Meaning Making Among Professional Master's Athletic Training Students

Research Design

A constructivist-based, grounded theory methodology was selected for this study,^14,15 as the topic of meaning making among professional master's (PM) athletic training students had little exploration within the existing literature. Examining data through this lens allowed for a shift away from discovering a truth, as in a positivist paradigm, and toward a development of understanding.¹⁴

Recruitment and Participants

After we gained Institutional Review Board approval from University of Connecticut, we recruited participants by emailing program directors from 51 National Collegiate Athletic Association (NCAA) Division I PM ATPs requesting student participation. Division I ATPs were chosen as there were 51 PM ATPs listed in good standing¹⁶ at the NCAA Division I level at the time of recruitment, significantly more than in any other category (Division 2 = 27, Division 3 = 23, National Association of Intercollegiate Athletics = 5).¹⁷ Targeting PM ATPs at the NCAA Division I level provided a robust sample of the PM athletic training student population. Given that the NCAA division level is a key factor in the organization and scope of an institution's athletic programs, and, by extension, students' experiences related to athletic programs, it is a key consideration for transferability of these findings. Students enrolled in PM ATPs at NCAA Division I institutions will have experience in the Division I setting and are also likely to have experienced additional settings. In qualitative research, transferability involves the ability to apply the findings in new contexts and requires readers to gauge the degree to which the new context aligns with the context of the study.¹⁸ For this study, participants' meaning making of athletic training knowledge and skills occurred, at least in part, within the Division I context. Thus, the Division I context was a key contextual factor that influenced the findings of this study. Among the participating institutions, 3 of the PM programs had less than 6 years of experience operating at the graduate level, 2 had between 7 and 10 years, and 2 had more than 10 years. Twelve students were recruited. Participants verbally self-identified their age, sex, and race to establish demographic information. Participants were, on average, 24 ± 2 years old. Nine females and 3 males were recruited. Further participant demographics, including participants' pseudonyms, are included in Table 1.

Table 1 Individual Demographic Information

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All participants were in the fall semester of their second year of athletic training education. This selection was purposeful as researchers wanted students to reflect on learning experiences without potential influences of adjusting to the new role of a graduate student. All were engaged in various clinical experiences, many of which were further identified as immersive clinical experiences. The definition of immersive clinical experience was adopted from the CAATE 2020 standards:³ “practice-intensive experience that allows the student to experience the totality of care provided by athletic trainers.”

Data Collection

All participants completed videoconference interviews, guided by an interview protocol that was piloted and validated through peer review. The questions were designed to better understand participants' ways of making meaning. For example, the interview protocol involved not only asking a participant to identify a valuable learning experience, but also following up and allowing a description of how that experience affected the participant or influenced their thinking. Questions from the interview guide for more specific examples are provided in Table 2. Each interview lasted approximately 45 minutes, and all were conducted by the same researcher for consistency in the interview sessions among all participants. Field notes were taken during the interview (S.L.M.). These notes were taken when participants began to discuss topics they felt strongly about and resonated with them personally, as well as when the interviewer noticed developmental cues, to capture the interviewer's real-time interpretations of the described experiences. Examples of developmental cues were verbal cues such as “This experience made me think differently,” paraverbal cues such as hesitant speech or difficulty articulating thoughts, and nonverbal cues such as the participant appearing worried or anxious. These field notes accompanied the transcribed interviews for analysis. All participants were identified by pseudonym. An external transcription company transcribed the audio recording from all interviews, and participant member checking of transcribed interviews occurred before analysis.

Table 2 Sampling of Interview Guide Questions

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Data Analysis

Researchers (S.L.M., K.B.T.) analyzed the interview transcripts using a grounded theory approach, a method of qualitative research analysis, using constant theoretical comparison throughout data collection, affording comparisons at each stage of analysis.¹⁹ Line-by-line analysis of the transcripts was completed as an initial in vivo open coding process to identify and gain an understanding of each participant's experiences by assigning a word or label to specific lines of segments of the transcript, for example “confidence” or “hands-on.” Subsequent readings of the transcripts were completed to identify examples of ways participants were making meaning of those experiences through focused coding.²⁰ If a participant discussed an example of more complex meaning making, researchers further reviewed the transcript to explore the process or experience that prompted the deeper meaning making. The experiences that prompted deeper meaning making were initially termed “deeper understanding” and “thinking differently.” Researchers coded these responses as such if participants described them as transformative to learning, which is to say that an experience in a participant's education prompted them to think a different way or hold a new perspective.¹⁰ For example, if a participant used phrases like “I never thought of it that way before” or discussed using the mindset of a practicing clinician, those would be coded as a way students were making meaning. Codes were examined individually, compared with other codes from the focused coding phase, and grouped based on relationships to create categories.¹⁹ Further groupings and categorizations occurred to reduce redundancy until core categories emerged that were as holistically representative of the data as possible. For example, codes labeled “specific instructions,” “how to get an A,” and “tell me what you want” were grouped together and labeled “need for step-by-step guidance.” These groupings were examined to determine where the influence of meaning making was occurring. What emerged was 2 distinct categories: examples of meaning making that were heavily influenced by external authorities and examples of meaning making that were beginning to be cultivated from within the self. Once the researchers formed the codes and categories, the lead author consulted with existing literature on student development and found the resulting core themes aligned well with key tenets of the early phases of self-authorship development: following external formulas and the crossroads⁵ (Figure).

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Credibility Strategies

Three credibility strategies were used to establish rigor and trustworthiness. A coauthor of this manuscript (S.M.S.) with expertise in athletic training qualitative research methods provided a peer review of the raw data, coded transcripts, and subsequent categories and subcategories that the lead researcher developed. The review yielded agreement between the lead researcher and reviewer regarding the identified categories. A second coauthor (K.B.T.), an expert in self-authorship, completed triangulation to blend the athletic training education perspective with a developmental psychology perspective. The lead researcher (S.L.M.) also invited each participant to complete a member check by reviewing the full transcript and a brief synopsis of the interview; 3 participants provided the requested feedback. The responding participants confirmed the respective transcript and synopsis were true to their experiences. We used theoretical sampling during the recruitment process to allow for saturation to occur.²¹ Saturation occurred with 12 participants. Furthermore, the study was designed and evaluated in accordance with the COREQ²² checklist as a quality assessment tool.

External Guidance

Most participants (11 of the 12) described learning experiences in which they placed responsibility of knowledge on classroom or clinical educators, sought out approval from authority figures, and needed right or wrong answers, which were strong indicators of participants making meaning from external guidance.

Movement Toward Internal Guidance

Most participants (8 of 12) were able to make meaning on a deeper level and articulate not only which learning experiences were valuable, but also how those experiences were transformative to their learning. Participants demonstrated more complex meaning making by describing experiences that helped them build confidence and explore their professional roles and identities.

External Guidance

In the following external formulas phase of self-authorship development, students rely heavily on external sources, as supported by our findings in the external guidance category. Athletic training students look to their instructors to disseminate the essential information, they view knowledge as right or wrong, and they need approval from others to affirm their choices. Students in this phase are reliant on authorities for knowledge acquisition and do not possess the meaning-making skills to decide for themselves what is important to know. An example of this phase was found among the participants as needing a road map for success, a clearly detailed directive from the instructor about expectations for what the instructor deemed important. Students operating at this phase of development would likely prefer a more traditional classroom education model. This model is teacher centered: the educator states the information, the student memorizes it, and little practical application occurs. For a student following external formulas, the teacher-centered model of education perpetuates the perception that educators are responsible for giving knowledge; students are passive learners, and they memorize only the information the educator believes important. Although students may prefer this model of education, as detailed by our participant responses, it does not effectively promote their development because it does not challenge them to make meaning in more complex ways.

Participants voiced anxiety about lack of clarity from instructors about expectations or grading. This anxiety is consistent with making meaning in the following external formulas phase of self-authorship because individuals in this phase tend to be very concerned with how others perceive them, seek approval from authorities, and place heavy emphasis on tangible benchmarks, such as a grade. Although research questions for this study were not developed specifically to examine male versus female perspectives, the seeking approval theme appeared to be most prominent among our female participants, whereas the other themes were well represented by both sexes. Women often feel the need to prove themselves in college, as stereotypes exist supporting the belief that women are best suited for at-home childcare or traditionally female-dominated careers like nursing or teaching.²⁴ Women comprised the majority of the sample in this study, and it is not surprising that they sought approval from instructors, as literature supports women often have more difficulty developing confidence in their internal voice than men, especially men with other dominant social identities in terms of race, social class, sexual orientation, etc.²⁵ Legitimization occurs as students gain confidence in their emerging professional identity²⁶ and perhaps female participants' marginalized gender identity led to their having lower levels of confidence than their male peers and thus requiring a greater need for affirmation from others.

Traditional didactic delivery of content such as lectures with little to no student interaction does not allow for thinking partnerships and mutual construction of knowledge.¹¹ DelPrato¹¹ explained, “When students are never called upon to know, what is subtly communicated to them is that they need not question knowledge presented by authorities.”¹¹ Mitchell²⁷ stated that in order for students to develop new ways of making meaning, educators must progress away from giving answers to students and exercising authority over them. Instead, teachers must attempt to encourage questions from and share authority with students. Baxter Magolda¹ highlighted the need for educational practices to allow for students to change the question from “How you know” to “How I know.” Additionally, Baxter Magolda¹ concluded that learners had difficulty reaching self-authorship because they were provided formulas for success rather than experiences that allowed students to navigate challenges that fostered development toward knowing how they know (cognitive dimension), how to engage in authentic relationships (interpersonal dimension), and who they are (intrapersonal dimension).^1,11,28

Movement Toward Internal Guidance

Participants demonstrated more complex ways of meaning making when discussing their clinical experiences. The deeper meaning making was noted when participants mentioned clinical experiences helping them build confidence, practice autonomously, and wanting and/or appreciating performing the role of an athletic trainer. These responses demonstrated readiness to move away from following external formulas and closer to the crossroads, which is a developmental point at which students realize the need for internal guidance.

According to findings from this study, participants were able to move toward the crossroads phase of self-authorship by engaging in a learner-centered model as opposed to the previously discussed traditional teacher-centered education model.¹¹ Barr and Tagg²⁹ termed this shift as a change from an “instructional” paradigm, in which teachers tell students what they need to know, to a “learning” paradigm, which stresses the importance of designing active learning environments that promote unique idea development on the part of the learner. In a learner-centered model, students are encouraged to construct a point of view based on their own experiences and in collaboration with educators. Learners shift their thought process from knowledge being absolute, right or wrong, to understanding that many possible answers could exist. In clinical education, students can navigate these many possible answers through activities like injury evaluations. Gathering information from the exam and arriving at multiple differential diagnoses based on available evidence is an example of how students could begin to explore a learner-centered model in clinical education. They could then engage in meaningful discussion about their findings with their clinical preceptor or other students in the same clinical rotation. Educators working to foster self-authorship would not ask students to recite information from rote memorization, but instead would engage them in discussion of multiple perspectives.¹¹

In athletic training literature, confidence has been cited as an important factor to address, as it can increase student motivation for learning.³⁰ Active learning strategies in athletic training education, such as problem-based learning, game-based learning, and flipped classrooms, are supported as ideal teaching strategies to foster soft skills³¹ like critical thinking, problem-solving, and confidence, especially among PM athletic training students.³² In adjacent literature related to confidence, researchers suggested individuals with more confidence would be less likely to become discouraged when faced with obstacles.³³ Additionally, gaining confidence is critical to self-authorship development, and oftentimes success breeds confidence. Creating opportunities for success while challenging a student could be transformational to their learning and allow them to view their world with a deeper, more complex perspective. The participants described examples of being afforded opportunities to build confidence and examples of how they built their confidence through their clinical experiences. Similarly, confidence of a clinical preceptor was viewed by students as a helpful clinical teaching characteristic. Observing confidence may in turn allow students to practice developing their own confidence. Modeling desirable attributes of an athletic trainer for students, such as confidence, could allow them to envision their future and to better develop their role identity. This modeling of professional behavior, confidence in particular, was identified in the literature as the most helpful category of clinical instructor characteristics in student learning as perceived by students and preceptors.³⁴

Geisler articulated the importance of helping students to construct a professional identity by noting,

Allied health educators need to go beyond teaching their students how to “do” athletic training, nursing, or medicine … but teach aspiring healthcare providers how to “be” athletic trainers, nurses, and physicians by modeling expert practice, and teaching them how to think like duly experienced clinicians think.³⁵

Development of a professional identity role fits most directly within the intrapersonal dimension of self-authorship. Exposing athletic training students to practicing clinicians can help foster professional identity development through opportunities to become partners in practice with a focus on problem-solving, reflection, and discussion.³⁶ Surrounding athletic training students with experienced clinicians may help foster aspects of self-authorship, such as challenging learners to be independent thinkers while still affording the opportunity to mutually construct knowledge with experts.³⁷ The outcomes of a focus on self-authorship are highly positive for both the learner and educator, as described by Baxter Magolda:

Students consistently report learning a great deal about themselves, collaborating effectively with others, learning to critically analyze multiple perspectives, and self-authoring their own professional beliefs. Faculty also report continuing learning from their mutual partnerships with students.²

Recognizing and Fostering Development

Combining the results of this study with existing literature on student development, it is apparent that if educators effectively recognize the developmental level of their students, they can in turn identify and implement effective educational practices that provide an appropriate balance of challenge and support for students. For example, if a student is operating in the following external formulas phase of self-authorship and views the responsibility of knowledge on authorities, providing that student with an assignment that requires self-exploration of knowledge may be ineffective or perceived negatively, because it creates too much challenge. Negative perceptions of coursework could potentially lead to frustration, lack of effort, or placing blame on the educator for their failures. This is not to say that educators should not challenge students, as challenges are shown in the literature as a catalyst for a shift in meaning making³⁸; however, instructors should use their best judgment on knowing how much to push and when to pull back. Some educators may currently be untrained in recognizing meaning making in their students. Specific to this study, the results showcase that educators should lean in on experiences that promote building confidence and role identity development, especially when a student begins to display cues associated with arrival at the crossroads. Sometimes these cues from the student are verbal (“I was surprised…”), but more often the cues are paraverbal (speech becomes hesitant) or nonverbal (the student appears nervous or worried).¹³ The educator should probe the student with follow-up awareness questions such as “Why does that surprise you?” in an attempt to allow the student to acknowledge this crossroads experience and practice grappling with conflicting information. Further, the educator should allow for a reflective period, formal or informal, soon after an awareness-raising moment. The educator could engage in discussion about how the student will use this new information in the future, setting the stage for the learner to construct their own meaning of the event and future applications to practice. The medical educator should provide feedback that is timely and related not just to outcomes, but to the process as well. Educators hoping to align their own practices with strategies for promoting self-authorship should consider the following questions²³:

1. What characteristics do your students bring to your environment?

2. What experiences do you offer?

3. How can these experiences be tailored to students who are externally defined to promote their growth?

4. How can these experiences be tailored to students who use a mixture of external and internal self-definitions to promote their growth?

Ultimately, the development of knowledge for an athletic training student often begins in the classroom and extends to the clinical setting. Many of our participants (7 of 12) were on the edge of external guidance, beginning to explore a deeper level of meaning making at the crossroads. Based on these findings, classroom and clinical educators alike should consider ways to spark deeper meaning-making opportunities. For example, to encourage new ways of knowing, an educator can provide multiple sources of information, as opposed to one textbook. Highlighting established peer-reviewed journal articles with different results or types of research for a given topic, incorporating diverse guest lecturers with unique perspectives or real-world experiences, finding examples of injuries or case studies that do not have a clear-cut right/wrong answer, and allowing students to discuss the merit of multiple perspectives is also beneficial for deepening meaning making. This practice aligns well with an evidence-based practice approach to education in that students are not relying on only one source (the instructor) for their information, but instead are able to triangulate multiple data points for the same topic or concept and evaluate which sources of evidence are strongest. Additionally, educators can encourage as much variety among instructors' and clinicians' viewpoints as possible and provide opportunities for critical thinking. For some students who are still following external formulas, this can be challenging; however, an educator can demonstrate an example of how they move from point A to point B through asking themselves a series of questions, talking about each consideration made along the way before allowing students to perform a similar task in groups, and then on their own. Asking students to reflect on the things that were valuable about that exercise and how they can use that skill in future clinical practice (or their current clinical experience) can be beneficial for students who are ready for deeper meaning making but might need extra support before being developmentally ready to handle that type of autonomous thought processing.