of 8 questions was developed and was amended on the recommendation of 2 reviewers with an average of 10 years of research and clinical education experience. These reviewers were provided with both the focus group guide and research questions and were asked to provide feedback with regard to the flow and clarity of the focus group guide as well as alignment of interview questions in relation to the research question. The focus group guide was edited to improve clarity on the basis of both reviewers' feedback. Moreover, the focus group script was piloted with two 10-person focus groups to further improve the quality of the focus group guide and identify potential issues with the focus group process. The practice focus groups resulted in changes to language for clarity and were integrated into the final focus group question guide (Table 3).

Table 3 Focus Group Question Guide

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Procedures

A total of 4348 potential participants were emailed with a call to action for participation and a link to a Web-based platform (Qualtrics, Provo, UT) for basic demographic information and informed consent as well as initial scheduling for focus groups. A follow-up email was sent every week for 3 weeks to individuals who had not responded to the recruitment email. A second round of recruitment emails was sent out to 4296 potential participants following the same format as the first round. Once potential participants had completed the informed consent, demographic information, and scheduling availability, they were scheduled into focus groups of at least 3 attendees. Focus groups were scheduled throughout the day and week to allow for maximum availability. Once participants were scheduled for a focus group, reminder emails were sent out at the 2-week, 1-week, and 48-hour time points. If participants had completed the demographic information but the available scheduling option was not suitable, follow-up emails were sent to create new scheduling options for a minimum of 3 attendees. The focus groups were conducted from October 2018 through January of 2019.

Focus groups were conducted via Zoom Video Communications (San Jose, CA), an online videoconference tool. Online focus groups allow for the capture, in real time, of data from participants in different locations who would otherwise not be able to participate simultaneously.¹² In addition, evidence shows that the content produced from online focus groups is very similar to that of in-person focus groups.¹³ The focus group process uses video and audio functions to accurately track the speaker throughout the focus group session. These video sessions were recorded with the program recorder of the Zoom program. Once focus groups were completed, the audio files were transcribed for analysis.

Data Analysis and Trustworthiness

Once reproducible themes emerged throughout the focus groups, it was determined saturation had been reached.¹⁴ We used inductive coding using the phenomenological tradition to analyze the focus group transcripts. This approach allowed the research team to determine themes and subthemes within the data and reach consensus.^10,15 All focus group transcripts were transcribed and all identifying participant information including participant, organization, and student names was replaced with a pseudonym. Quantitative data were analyzed using measures of central tendency (Microsoft Excel, Redmond, WA).

After completing transcription, 2 members of the research team (D.H., E.R.N.) completed multiple analyst triangulation. Consistency throughout the creation of a codebook was essential; thus, constant comparison was used throughout the analysis process to confirm consistency between the research team. By using multiple analyst triangulation, we were able to reduce the bias of a single researcher.^10,15 All focus group transcripts were initially analyzed by both research team members to establish a general familiarity with the data. Once familiar, the first 3 focus group transcripts were analyzed by the research team, and consensus was reached for the basis of the codebook. After that, the remaining focus group transcripts were analyzed for consistency with the initial codebook. The codebook was edited on the basis of needed changes from application across focus groups 4, 5, and 6. Last, having established a revised codebook, all focus group transcripts were checked for consistency with the final codebook. The coded focus group transcripts and final codebook were sent to an internal reviewer with 10 years of experience in qualitative research for peer review to establish the validity of the codebook. The internal reviewer determined whether they agreed upon the coding and themes within the codebook or whether further edits were required. Once reviewed and the codebook finalized, each quote was separated into its appropriate theme and subtheme.

Programmatic Responsibilities

Programmatic responsibilities was a theme among participants and included ways in which preceptors were trained to be compliant with regard to the CAATE standards, programmatic expectations of preceptors, and formal feedback and communication with preceptors. Preceptor training was used to denote the experiences participants had that could be categorized as formal preceptor training experiences. The communication subtheme was used to categorize formal communications and feedback from the program to the preceptor.

Creating an Ideal Environment and Culture

Participants described creating an ideal environment and culture where preceptors worked to create a positive learning environment for students. Donna spoke about both positive and negative behaviors she had experienced as an ATS and how she leveraged those experiences as a preceptor in an attempt to create an ideal culture: “You're still learning. I'm still learning. Let's learn together.” Participants discussed creating an environment of reciprocal learning for students and for the preceptors to continuously reevaluate their level of knowledge.

In addition to fostering an environment of mutual learning, participants spoke about creating a transparent environment with students. For example, Kate works to remain professional while still exposing students to the realities of athletic training, both positive and negative:

I think we do them a disservice if we pretend like this is easy all the time and it's all sunshine and rainbows and everybody loves watching practice when it's 20° outside. I think we need to talk to them about that and sometimes when things are stressful, we can use it as an example or as a teaching moment to help them develop some resilience strategies for when things get tough or are stressful.

Whereas participants spoke about creating an open, vulnerable, and trusting environment, Clark also discussed the natural conflict between clinical education experiences and students' use of time. “The struggle of [being a preceptor] is trying to prepare the student for what they're going to have to do as an athletic trainer while also respecting their time, things like tests and other things that they have.”

Perceived Preparedness

Preceptors model their behavior from experiences, both precertification and postcertification. Whereas preceptors did speak about their overall level of preparedness, they generally addressed their initial perceived lack of preparedness. Preceptors often seek to expand their knowledge outside of the ATP, seeking formal learning about clinical teaching if they feel it is lacking. Seeking these formal learning experiences often facilitates informal learning experiences of the preceptor through the application of, and reflection on, this new knowledge or new technique. Preceptors will also try to fill a knowledge and skill gap by mimicking previous learning experiences.

Formal Learning About Clinical Teaching

There is a cyclical relationship between formal and informal preceptor socialization. Formal learning about clinical teaching can take various forms, such as coursework, continuing professional development, and certificates. Preceptors can apply lessons and strategies learned from formal learning, then reflect and iterate upon those strategies. Reflection and iteration are types of informal learning. Kennedy described seeking additional education as part of her professional development and how those experiences influenced her preceptorship.

So [I] took a lot of teaching-effectiveness classes, courses where we had an opportunity to teach. I got to learn a lot of strategies and ways to become a preceptor that weren't necessarily focused on preceptor training, but it was teaching strategies, which, obviously, are very similar.

Another avenue of formal learning about clinical teaching was continuing education. Continuing education provided an avenue for ATs to increase their knowledge of pedagogy to better understand what young professionals and incoming athletic training professionals are likely to experience. Samantha described what types of continuing education courses she sought out and the ways in which those courses provided utility:

I was seeking out continuing education based on being an effective preceptor or bridging the transition to practice. I've found that those were actually really helpful to be able to engage students from some of the key researchers in AT education. But they also understand the demands we have on our time and had some really good suggestions about how to bridge the transition to practice, especially older students, with health care administration tasks and decision-making.

Self-Directed Development

The participants in this study exhibited a strong desire to be better preceptors. They engaged in self-directed development behaviors to enhance their skills. Specifically, they sought informal feedback from students, they continued to evolve and change as mentors, and their personal growth and reflection helped in their development as preceptors.

Personal Growth and Reflection

Mindset plays a significant role in how individuals develop. Preceptorship is no exception. Joan described health care, education, and preceptorship as an ever-changing landscape: “How they view education, challenges, and change I think is important. You have to have someone in education who doesn't look at change as something scary but looks at it as maybe a challenge, especially if it's a change that they don't necessarily like.” An individual with a growth mindset continuously seeks to improve; they do not change for change's sake, but seek to continuously better themselves and what's around them.

Whereas there is a need to change due to external factors, there is also a need to change internal factors that may negatively affect student and patient outcomes. Jacklyn spoke to her own personal characteristics, how she may need to change to improve her ability as a preceptor, and how it related to student feedback:

I'm very assertive, which can come off as aggressive. A lot of self-reflection on why I communicated that way; how can I communicate that better next time? Was that appropriate to communicate that at that time? I always try and self-reflect: “Okay, did I help them during that time? Did I let them know that they were failing to meet certain expectations?” Because if I didn't, I wasn't doing my job helping them make a change while they were with me, and that's not fair.

Conversely, a fixed mindset describes individuals who are set in their ways and expresses either resistance or indifference to change. Often this can be viewed as complacency or masked with a mindset of current successes, as described here by David:

We have one preceptor who [has] been there for 25 years . . . They have good facilities and they run like [a] college program. However, the preceptor doesn't really understand what CAATE does, but because of the experience students can get from the atmosphere and how they run a high school football program I would say that's necessary . . . the preceptor there doesn't really understand what he's expected to do . . . he doesn't fully understand it. But the feedback from students who went to that high school is always positive because of experience, not necessarily the preceptor.

Participants discussed a number of topics throughout the focus group process, but themes primarily emerged around (1) programmatic responsibilities, which entailed preceptor training and communication; (2) creating an ideal environment and culture, which included real-life experiences and guided self-reflection; (3) perceived preparedness, including lack or preparation, formal learning about clinical education, and mimicking previous experiences; and last, (4) self-directed development, which entailed informal student feedback, changed mentorship behaviors, and personal growth and reflection.

Programmatic Responsibilities

The purpose of clinical education is to integrate behaviors taught in didactic curriculum into real-life clinical experiences.¹⁶ This can become an issue when preceptors do not desire to be clinical teachers. There were instances where participants discussed knowledge of colleagues who had no desire to become preceptors but were required due to programmatic obligations. Evidence suggests that before accepting the role of preceptor, potential candidates should be willing to explore and research what the role entails.⁸ In addition, individuals who do not exhibit behaviors consistent with characteristics congruent with preceptorship should be considered for deselection.^1,11

Participants noted that although they were interested in becoming preceptors, they did not feel prepared early in their career or job placement; they indicated that with greater levels of establishment they were more able to devote time to preceptorship, which is consistent with current research.^3,6,8 Past research has indicated that ATPs should ensure that preceptors have sufficient experience to provide adequate support and instruction to ATSs.⁸ To create the best scenario for the development of a positive learning environment, ATPs should take care to ensure the preceptors they select are comfortable in their current job role and in establishing themselves as a professional before placing ATSs at that clinical site. In other medical professions as well as in athletic training, there is no designated minimum amount of time one must practice before becoming a preceptor as long as the minimum qualification requirements have been met. Whereas this remains an area of discussion, ATPs should use good judgment to determine a clinician's readiness for preceptorship. Suggested criteria broadly include legal and ethical behavior, communication skills, interpersonal relationships, instructional skills, supervisory and administrative skills, evaluation of performance, and clinical skills and knowledge.^1,11 However, these are not required qualifications or characteristics of preceptors.

Throughout the focus groups conducted for this study, participants discussed both the benefits and the downfalls of formalized preceptor training. Participants described the training as helpful to familiarize themselves with programmatic expectations early on in their preceptor experiences; they also described frustration from the lack of opportunity for growth or exhibited a resigned attitude with regard to further formal training. Training was described as surface level with little attempt to enhance pedagogical skills. This differs somewhat from current research,² which described formal training as benefiting preceptors by training them in instructional methods, and mentoring. The 2020 CAATE Standards for Accreditation of Professional Athletic Training Programs state that the coordinator of clinical education is responsible for “the professional development of preceptors,” whereas the “professional development of preceptors is specific to development of their role as a preceptor (Standard 40).”^9(p8) This standard implies that ATPs need to develop the clinical knowledge, skills, and abilities of preceptors as well as provide them with education on how to be a good clinical teacher (specifically, pedagogy in the clinical environment). The implementation of these strategies may be perceived as barriers by preceptors, especially in regard to time.^1,11 However, ATPs can work to create alternative means of compliance on a systems level, such as collaborating with stakeholders to include potential preceptorship in a job description, seeking out ways to compensate preceptors in some fashion, and including the preceptor-development plan within the professional-development plan of the preceptor's organization.

A primary concern for participants was the lack of communication from ATPs. Participants with a long history of preceptorship experience recall when a coordinator of clinical education would visit sites more frequently than once a semester and when communication at regular intervals was integral to student success. Despite research findings about the importance of communication,^1,16–18 many of the participants discussed a lack of formalized feedback and communication as an area of frustration. This lack of communication conflicts with current research and the CAATE standards, particularly Standard 32, which states: “Regular and ongoing communication occurs between the program and each preceptor.”^8,9 The standard, however, is ambiguous in its relation to execution. The ATPs should discuss with preceptors and decide as a program the parameters for engaging in communication that is effective and ideal for their situation.

Creating an Ideal Environment and Culture

Modeling of desirable characteristics by preceptors is integral to the development of ATSs.^16,18 Participants used both positive and negative experiences with previous preceptors to help inform their style of preceptorship. A unique trend among these participants was that previous preceptors had modeled behaviors that made them uncomfortable, specifically pushing them out of their comfort zone. Participants also noted that once they became a credentialed health care professional, they sought out peers, mentors, and other health care professionals to learn and seek support in becoming a preceptor. This supports current research detailing the perceived learning needs of athletic training preceptors, which includes teaching and learning in the clinical setting, evaluating students, communication, student development, and mentorship.^5,6

Participants frequently discussed how they worked to model positive behaviors including empathy, resiliency, vulnerability, and transparency to the ATSs. These traits are not specifically listed within preceptorship-characteristics literature but are described broadly in the context of “humanistic orientation” or “interpersonal skills.”^16,18 One behavior specifically noted by participants was critical thinking. This is explicitly outlined in current literature as a critical skill.^16,17,19 Participants described experiences in which they were placed in uncomfortable situations by their preceptors. Upon reflection, participants were grateful for these uncomfortable situations because of the opportunity for growth, but recalled that in the moment they were dissatisfied. This phenomenon is a component of experiential learning in which they assumed responsibility for their learning.²⁰ Experiential learning is the primary means of clinical learning in which students participate throughout their education whether through concurrent or immersive clinical experiences. Experiential learning facilitates the creation of lifelong learners by transitioning students from a passive to an active learning environment.²⁰ Facilitating patient-care experiences from which students can learn is a primary responsibility of preceptors.^{1,2,11,17–19} This is also reinforced within the 2020 CAATE Standards for Accreditation of Professional Athletic Training Programs' definition of preceptor supervision of students, which states that progressive autonomy is achieved by “allowing a student to move from interdependence to independence based on the student's knowledge and skills as well as the context of care.”⁹

Goal setting, an informal method of socialization, from preceptors remains an activity that contributes to an active learning environment and benefits the ATSs.^11,16,18,19 Whereas feedback and goal setting are useful techniques to foster self-reflection and planning, participants discussed how using goals functions as a means to empower the ATSs. Participants discussed that they were able to foster confidence through goal setting, such as entrusting the ATSs with situations of greater responsibility such as taking over more treatment duties or acting as the primary health care provider for a day while still under direct supervision. These behaviors in conjunction with goal setting compound to foster a conducive learning environment through student empowerment.

Ultimately, creating an ideal environment and culture is a broad topic that is not well explored within athletic training. The discussion from participants revolved primarily around a culture that was established by the preceptor and other stakeholders. At its most basic level, these discussions focused mainly on presenting an open attitude with the ability to display vulnerability. This environment of vulnerability was fostered by creating an equal and honest teaching relationship. By delineating equity of job responsibilities, fairness was established. Creating and modeling honest communication, even within difficult or uncomfortable conversations, further facilitated this environment.^16,18 Communication was reinforced through guided self-reflection.²¹ Last, allowing students to engage in real-life experiences empowered students and helped them develop a sense of confidence and resiliency, which was a goal for participants. Real-life experience has been more formally integrated into clinical education within the new 2020 CAATE Standards for Accreditation of Professional Athletic Training Programs as immersive experiences.⁹Immersive experience has been defined by CAATE as “a practice-intensive experience that allows the student to experience the totality of care provided by athletic trainers,” and calls for a minimum of “one four-week continuous period.”⁹ Immersive experiences are designed to allow students to be present and active for all aspects of an AT's typical duties. This could expose them to a more realistic and comprehensive version of athletic training practices, facilitating more real-life experiences.²²

Perceived Preparedness

Preceptors described their perceived preparedness to fulfill their role as a clinical educator, most often discussing their lack of preparedness and some of the ways they worked to remedy their lack of preparation. Remedies ranged from seeking formal continuing education or coursework to reflection on previous experiences with their own mentors to be more effective at instructing students.

There is current research available regarding effective preceptor qualities and characteristics.^1,11,17,19 Older research, which was conducted when there were different accreditation requirements and standards, described a 7-point criterion for the selection and evaluation of preceptor effectiveness, including legal and ethical behavior, communication skills, interpersonal relationships, instructional skills, supervisory and administrative skills, and student performance evaluation.^1,11 Other researchers^16,18,20,23 have found that preceptors and clinical educators across disciplines help their students grow and improve when they demonstrate and model good communication skills (including listening and outlining expectations), confidently demonstrate clinical proficiency and expertise the student can then both model and participate in, and are willing to be accessible and vulnerable with students (including admitting when they do not know answers). Furthermore, researchers have described^16,23 criteria for the development of exemplary clinical environments including “matching clinical teaching skills to student understanding and experience, . . . providing constructive feedback, facilitating a student centered environment, and training clinical instructors.”^16(p13) Research from Laurent and Weidner¹⁸ provided additional characteristics: models confidence, clinical emergencies, and skills; respects the students and remains accessible to them; communicates effectively, and admits what they do not know. There is an additional framework of skills that preceptors should cultivate to better serve ATSs, including competence, communication, instruction, administration, professional development, interpersonal skills, injury evaluation and assessment skill, and legal and ethical behavors.¹⁶ These criteria are also reflected within the new professional educational standards.⁹ When viewed together these separate results show that vulnerability, communication, and an emphasis on student learning help to foster a supportive environment.

Although these behaviors have been well researched, our participants noted a lack of pedagogical training through their formalized preceptor training. In addition, participants noted they felt more comfortable as preceptors as they gained more clinical experience, a sentiment that is supported by research.^1,11 Preceptors are often selected due to clinical aptitude regardless of their instructional experience or student-evaluation skills.¹⁷ In light of their perceived lack of preparation, participants sought out other methods of instruction including educational coursework, certification, or continuing education. Common areas of continuing education pertaining to preceptorship included transition to practice, pedagogical learning, preceptor characteristics, and mentorship.^{1,6,11,16–18} We inferred from the discussions of the participants a distinction between those who sought formal education in pedagogy and those who gained knowledge solely through experiencing preceptorship. Those participants who had more experience in preceptorship described the ability to provide more varied instruction due to their past experiences. Whereas experience is a valuable trait, this lack of instructional knowledge should be a disqualifying factor in preceptor selection because it is possible and even likely that these experiences are only reinforcing poor clinical teaching behaviors. Conversely, those who sought further instruction described the ability to be more comfortable discussing and displaying a broader spectrum of their own experiences to the students; there was less of a perceived barrier. These behaviors are essential to model for the growth of ATSs and should be encouraged by the ATP through preceptor training.

Self-Directed Development

Informal student feedback was characterized by preceptor feedback and discussion with students, which falls outside of the confines of formal programmatic requirements. This feedback was not recorded with the program unless the student recorded the same information on the ATP's formal site or preceptor evaluation form. Due to the nature of this type of feedback, the only way for change to be implemented is for the preceptor to consciously take action to change their mentorship behavior. A specific behavior that participants spoke about consciously directing was empathy. Empathy, the ability to understand the feelings of others, plays a large role in patient care but also in student education.¹⁸ It is worth noting that participants actively discussed the development of other characteristics they were trying to facilitate within their students such as vulnerability and critical thinking. These behaviors are listed in the research as critical areas of development.^7,9,17

By actively seeking out feedback from students, preceptors helped to foster an environment of honesty and vulnerability. In addition, by working to embody the characteristics they intended to foster, preceptors begin to model behavior effectively. By creating this environment and making changes to their mentorship behaviors, they were actively participating in reflection and personal growth.²⁴ An individual with a growth mindset enjoys incremental personal growth over the course of a lifetime.²⁴ Conversely, an individual who exhibits a fixed mindset is resistant to change on the basis of a fixed view of traits.²⁴ Whereas this is a characteristic that is present in people, it should be noted that health care is an ever-changing, ever-evolving field of knowledge; to stagnate in one's pursuit of new and innovative techniques is to become out-of-date, which is a disservice to both patients and students.²⁵

Limitations and Future Research

On the basis of current literature this study expands upon the research of Mazerolle et al² regarding preceptors' socialization experiences. Although this study is certainly exploratory, the key findings can provide a contextual framework for preceptors to create an environment in which ATS may thrive, as well as a context for how ATPs can develop preceptors more effectively. Our findings may prove novel; however, there were some significant limitations. One such limitation was a limited sample size (n = 18). We allowed data saturation to guide data collection, as is indicated in qualitative research, but findings should be considered within the context of the represented sample, and it is possible that a larger sample could prove to be more representative of the overall population of preceptors.¹⁴ Self-selection is an inherent limitation of qualitative research and in this case, preceptors interested in preceptor development were more likely to participate. Future research should focus on expanding our knowledge of informal socialization experiences of preceptors, as well as trying to obtain data from preceptors who are not as keenly interested in clinical education. In addition, exploring the programmatic implementation of preceptor-development plans and individual self-directed preceptor-development plans should be a priority.