Barriers to Scholarship Integration in Professional Athletic Training Programs and Resources Needed to Overcome Barriers: A Report from the Association for Athletic Training Education Research Network

Culture

Participants identified that, if their institution did not promote a culture of research and scholarship, it was particularly challenging to try to build such a culture in the program. Participants also recognized that the differences in university culture exist in part based on institutional philosophies that differ in focus on either teaching or research, and some suggested that this impacts the ability to even attempt to require a student to participate in certain types of research. Lastly, participants identified that, institutional culture notwithstanding, the role of the student and preceptor are significant contributors to the development and maintenance of a culture of scholarship. A lack of preceptor and student interest in research was a deterrent for some programs to even require research activities. Our participants felt that, without preceptor and student interest, the cultural void was difficult to reverse.

Buy-In From Stakeholders

It was noted by many participants in our study that buy-in from stakeholders was a challenge, one that precedes the challenge of attempting to build a culture of scholarship, as the culture cannot be developed without buy-in. Buy-in, as described by our participants, is the commitment to complete the entirety of the project, the motivation to actively participate in the process, and an appreciation for the impact or relevance of the findings of the activity. Participants identified a need for the buy-in of the importance of scholarship and research from students at all points and preceptors in cases where scholarly activities are assigned to occur at clinical sites. Buy-in has been sought from students and preceptors by reframing the idea of research and scholarship from the perspective of its influence on patient care. Specifically, participants felt that if they could tie research that the students were required to perform to their clinical experiences, then preceptors would become interested in participating because the benefit to the patient might be more visible. Some of our participants did note that buy-in from preceptors specifically seemed to be influenced by the age or experiences of the preceptor: younger or more recently graduated preceptors were exposed to more evidence-based practice and research in their professional programs, but older or more experienced preceptors were resistant to evidence-based practice or research because they might not have been as comfortable with it. Some also noted that student buy-in appears to be influenced by the culture of the institution, which was already identified as another challenge because, if students were not seeing research being conducted by faculty and other graduate students, they were reticent about having to participate themselves.

No Clear Expectations

Participants indicated a lack of clear expectations as to what constitutes scholarship as a challenge that they face in incorporating it into their curriculum, especially considering that not every student has the same capabilities to meet high research expectations, such as independently conducted complete research projects. A few of the program administrators we spoke with were still teaching at the bachelor's level and were planning to incorporate more scholarship once they elevated to the master's level, but still had not identified a clear expectation for what their scholarship requirements would be.

Overall, our participants felt that there were expectations of the program to deliver scholarship outcomes in a tangible way, but without explicit requirements from either their institution or the accrediting body on an outcome, this became a challenge. The educators we spoke with interchangeably discussed scholarship and research as synonymous activities and did not identify with one type of activity or the other. Typically, our participants indicated that, despite a desire to include scholarly activities in their program, they had no clear plan for how to do so, thus could not relay clear expectations to their faculty and students.

Time Intensive

Some of the program administrators that we spoke with clearly recognized that to implement scholarship into a professional program was going to take time on the part of the program and faculty and that scholarship done well could not be accomplished in a single semester. Both time in the curriculum and faculty time were typical issues identified during our interviews. Multiple participants noted that, at the master's degree level, scholarship expectations needed to increase and that students might struggle to meet those time-intensive deadlines. Participants already at the master's level felt the 2020 Commission on Accreditation of Athletic Training Education curricular content standards included many new standards that will take more curricular time and limit available time to include scholarship or research. Other participants pointed out the time commitment of the faculty to participate in scholarship with the students was prohibitive, and most faculty were already operating on a full load. Overall, the time in the curriculum and the time spent by faculty to mentor and guide research projects were highlighted as challenges that programs face or expect to face at the master's degree level.

Faculty Load or Expertise

Our participants acknowledged that, in addition to faculty time, there is a challenge associated with finding faculty who have expertise in conducting research or scholarship, and even if you do have the expertise, those faculty may not have the availability in their assigned teaching load to oversee multiple projects. Participants also pointed out that, even if you have faculty expertise, faculty are already loaded with other job requirements, so the addition of mentoring students through a project almost had to occur within the faculty member's research area to make the project mutually beneficial. Some agreed that it was challenging to find faculty with the expertise and available workload to mentor and oversee the amount of scholarly activity that is necessary for a student to become proficient at understanding and completing a research process. It is important to note, relative to this theme, that participants responded based on the experience and expertise of their program as a whole, not just their own experience in conducting scholarship. There also appears to be some connection to this theme with the availability of time as well as a need for a culture of research within the institution.

Institutional Support

Institutional support was suggested as a potential resource to address the challenges of culture, stakeholder buy-in, and faculty load and expertise. As mentioned within the challenges section, participants noted that institutional focus on teaching or research has the potential to affect the amount of support of scholarship that a program can expect, as well as the students' access to mentorship and expertise. Library services provided by the institution were also identified as quintessential resources for completing scholarship projects. Our participants primarily acknowledged that institutional support was imperative when it comes to overcoming the challenge of faculty load and expertise, especially in the case of pretenure faculty or when there may not be enough tenure-track faculty. Overall, institutional scholarly expectations, the hiring of qualified, trained faculty, and the provision of mentorship and adjusted faculty workload were forms of institutional support resources that our participants felt would be the most useful in implementing scholarly projects into their curriculum.

Culture

Participants identified that the lack of research culture at their institution created a challenge to the implementation of scholarship within their curriculum. Our participants described professional development in research and scholarship for faculty and support and encouragement for student involvement in research and scholarship as necessary to build an institutional culture. This aligns with findings in emergency medicine education programs, whereby Bandiera et al¹⁵ noted that universal challenges were repetitively identified. Specifically, insufficient training of faculty in research design and methodology, inadequately protected time from other institutionally required responsibilities, lack of funding, and lack of mentorship for faculty were barriers to integrating scholarly activity in medical education programs.¹⁵

It has also been found for nursing and pharmacy faculty and university hospitalists that those who received mentorship and support from their institution had increased scholarly productivity compared with those who did not receive adequate mentorship and research training.^16–19 Very similar to our participants, nursing faculty identified that an institutional climate of scholarly productivity was necessary for support within their program. Nursing faculty specifically identified perceived support, job satisfaction, mentorship, and organizational efforts to facilitate their research as the seminal components of an institutional climate that facilitated research production.¹⁶

The Hanover Research Group has developed a best practice guideline to address the specific issue of building a culture of research.²⁰ The Hanover group identifies that a culture of research is necessary for faculty productivity and success and that culture begins from the top down. Some recommendations guide the building of such a culture, and these necessitate institutional and department level leaders to set clear expectations for research for faculty and students, communicate those expectations clearly and consistently, and develop an accompanying mechanism of evaluation to determine achievement of research goals. The report goes on to recommend that, if research is a clear goal and expectation of faculty, then job descriptions and teaching expectations should be adjusted to accommodate this workload accordingly.²⁰

Of particular note, the questions posed during the interview portion of this study specifically asked about the inclusion of scholarship, and almost all of our participants equated scholarship to research. It seems highly plausible that the challenge of building a culture of research stems from a lack of understanding from many athletic training educators that scholarship does not have to be done in the form of research, especially if the institutional structure is not one that facilitates research.

It is clear from our findings that a culture of research is necessary for athletic training programs to adequately incorporate research components into their curriculum, and this culture clearly must begin higher in the institutional administration. Faculty who teach within athletic training programs at institutions that more highly value teaching or service in the evaluation of faculty for promotion or tenure will likely continue to face this challenge until such a culture is adopted across their respective institutional administrations. Programs at those institutions might be better directed at considering forms of scholarship that do not fall under research specifically.

Buy-In From Stakeholders

Our participants identified that buy-in, primarily from preceptors and students, was a substantial challenge that they faced. Relative to preceptor buy-in, the program administrators we interviewed specified that preceptor age was a contributory factor to the level of respective buy-in on scholarly activities being conducted by students at their clinical sites. Previous research noted similar findings in nursing preceptor buy-in, citing the age of nursing preceptors as the cause for the lack of buy-in, and attributing the lack of buy-in to the nonexistent research requirements and concepts of evidence-based practice in the curricula from which they graduated in the past.²¹ This sentiment can be found in physical therapy and athletic training literature, both identifying that these continue to be barriers to the inclusion of evidence-based practice into clinical practice.^8,22 Recommendations to overcome this barrier include providing access to journals and other resources to preceptors and attempting to bridge the gap between research and practice to make the research outcomes more relevant to clinicians.^8,22

In addition to the challenge of getting preceptor buy-in, our participants struggled to get student buy-in to the research or scholarship process as well. Students in medical education have previously cited lack of time allotted in the curriculum, unreasonably high expectations, lack of mentorship or faculty oversight, and a paucity of acknowledgment for their contributions as the rationale for their negative perception of research or scholarly activity.⁷ When asked after completing a research project, medical students often had positive characterizations of their experience; they concluded that the experience benefitted their clinical practice and contributed to the achievement of their career goals.⁷ Much like our participants, the struggle of buy-in consistently appears before the start of a research project, but might be overcome by the time of completion. Programs could benefit from having students nearing the completion of a research project speak to incoming students about the positive attributes of their experience, and that may increase initial buy-in.

A lack of trained faculty mentors may also contribute to the lack of student buy-in. Medical education had found that students are motivated to participate in research projects by the prospect of increased faculty interaction.⁷ Those findings are further supported by the Hanover Research Group's recommendations for building a culture of research. The Hanover group explicitly identifies that student involvement in research is imperative to develop an institutional culture, but that student involvement requires faculty mentorship and guidance to develop student confidence and research abilities.²⁰ This sentiment is echoed by another study in medical education that determined that faculty supervisors were necessary to encourage and motivate students to participate in research.⁸ Additionally, a study in athletic training education found that the requirements of a thesis or structured research requirement were correlated with higher first-time Board of Certification pass rates, and although this study was conducted on a small number of graduate-level professional education programs, this could serve to motivate buy-in for faculty and students.²³

Student and preceptor buy-in might also be influenced by the confusion surrounding the interchangeable use of research and scholarship. Programs including research projects or theses might see better student buy-in due to structured and clear expectations. Because scholarship can take many forms, this may contribute to the challenge of not having clear expectations, but might also eliminate the negative connotation that students and preceptors can at times have toward research and the impression that it is not relatable to clinical practice.⁵

No Clear Expectations

Our participants felt that, although some form of scholarship should be a component of their curriculum, they struggled to pin down what the appropriate outcome of that experience would be. Diamond et al²⁴ characterized the challenge of expectation as a struggle for this current time in academia, in that more mainstream adoption of Boyer's⁶ model of scholarship successfully increased the view of what scholarship is, making it tangible to those who struggled to meet the more narrow definition of original research, but it also made the target outcome of that model vaguer and less definable.

Connolly et al⁹ pointed out that, similar to the 2020 Commission on Accreditation of Athletic Training Education Standards, standards for accreditation in physical therapy require components of evidence-based practice throughout entry-level curricula, but the standards do not have an explicitly stated minimum outcome. As mentioned previously, our participants used scholarship and research interchangeably and synonymously when discussing program requirements; therefore, it would stand to reason that, if program administrators and educators were not differentiating between the two, it would be difficult to expect students to as well.

Participants in our study also indicated that deciding at which point the student's participation in a project is sufficient for a scholarly activity to be considered completed can be a challenge; this uncertainty has also been documented in the existing literature. An early study of graduate-level professional athletic training programs identified that 91% of the programs studied required either a thesis or structured research project before graduation, but only 9% of those programs required a presentation of the project's findings at a professional venue.²³ Educators in pharmacy presented a similar dilemma in deciding if publishing a manuscript should be a required outcome. What happens to the student's ability to complete the program if the revisions take more time than the student has left in the curriculum or if the manuscript is rejected?²⁵

To address the challenges surrounding expectations, we should refer back to the Hanover Research Group's recommendation. In the context of building a culture of research at an institution, that institution, department, and programmatic leaders must set clear and concise research goals and communicate those effectively to faculty and students.²⁰ It is important to note that, historically, accrediting bodies of health care programs have not identified requisite outcomes concerning the incorporation of scholarship or evidence-based practice into curricula, so it falls to the institution to do so.^1–3,8 As a result, faculty should exercise this freedom to consider which aspects of scholarship align with their programmatic goals and use the opportunity to include forms of scholarship that address challenges at their particular institution. Specifically, this is an opportunity for faculty to examine the benefits of activities such practice-based research or quality improvement to meet the scholarship goals they have established.

Time Intensive

Participants identified that research, especially done well, takes time and there were 2 particular areas of time commitment that were significant: time needs for the students and time demands for the faculty. The faculty we spoke with were concerned about the time it takes for a student to develop and complete a full research project and whether the 2-year master's curriculum is sufficient to accomplish that. This concern is not unique to athletic training education. Pharmacy faculty have specifically noted that one of the biggest challenges to completing a scholarly activity within their curriculum is the ability to select a project that can be completed in the time that a student is in the program, especially with the unpredictability of the time needed to complete institutional review board review and approval.²⁵ This same barrier has been cited in medical education, with more than 70% of medical students indicating that the lack of time specifically set aside to complete such projects was one of the largest barriers to completing research while in a professional education program.⁷

The time demands on faculty to mentor and motivate students through a scholarly activity were not lost on our participants. Multiple interviewees noted that they limit the number of students they accept into their program as a result of this challenge. The perception of this challenge is not unfounded, and it may influence the challenge of student buy-in as well. Although Al-Ghamdi et al⁷ found that student time was indeed a barrier to student research participation, the lack of faculty availability for supervision and mentorship was the number 1 barrier to student desire to complete a research project as a component of their professional education. Many educators across multiple professions have identified time as one of the largest barriers to promoting and supporting research activities among their students, and time is a barrier to completing research in general.^{21,26,27–30}

The Hanover Research Group states that reduced teaching loads must be implemented if an expectation of scholarly production is a component of faculty expectations.²⁰ Fairweather³¹ said that, “for most faculty members, generating high numbers of student contact hours diminishes publication rates and vice versa.” Bland et al³² echoed that finding, stating that faculty with fewer teaching hours tend to produce more research. The barrier of time availability for faculty is one best mitigated by institutional policy and practice, and addressing this barrier will likely allow faculty to further address the issue of time for students as a result.

Faculty Load or Expertise

Not surprisingly, our participants acknowledged that, in addition to faculty time, there is a challenging barrier associated with finding faculty, across all program faculty, who have expertise in conducting research or scholarship. They also noted that, for the faculty who do have the expertise, the time barrier does once again come into play, as the limited faculty with research expertise cannot be expected to oversee entire cohorts worth of projects, especially if those projects do not contribute to the faculty member's research agenda.

The barrier of finding faculty with expertise to supervise student scholarship has been identified in other health care education programs. In medical education, nearly 85% of medical students identified the lack of capable professional supervisors as the primary barrier to conducting scholarly activities while in education programs.⁷ The lack of well-trained, research-active, mentors in health care education is one of the most pervasive barriers cited by students as a limiting factor to their ability to complete research activities during their professional education programs.^7,8,15 Students identify the mentorship from expert faculty members as the most motivating factor in their desire to participate in research.^7,15 This highlights the need for not only the training of faculty to be prepared to mentor students but the release in load to increase their availability to conduct such mentorship. There is a documented inverse relationship between teaching load and scholarly productivity for faculty, so if there is a programmatic expectation of scholarly productivity of students under faculty mentorship, it stands to reason that the faculty member's teaching load must be reduced to accommodate that.^15,20 The findings of our study are consistent with the existing literature; our participants perceive a need to develop skill and expertise at conducting and mentoring research projects, and they recognize the need for an adjustment in teaching load to complete such activities.

As professional athletic training programs transition to the master's degree, programs will be required to have a minimum of 3 core faculty members, an increase from the previous requirement of 2 core faculty.^1,33 Some of our participants stated that their programs were specifically looking for faculty members that could aid in the distribution of student scholarship mentorship. It stands to reason that many programs that will be hiring a faculty member to meet this minimum may consider hiring faculty based on their competence and expertise to mentor students through scholarly activities. Bandiera et al¹⁵ had previously noted that, for scholarship requirements to be successfully achieved in medical education, accumulating a critical mass of faculty scholars is essential. This may be amplified even more in master's athletic training programs because such programs will typically span 2 academic years, and this will require faculty accustomed to completing projects in a timeframe much shorter than a typical dissertation project. Doctor of Nursing Practice (DNP) programs have discerned this exact challenge in attempting to have DNP students complete a scholarly activity in a relatively short timeframe as compared to the typical PhD student dissertation project. Such DNP programs have determined that the ability of faculty to conduct such projects is instrumental to the success of the students.¹⁶ If athletic training programs do not have existing faculty researchers or do not have a culture of research institutionally that supports the development of faculty researchers, then they may need to consider this need for future programmatic hiring decisions.

It has also been identified that students in health care programs who are successfully mentored through a scholarly activity are better prepared to do the same for students they oversee in the future, and those who enter into faculty or mentorship roles without research training are ill-prepared to guide students through that process.³⁴ Athletic training programs that invest in research-trained faculty or who invest in the development of existing faculty to create active experts in conducting and mentoring scholarly activities may have long-lasting impacts on not just the use of evidence-informed clinical practice, but the generation and dissemination of future practice-based research. By allowing expert faculty to mentor student scholarship activities, those students who graduate from such programs will likely be more prepared to conduct scholarly activities and supervise students conducting such activities within their own clinical practice in the future.

The Hanover Research Group recommends that institutions support the mentorship and continuing education of faculty to best promote a critical mass of expert faculty scholars who can then mentor and educate their students in a similar way.²⁰ Faculty at athletic training programs that are planning to implement scholarship opportunities for students should seek continuing education opportunities to develop their research and mentorship abilities.

Institutional Support

Our participants felt that several of the barriers identified, such as faculty time, load and expertise, and the lack of a culture of research within the institution, could be addressed through institutional support mechanisms. This finding is echoed in medical education, in which the enablement of the ongoing success of scholarly endeavors pointed to supportive administrators, including department chairs and mentors, the provision of faculty development programs, and the administrative support of faculty through protected time, financial support, and access to expert assistance.¹⁵

Especially in institutions that emphasize teaching aptitude in the hiring and promotion process, it has been well established that faculty with little to no research experience will require training and support to become proficient.^20,35 Additional protected time and load is also necessary if faculty are expected to relay that expertise to students' scholarly experiences.^20,35 Development of faculty scholars is quintessential to developing scholarly activities in health care education programming that students partake in and benefit from.^7,8,15

Our participants specifically identified library resources as another component of the resources needed and used to facilitate student scholarship, specifically identifying the librarian's expertise in teaching the process of searching online indexes and abstracts to their students. One study of a university library found that more than 90% of graduate students use the library sometimes or often, but only about half of them ask the librarian for help or information.³⁶ A study on data information literacy found that graduate students had not received much, if any, formal training in data mining or data management and were left to their own devices to figure out mechanisms of literature review and data analysis.³⁷ Programs attempting to incorporate scholarly activities should seek out library support services as institutional resources available to students and encourage students to take advantage of librarian expertise and availability during the scholarship process.

Collaborative Research

Our participants felt that collaborative research was a mechanism by which they might overcome the challenge of faculty load and expertise. Specifically, they felt as though collaborative research opportunities, both within their institution and across institutions, would allow for a better spread of expertise and student mentorship load, which might make scholarly activities more attainable. The Hanover Research Group indicates that an important component of an institutional culture of research is the establishment of intentional collaborative relationships among faculty members.²⁰ Bland et al³² found that research productivity within an institution is influenced by the provided availability of a vast network of colleagues with whom they have substantive research interactions.

Associated findings show that, institutionally, improved collaboration on research projects corresponds to improved collaboration in other areas as well.²⁰ The supposition could be made that, by demonstrating collaborative scholarly activities to students during their professional education, this could improve upon collaboration in clinical practice areas as well, although this has yet to be proven. Participants alluded to this prospect when they spoke about creating point-of-care research activities to promote buy-in by both students and preceptors. This concept is reiterated in medical education research which suggests that the student, faculty mentor, and any other parties involved in conducting the research project sit down and discuss project ideas that they are passionate about, which in turn influences that enthusiasm with which such projects are completed. However, this study did not include preceptors, nor did it measure collaboration in clinical practice.³⁸

A few of our participants felt that students might benefit from collaborating with students from other programs if their mutual requirements and expectations were similar. It should be noted though that, in surgical education programs, additional challenges arose from attempting to conduct collaborative research projects with students. Participants of collaborative projects felt that the variability in institutional review board coordination and a variety of institutional research cultures made it challenging for faculty and students to conduct collaborative research projects.³⁹

Publicly Available Examples or Resources

Lastly, our participants felt that having the opportunity to view publicly accessible examples of what other programs have successfully achieved in terms of scholarly activities would be beneficial to their program pursuits. In emergency medicine, the recommendation has been made to promote and encourage the use of networks, digital or in person, that allow for the championing of innovative techniques or to help education programs answer important education questions.¹⁵ This has the potential to not only increase collaborative opportunities but allow for programs to identify mechanisms that other programs have found to be successful.

One such mechanism would be through the use of Athletic Training Education Journal education technique manuscript submission.⁴⁰ The author's guide indicates that this type of publication should “explain the advantages and disadvantages of the technique in comparison with other techniques,” which might achieve the outcome our participants desired. Other mechanisms to publicly disseminate successful integration of scholarly activities within an education program might include educators' conferences, Web-based learning communities, and purposeful, cross-institutional collaborative partnerships.¹⁵

The lack of clarity for our participants as to the difference between research and scholarship gives greater strength to the need for public examples of all types of activities. As program faculty are determining whether to include research or scholarship, this might be an ideal opportunity to consider quality improvement activities that would be considered scholarship but that also influence clinical practice. In that same vein, a more thorough consideration of practice-based research is warranted for programs seeking to overcome the barriers of buy-in from preceptors and students. Resources are publicly available that describe some of the scholarship options that align with practice-based research.⁴¹