Professional Program Preparation, Orientation, and Mentoring Tactics Used to Develop Professional Responsibility in Early-Career Athletic Trainers

Research Design

We used a cross-sectional descriptive study to explore recently certified ATs' perceptions of their transition-to-practice experience. With our approach, referred to as sequential-mixed methods, we used previously established qualitative findings and aimed to confirm their generalizability through quantitative methods. This previous qualitative research guided our survey-instrument development.¹ We gained approval from Indiana State University's Institutional Review Board before data collection.

Participants

We used the Board of Certification (BOC) to recruit participants who fit our inclusion criteria of individuals in a true initial transition-to-practice period, which is the time from the first weeks of employment through the first few years of practice.¹ These criteria included all ATs certified by the BOC from 2016 through 2018 who graduated from a Commission on Accreditation of Athletic Training Education–accredited professional master's athletic training program. All other individuals not meeting the aforementioned criteria were excluded and did not receive a survey or were guided to the end of the survey if they had mistakenly received it.

Before participation in the survey, participants electronically provided their informed consent. The BOC sent 889 initial e-mails, and of the 173 participants who accessed our survey (19.5% access rate), 137 ATs (103 women, 34 men; age = 26 ± 3 years) completed the survey in its entirety (15.4% response rate and 100% completion rate). Table 1 provides complete participant demographics.

Table 1 Participant Demographics (N = 137)

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Instrumentation

We initially developed the instrument from the previous athletic training literature,¹ and it was reviewed by content experts to gain knowledge of participant transition-to-practice experiences. Two content experts of transition-to-practice research were consulted through 5 drafts to help develop and review the instrument before pilot testing. Protocol optimization, to determine time to complete and navigation of the survey, was performed by 21 ATs who met the inclusion criteria. Preliminary analysis showed that the survey required an average of 12 minutes to complete, despite the tool varying in length because each participant's transition-to-practice experience was different. After protocol optimization, minor modifications were made to the instrument for improved navigation. The final instrument was piloted and validated using main constructs derived from previous qualitative transition-to-practice research¹ and expert review. The final survey was delivered using an online survey platform (Qualtrics, Provo, UT) for Web-based distribution.

The instrument comprised 3 sections: (1) demographics, (2) preparation, and (3) tactics. Section 1 included 6 demographic questions including age, sex, BOC certification year, and job descriptors including setting, position title, and number of colleagues. Section 2 comprised 2 items about the participants' overall feelings of transition-to-practice preparation and how well their professional master's athletic training program prepared them for the transition. Next, the participants completed Section 3, which involved 4 subsections of items identified as key factors in the transition-to-practice literature^{1,5,6,12–16} that included formal coursework, clinical experiences, mentorship, and orientation (sections 3A–3D, respectively). For 3A through 3D, a list of educational tactics were provided for the participants to select the strategies they had used. Section 3A contained 8 tactics and a not applicable option; Section 3B contained 6 tactics and a not applicable option; Section 3C contained 4 tactics and a not applicable option; and Section 3D contained 9 tactics and a not applicable option. As the participant completed each of the subsections, additional questions were displayed for those tactics selected. For each tactic that the participants stated they had used in their transition to practice, follow-up items were generated asking the participants to select how helpful (a 5-point Likert scale: extremely helpful, very helpful, moderately helpful, slightly helpful, or not helpful at all) each of the previously indicated tactics were at preparing them for transition to practice. If the participant stated the tactic was between extremely helpful and slightly helpful, a final item was generated asking the participant to consider what areas of professional behaviors (developing confidence, making decisions, understanding your position and role, communicating professionally, managing administrative duties, managing patient load, resolving conflict) the tactic helped them to develop during the transition to practice. The question breakdown is further highlighted in the Figure. These data were not included in the data analysis.

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Procedures

The BOC sent an initial recruitment e-mail to potential participants in mid-October 2018. To increase the response rate after initial e-mail contact and distribution of the survey, 5 follow-up e-mails were sent by the BOC to participants who had not completed the survey. The initial and subsequent e-mails were sent over 6 weeks spanning October and November 2018. Much like those conducting other survey research in athletic training, we paid the BOC for access to the target population.

Data Analysis

Data were analyzed using descriptive statistics including measures of central tendency (mean, mode, frequency). These analyses were applied to each of the 4 topic areas of formal education, clinical education, orientation, and mentorship prompted across participant responses, as found in previous transition-to-practice research.¹ Frequencies were calculated for each tactic within the topic areas, tactic helpfulness, and how each tactic was helpful (Tables 2–5) using SPSS (Windows version 25.0; IBM Corp, Armonk, NY).

Table 2 Formal Coursework Tactics and Their Reported Helpfulness in Transition to Practice (N = 137)

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Table 3 Clinical Experience Tactics and Their Reported Helpfulness in Transition to Practice (N = 137)

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Table 4 Orientation Tactics and Their Reported Helpfulness in Transition to Practice (N = 137)

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Table 5 Mentorship Types Reported and Their Helpfulness in Transition to Practice (N = 137)

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Responses to the transition-to-practice survey were also studied across different athletic training settings to determine any differing trends seen in newly credentialed ATs in the emerging settings. We compared the ways in which the ATs perceived how their professional educational experiences prepared them by setting, position type, number of coworkers, and year of graduation (recency) using 1-way analysis of variance with Scheffé post hoc comparisons.

Formal Coursework

Participants most often indicated that they discussed professional behaviors (78.1%, 107/137) and discussed potential job responsibilities in future employment settings (75.2%, 103/137) during formal coursework. Both of these formal coursework tasks were found to be very helpful by newly certified ATs (43.9% [47/107] and 52.4% [54/103], respectively). Discussing professional behaviors was mentioned to be most helpful for preparing an AT to communicate professionally (70.1%, 96/137). Participants indicated that discussing potential job responsibilities in future employment during formal coursework was the most helpful in preparing ATs to understand their position and role (62.0%, 85/137) during the transition to practice. The least commonly selected tactics in formal coursework were what to expect from formal orientation (22.6%, 31/137) and what questions to ask employers about mentoring (21.2%, 29/137). Participants who did select these tactics found discussing what to expect from formal orientation moderately helpful (35.5%, 11/31) and discussing what questions to ask employers about mentoring moderately helpful and extremely helpful (31.0%, 9/29 [same for both responses]).

Clinical Experiences

The other aspect of professional preparation programs that affects the transition to practice is clinical experiences. Analysis of the data suggested that being encouraged to make patient-care decisions under the guidance of a preceptor (82.5%, 113/137) and being provided feedback about performance (81.8%, 112/137) were the most commonly used tactics of preceptors. Both of these clinical-experience tactics were labeled as extremely helpful in the transition to practice (76.1% [86/113] and 66.1% [74/112], respectively). Being encouraged to make patient-care decisions under the guidance of a preceptor was most helpful at preparing ATs for transition to practice by developing their confidence (75.9%, 104/137) and decision-making skills (75.9%, 104/137). Feedback provided by a preceptor about ATs' performance prepared the ATs for their transition to practice by their developing confidence (75.9%, 104/137). The least common tactics in clinical experience were discussing job expectations (62.0%, 85/137) and being provided the opportunity to perform administrative tasks (63.5%, 87/137), yet these were found to be extremely helpful (48.2% [41/85] and 50.6% [44/87], respectively) in transition to practice when participants did have this experience.

Orientation

Orientation tactics used to introduce newly certified ATs to their new position varied widely. The majority of participants experienced a form of informal orientation (92.7%, 127/137); some had formal orientation (39.4%, 54/137), and others had no orientation provided (14.6%, 20/137). The most common orientation tactics were informal orientation through learning on the job independently as things came up (44.5%, 61/137) and informal orientation through help from a peer or colleague as things came up (40.1%, 55/137). Both were perceived as very helpful in the transition to practice (32.8% [20/61] and 34.5% [19/55], respectively). Learning on the job independently as things came up helped with role understanding and making decisions (29.2%, 40/137). Learning on the job through a peer or colleague as things came up helped with role understanding and managing administrative duties (24.8%, 34/137). The least commonly used orientation tactics were formal orientation administered through clinical placements (24.1%, 33/137) and formal orientation administered through an academic program (3.6%, 5/137). Despite these formal orientations being the least likely used orientation tactics, the individuals who did have these types of orientations rated them as extremely helpful (39.4% [13/33] and 60.0% [3/5], respectively) at developing professional communication (16.1% [22/137] and 2.9% [4/137] respectively) and managing administrative duties (17.5% [24/137] and 0.7% [1/137], respectively).

Mentorship

Mentorship was also found to be influential in the transition-to-practice experience, when it occurred. Some ATs had a mentor assigned to them in their current position (25.5%, 35/137), but the majority did not (70.1%, 96/137). The ATs who had an assigned mentor in their position indicated this individual most commonly was a coworker (13.9%, 19/35). Many newly certified ATs did have a mentor outside of someone assigned to them (52.6%, 72/137), and these were most commonly former preceptors (24.8%, 34/72). Regardless of the mentor being assigned or unassigned, newly certified ATs viewed these individuals as being extremely helpful (40.0% [14/35] and 61.1% [44/72], respectively) in their transition to practice. Assigned mentors most often helped individuals understand their role in their new position (16.1%, 22/137). Mentors who were chosen by the individual and were not assigned most often helped individuals develop confidence (43.1%, 59/137) as they transitioned into their new role.

Professional Program Preparation

Formal coursework is a major preparatory factor for the transition to practice.^1,5,12–15 In our current study, the 2 tactics most frequently used in formal coursework included professional behaviors and potential job responsibilities in future employment. Discussion of these topics in formal coursework made newly certified ATs feel as though they were more prepared to communicate professionally and to understand their job roles. These findings are consistent with those of previous researchers who found the actual transition-to-practice experience was rarely discussed during professional preparation¹; however, information related to professionalism and future job responsibilities was discussed.¹ Professional education programs place little emphasis on these topics, most likely because their role in the actual transition period from student to independently practicing clinician is perceived as limited. As professional programs begin to shift to meet new educational standards, there is opportunity for inclusion of discussions on transitioning from interdependence to independence in practice. Discussion of transition-to-practice topics, specifically professional behaviors and future job responsibilities, will prepare early-career ATs to enter their new role more confidently, understand their job roles, and enhance professional communication. Introducing professional behaviors more frequently in coursework would allow those transitioning to practice to apply professional communication in their professional roles more aptly and with greater ease.

Our participants indicated that their professional programs infrequently discussed what questions to ask employers about mentorship and what to expect in a formal orientation process. These were the least commonly cited tactics presented in formal coursework. Reasons for this may be faculty in professional programs not feeling responsible for educating students on these topics, given that these are more related to future employers and may fall more aptly as an employers' responsibility to inform potential employees. Regardless, professional programs should be discussing tactics the newly credentialed ATs could use to better prepare themselves for their new work environment. Specifically, programs can prompt newly credentialed ATs to ask potential employers about mentorship, and the importance of orientation processes should be discussed to prepare students as they are looking to transition into their initial professional roles. Discussions of future job responsibilities should also be included in a more structured format because according to the current study, those transitioning to practice perceived this information to increase their role and position understanding. The responsibility of professional education is not to anticipate each and every future workplace for newly credentialed ATs, but to equip them with awareness about health care facilities and what those facilities should be offering to new employees.

Beyond formal coursework, clinical experiences also positively shape clinicians in their transition to practice. Positive clinical experiences were found in this study as well as previous studies to be a driving force in adequately preparing students for the transition to practice.^1,14,16 When participants were questioned about their clinical experiences, they cited being encouraged to make care decisions under the guidance of a preceptor and receiving feedback on those decisions as the most helpful experiences. Having the opportunity to make care decisions under a certified AT's supervision allows for some independence, which builds confidence.^13,16 This opportunity also allows students to become more comfortable with making care decisions.^13,14,16 This confidence and the ability to make decisions translate well in transition to practice as newly certified ATs come across difficult situations in their new role and are ultimately responsible for the delivery of care.^1,5,14 Receiving feedback on performance is another positive benefit that most students experience in their clinical experiences.^12,16 After receiving feedback, students were able to make appropriate changes, which made them more confident moving forward because they had the proper knowledge to make improvements.

Clinical experiences provide students with the opportunity to experience a meaningful and relevant reality of the clinical practice of athletic training. These experiences are then translated and integrated into the newly certified professionals' practice. To properly socialize athletic training students for clinical practice, it has been agreed by preceptors and students that there needs to be diversity of experiences in realistic and positive learning environments.¹⁶ These experiences are the drivers in increasing awareness of the realities of the profession, preparing students for their role change.^14,16

Areas in which clinical experiences seem to be lacking are in regard to allowing students to partake in administrative tasks and discussing job expectations.^5,15 When newly certified ATs were asked about how prepared they felt to transition to practice, the areas they usually rated lowest were feeling prepared to perform administrative duties or knowing what their job responsibilities were.^5,15,17 Not having much exposure to administrative tasks and job expectations during clinical experiences may be the major contributing factor to these areas being rated lower in preparation for transition to practice. A survey of employers noted similar findings.^5,15,18 The ATs were seen by employers to be competent in regard to their clinic skills; however, they lacked procedural business skills and interpersonal communication skills.^5,17 If students are not being exposed to these areas, they will not be prepared to encounter certain tasks such as administrative duties on their own. Suggestions for improvement of clinical experiences would be to allow students to partake in administrative tasks under the supervision of their preceptors and to include feedback to the students regarding their ability to complete administrative duties. The combination of these clinical experiences would offer those transitioning to practice a greater development in confidence.

Orientation

As previously seen, this study confirmed that informal orientation is used more often than formal orientation methods.¹ Informal orientation has positives and negatives. When informally trained in a new position, individuals are forced to either figure things out on their own as they arise or turn to find help from their coworkers. This does have a tendency to help with role understanding, given that an individual is required to work through things without any sort of formal guidance.¹⁹ This form of socialization, just as students experience when under the guidance of their preceptors, facilitates a readiness to assume their role.¹⁴ On the contrary, not having a formal orientation can be detrimental because actual employer expectations are not established.^14,19,20 The downsides of not providing a formal orientation have been studied in other health care professions such as nursing. One example of the detriments of lack of orientation is the choice for young nurses to exit the profession due to burnout and stress.^3,4,21 The decision to leave the profession has more recently been linked to dissatisfaction with the orientation.²¹ When nurses were introduced to their new role with some form of formal orientation, their confidence increased and they felt more competent to work independently; in addition, their overall well-being improved.²² Similarly, in the current study, formal orientations were actually found to be more helpful than informal orientation, despite not being encountered as often.

Research based in human resources also supports the implementation of formal orientation or onboarding programs for several reasons. When organizations use onboarding programs, they are able to expedite the employee socialization process, which results in better role clarity, self-efficacy, performance, retention, perceived fit, and satisfaction among employees.²³ In addition, previous research supports the idea that the sooner knowledge is provided and the more specific it is, the better newcomers can understand the culture of their workplace. Such understanding makes it easier for these employees to contribute more quickly and more robustly to the success and competitive advantage of the organization.²³ Formal orientation processes have an impact on important individual outcomes for employees including their social comfort with an organization, which has the ability to increase productivity.^23,24 This reveals the importance of formal orientations being more closely aligned with acculturation of the individual to the organization than to training individuals on the tasks of their job.²⁴ In athletic training settings, previous experiences in formal coursework and clinical experiences have the potential to prepare early-career ATs for knowing job tasks^1,5,14,16; however, formal orientations would be helpful introductions to organizational expectations.

There were also a significant number of participants who had no form of orientation. This is a problem because no expectations were established and new employees entering a role were unaware of what their role actually was. This inhibited the transition to practice, because new employees may have been more confused about their responsibilities and they likely had less confidence. Researchers studying the benefits of training for employees found that companies who properly develop their employees see a greater rate of retention and higher productivity, which ensures a competitive edge for the company.²⁵ Establishing a formal orientation is a responsibility of employers to new employees. Training sessions are essential to promoting learning and enhancing on-the-job performance.^19,20,25 This research serves to provide reasoning as to how employers will benefit from the implementation of a formal orientation and describes what benefit employees will have from different orientation tactics.

Mentorship

Mentorship is important in the transition to practice because having someone to discuss difficulties with or to get some guidance from can be helpful in building confidence. The current study and previous studies determined that most newly certified ATs sought their own mentors and were not necessarily provided one in their position.^1,12,19 On the basis of anecdotal evidence, it appears that ATs often did not encounter formal mentorship because they were not assigned a mentor by their employer upon hire. Regardless of being assigned or unassigned, mentors were found to be a very helpful resource in the transition to practice. They were a great source of information in several cases. Researchers studying nursing have suggested that both formal and informal mentorship models have fostered long-term growth and retention of the profession through a support system that enhances job satisfaction.²⁶ Usually individuals sought mentorship from previous preceptors.^1,12 This is likely due to the relationship students had previously built with that person and the respect they held for that individual.

Formal mentorships may be an alternative to implement if unstructured mentorships are not built. Employers would be able to implement this type of mentorship process the best because they have the ability to create a network of ATs they can then use as mentors for new employees. It is known that mentorship can facilitate a better transition to practice and be a positive experience beyond the transition period.^1,12,19 During transition, mentors have been found to help mentees gain self-confidence and advance clinical competence in addition to helping the individual learn role conflict management and how to deal with work-life balance issues.¹⁴ Mentoring relationships are also beneficial for providing a sense of connection, integration, and legitimization of one's role that allows for the development of appropriate professional behaviors.^27,28 This has the potential to create a better work environment and more productive employees, because they will be more aware of their roles and approach their job with more confidence.

Limitations and Future Research

We explored the first few years of transition to practice and asked participants questions falling within 3 categories of professional program preparation, orientation, and mentorship. This helped us confirm the results from previous research; however, we did not find any specific interactions between characteristics including practice setting, position type, number of coworkers, and year of graduation that affected transition to practice. Although we surveyed participants who graduated from professional-level master's programs, we did not gather information regarding what their specific clinical experiences were before graduation or characteristics of their mentors or orientation sessions. These are factors that could affect the transition to practice because a variety of factors go into preparing an individual for independent health care practice. Many professional education programs are already taking steps to help prepare students for the transition to practice; however, the rapidly evolving environment of athletic training in health care needs to continuously be evaluated. This continuous reflection process offers the opportunity for professional education programs to continue to improve their support structure. Future research should further examine the best practices for preparing students for the transition to practice and should also explore the impact of immersive clinical experiences on the transition to practice.

Employers also have a role in the transition to practice; however, only ATs were surveyed in this study. Unfortunately, there is no information about whether employers believe their employees are prepared for the transition to practice. Future researchers should investigate employers' perceptions of newly certified ATs' preparedness in the transition to practice. Newly certified ATs perceive they are ready to transition to practice; however, their employers may not feel the same way. Having more research to be able to compare the perceptions would be helpful in developing better tactics such as formal orientations or assigned mentors that could benefit both employees and employers. Other research should focus on transitions in practice that are not initial transition to practice, but rather a transition to a new role in practice. This is a different transition to practice; however, it is not known if the ATs' experiences are the same or different. Despite the low percentage, the response rate was comparable to others in athletic training research with survey methodology. Nevertheless, the responses gathered in this research should be approached with caution due to self-selection bias.^29–32