Student Selection of Preceptors for Immersive Clinical Education Experiences Through an Advocacy Lens

KEY POINTS

• Immersive clinical education experiences allow programs to overcome geographic proximity challenges when selecting and deselecting preceptors.

• Programs should empower students to identify preceptors and clinical sites that best meet their needs.

• Historically marginalized students can identify preceptors who are best suited to provide mentorship for their future in athletic training, whether that be someone who shares their demographic characteristics or an advocate-mentor.

INTRODUCTION

The Commission on Accreditation of Athletic Training Education (CAATE) requires professional athletic training programs to integrate an immersive clinical experience into their curriculum.¹ The CAATE defines the immersive clinical experience as “a practice-intensive experience that allows the student to experience the totality of care provided by athletic trainer.”^1(p58) The immersive clinical experience must be a minimum of 4 weeks in length (Standard 16)¹; however, programs have the autonomy to decide how to best structure their clinical education experiences to align with their programmatic framework. Some programs are providing students the autonomy to choose preceptors and clinical sites that meet their future career goals, learning outcomes, and personal needs.²

An underlying tenet of the immersive clinical experience is to provide the student with an opportunity to progress toward autonomous clinical practice. To achieve autonomous learning, students must engage both cognitive and metacognitive strategies to understand their individual motivation, knowledge, and attitudes about learning.³ As educators, we have the responsibility to serve as facilitators of these cognitive and metacognitive processes to help students identify their specific learning needs and give them agency to advocate for themselves as learners. Motivation is also an integral component of self-directed learning and includes both intrinsic and extrinsic factors.⁴ The student's autonomy to choose a preceptor and clinical site provides an opportunity to engage intrinsic motivation in selecting a learning environment that may meet their specific needs.

Previous research^5–7 in athletic training education identifies the importance of preceptors in providing mentorship, exposing students to a realistic athletic training environment, and facilitating the application of didactic content in clinical practice. However, historically clinical sites and preceptors are selected based on their proximity to the institution housing the academic program.⁸ This may be particularly challenging for athletic training programs housed at institutions in rural areas of the country, where potential preceptors are likely found on their own campus or in local high schools. Program administrators may choose to use athletic trainers who meet the CAATE requirements of a preceptor and are regionally close out of convenience, without considering how well the preceptor facilitates learning for students.⁸ Previous research⁸ suggests that preceptors are deselected when they place students in harmful situations, such as when a preceptor has been disrespectful of the student's time or left the student without supervision for a period of time. Choosing to consider preceptors and clinical sites outside of an institution's own geographic area allows students and program faculty to identify preceptors who are invested in teaching and mentoring students. Additionally, students can consider more than just geographic location and clinical setting when pursing an immersive preceptor. Rather, they can identify a preceptor whose life experiences align with their own.

Historically marginalized students, also referred to as “minoritized students,” in other health care professions have noted the importance of finding mentorship in a person who mirrors their own demographics.^9,10 More specifically, LGBT (lesbian, gay, bisexual, transgender) trainees noted a number of benefits of having an LGBT mentor, such as having safe interpersonal space in which mentees can be themselves, having a mentor who is sensitive to LGBT concerns, developing a peer network of LGBT personnel from whom to seek out advice, and having a shared understanding of life experiences.⁹ In addition, in medicine students from historically marginalized racial groups reported¹¹ the lack of a race-concordant mentor-mentee relationship as a barrier to their success. Students commonly reported feeling that they had to explain their culture to their mentor.¹¹ In instances in which a historically marginalized student is unable to identify a mentor who aligns with their demographic characteristics, identifying an advocate-mentor may be a feasible alternative solution. An advocate-mentor is an individual who possesses societal privilege (eg, race, gender), and chooses to actively advocate for their mentees in meaningful ways and more broadly for social justice.¹²

Preceptors play an integral role in shaping the clinical education experience and have the opportunity to create an inclusive space in which the students feel welcomed, valued, and supported in their growth and development as athletic trainers and humans. Students must be equipped with the tools to identify the individual characteristics for a potential preceptor that will meet their educational and personal needs as learners. Therefore, the purpose of this educational technique article is to describe a curricular design for empowering students to choose preceptors and clinical sites that meets their needs.

EDUCATIONAL TECHNIQUE DESCRIPTION

Grand View University is a small, private, liberal arts, primarily white institution in an urban setting in the Midwest. The Master of Science in Athletic Training program comprises 4 semesters, and while clinical education runs concurrently throughout the 2-year didactic program, the immersive clinical experience spans the entire second year of the curriculum, or 32 weeks. Program faculty begin having conversations with students about this experience during the recruitment and application process. However, a majority of the development for selection of a preceptor and clinical site for the immersive clinical experience begins in the fall semester of the student's first year. The purpose of starting the discussions about this process early is to allow sufficient time for affiliation agreement negotiation to occur. Approximately 7 to 8 weeks into the fall semester, the students receive an immersive clinical experience packet. This packet includes an overview of the programmatic goals, learning goals, and deadlines for the immersive clinical experience (Table 1). The Clinical Education Coordinator discusses the specific sections of the packet and answers any questions the students have at that time. The immersive clinical experience packet provides an overview of the specific expectations the students will be required to meet during their immersive clinical experience (eg, types of patient encounters, volume of patient encounters, average weekly hours), the logistical processes for identifying and selecting a clinical site, and copies of documents (eg, preceptor agreement).

Table 1 Immersive Clinical Experience Site Process Timeline

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A few weeks after this initial meeting, the Clinical Education Coordinator schedules meetings with each student to discuss the preceptor/clinical site selection process and to have an individualized conversation about each student's specific needs. Before this meeting the students are prompted to consider the following questions: (1) What things have your preceptors done that have helped you learn?; (2) What things have you disliked about how your preceptor engages you in clinical education?; (3) What type of learning environment do you need to be successful?; and (4) What are your future career goals? In these discussions, the program also identifies any personal or financial preferences the students may have regarding the specific location of their immersive clinical experience (eg, staying in a specific area because of a partner/significant other's job; moving to a specific area to live with family or friends; cost of living for a specific area of the United States). Students, specifically students from historically marginalized populations, often share their desire to find a preceptor who reflects them and who shares similar demographic characteristics. Once the Clinical Education Coordinator has an idea what region(s) of the country the student is considering, what type of clinical site the student is interested in, and the specific preceptor characteristics desired by the student, the program works to help them identify some specific sites. This requires accessing the program's network of connections in various areas and/or connecting with colleagues to describe specifically what the student needs to help generate a list. The Clinical Education Coordinator also encourages the students to look through their desired regions to identify potential sites.

By the end of the fall semester, the students are required to submit a prospective list of potential preceptors and clinical sites. They are not bound to this list, but from a program planning perspective, this list allows the program to understand how many students will be pursuing new affiliation agreements in order to appropriately allocate administrative resources. For students pursuing an immersive clinical experience with a new preceptor and clinical site, the program provides them a specific set of questions that they must ask their prospective preceptor, and students are encouraged to ask any additional questions that will help them identify if the preceptor is a good fit for their learning needs. The key is to take time to explain why the specific questions that have been generated are important and then also to use the information from the fall discussions to provide suggestions for additional things the students should be asking based on what they value. By late January, the students must submit the answers to the questions, as well as all the CAATE-required preceptor and site paperwork (proof of BOC certification, state credential [if necessary], National Provider Identifier number, site emergency action plans, and site policies and procedures). The Clinical Education Coordinator then verifies the paperwork and reviews the responses to the questions to identify any “red flags” from the preceptor. For example, responses that center on students as a work force raise immediate red flags and prompt a meeting with the student for further understanding of the conversation and potential deselection/encouragement to pursue a different clinical site. This area is a red flag for the program because it indicates that the preceptor is looking for additional help to carry the load of the clinic, which may not be centered on the student's learning opportunities. It is expected that the responses will address how the preceptor and/or site will facilitate student learning and progression toward autonomous clinical practice. The Clinical Education Coordinator will then follow up with the student to discuss the materials and share concerns relative to the red flags. Unless a clear CAATE accreditation problem or an unsafe learning environment is identified, the student will be allowed to explore the relationship with the preceptor and clinical site. The Clinical Education Coordinator will work to mentor the student and encourage them to consider what might be seen as a red flag and/or help them to identify whether that red flag will be a barrier to future success. The program also works with students to weigh the pros and cons of a particular site and/or preceptor based on the initial preceptor conversations. The programmatic requirements for clinical education in the second year are reiterated, and the student is asked to reflect upon whether these requirements are achievable based on their conversations with the potential preceptor.

If the student fails to submit the paperwork because of a challenge with preceptor communication (particularly over the winter break) or changes their mind because of the red flags identified through the interview, we allow additional time for them to reach out to a new preceptor and collect all the paperwork to continue to allow the student to pursue a site that meets their needs. The program aims to be transparent throughout the entire process about the status of paperwork and continuously communicates that the student could be placed in an already-established clinical site if timelines are not reasonably met. To date, this program has not had to do this, but there was one instance in which the student was set to move across the country in 2 days and the affiliation agreement had not been signed. This is the reason for the late May deadline—to ensure that students have the time to find and secure housing wherever they are located in a timely fashion. The program does not want to have to require students to move back to the area last minute if an affiliation agreement does not get signed. The student is typically carbon-copied on every email exchange regarding the affiliation agreement, so they know the status of the agreements. This is done for 2 specific reasons: the first is to limit the questions about the status of the agreements, and the second is to access the students as a resource in the communication, as they may be able to better remind both sides to progress.

For the students who are pursuing an immersive clinical experience with an already-established preceptor and clinical site, interviews are set up with the preceptor(s) and student(s) early in the spring. Students are encouraged to ask similar questions of preceptors that target their specific learning needs and goals. This interview for existing sites helps keep the processes equal in the experience for students. The students have the same opportunity as a learner to practice their interviewing skills and to advocate for their needs. After the interviews have been completed the Clinical Education Coordinator communicates with the preceptor(s) at the site to determine the site's capacity for students and to identify which students they would like to select. At the time of this writing, there has not been an instance in which the site did not have capacity for the number of students that were interviewed, and thus far there has been no instance in which a preceptor does not think a particular student is a good fit.

If a student initially indicates they wishes to pursue an immersive clinical experience outside of one of our established clinical sites but fails to meet the established deadlines in January and/or does not communicate their challenges, they are required to choose from an established clinical site. To date, this has never happened, and the program remains optimistic that it will not have to place someone autocratically because the student failed to meet all expectations. Students have been invested in this process because they see it as an opportunity to pursue a learning environment that aligns with their future goals.

To date, 2 cohorts (13 students) have completed this process of identifying prospective clinical sites and preceptors for immersion. Of those 13 students, 8 have completed the process of establishing a new clinical site, while the remaining 5 completed the interview process for an established site. While there has not yet been formal assessment specific to the process, students' feedback has been overwhelmingly positive. Previously, in the initial 2 years of the program, students were placed at immersive clinical education sites based on their desired career goals, but they were not involved in the decision-making process. The students were dissatisfied with that process and had concerns about travel distance to clinical sites and alignment with preceptors. Since the implementation of the student-centered process, students have not expressed dissatisfaction with the placement process. Students like the flexibility of identifying a site in an area that aligns with their goals and that can potentially help them save on cost because they are able to live with friends and/or family. To date all students have been able to successfully meet the learning goals and objectives of both clinical education courses that span the immersive experience. Programmatic policies are in place, regardless of the route to site selection, to terminate a site in the event that a student is not able to meet their goals as the result of an unsafe learning environment.

CLINICAL ADVANTAGES

The process of student identification and selection of a preceptor and clinical site with program faculty input and guidance has increased student and preceptor investment in the students' learning process as well as buy-in from the students during their immersive clinical experiences. Specific quotes from students and preceptors can be found in Table 2. The comments from students align with the goals of self-directed learning in that they have increased motivation to engage in their immersive clinical experiences because it aligns with where they see themselves as future clinicians. Preceptors also noted increased engagement because of the students' ownership of their patient case load and their desire to approach each experience as a learning opportunity. Students also have the agency to advocate for both their professional and individual needs when considering their clinical education site. Some students start with their professional goals, such as clinical practice setting, patient population, and level of competition, before considering personal factors. Other students begin by looking in regions where they have friends/family, where cost of living is lower, or that align with their demographic characteristics. While both routes have different intrinsic motivations for the student, the importance of allowing the students to identify their own needs and lead the process allows for a student-centric clinical education opportunity.

Table 2 Alumni and Preceptor Feedback About Immersive Clinical Experiences

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The foundation for this process is 2-fold: (1) to facilitate student advocacy for their personal and professional needs and (2) to support historically marginalized students in finding demographically concordant or ally advocate-mentors in their immersive preceptors. Much of this is part of the hidden curriculum of the program, by facilitating opportunities for students to practice advocacy skills at varying levels throughout their learning. From the beginning of this process, it was emphasized that the student plays an active role in describing their needs, asking targeted questions to ensure the preceptor and clinical site align with those needs, and in developing the network and mentor-mentee relationship young professionals need to effectively transition to clinical practice. This process aligns well with students approaching graduation who are considering what jobs they will apply for, what questions they will ask their interviewers, and what types of environments they want to work in. The students get the opportunity to practice self-advocacy throughout the process of identifying potential sites and selecting a preceptor, which is believed to be essential to their future success as athletic trainers.

In a previous study,¹³ students indicated a desire for clinical education experiences that include diversity, equity, inclusion, and social justice concepts. Empowering students to pursue immersive clinical experiences with preceptors who possess the skill sets to effectively integrate these topics into learning is essential. Black female athletic training students noted¹⁴ that identifying a Black role model on the faculty or staff at their institution was important to supporting their success in athletic training. A student-centric clinical education opportunity may allow historically marginalized students to pursue mentor-mentee preceptor relationships that are concordant with their own personal demographics. Alternatively, these students can identify an advocate-mentor in a preceptor. This could decrease the cognitive load that historically marginalized students carry as they spend time thinking about their safety and explaining their culture or lived experiences, allowing them instead to refocus that attention to their learning in the clinical environment. Giving students the autonomy and agency to have choice in their preceptors and the locations of their clinical sites also provides historically marginalized students in regional areas that lack diversity the opportunity to gain experience and grow in an environment that may better align with their needs. Research¹⁵ suggests that historically marginalized students see the value of identifying mentors with similar demographic characteristics because they are able to develop an ally, lean on their mentor (who may have had similar life experiences to what they are now facing), and allow the student to create a network outside of their own institution. Programs that are facilitating this type of process may also use this technique as one of the ways in which they are compliant with DEI Standard 1.¹

This educational technique allows students to advocate for their needs as a learner and identify a preceptor who can meet those specific needs. Programs have the responsibility to provide feedback, input, and oversight. Students are encouraged to consider the enthusiasm of the preceptor and/or other officials at the site and to think about the language those at the site are using relative to the students' development. Previous research⁸ suggests that Clinical Education Coordinators often identify preceptors based on accreditation compliance and geographic location. However, we must help students identify a quality preceptor regardless of a program's proximity to the geographic location. As a profession, we need to deselect preceptors who place students in harmful experiences within their learning environment.⁸ We must continue to pursue and help develop preceptors who are devoted to patient care and the development of the students they are precepting.

Program administrators have a responsibility to provide preceptor development that improves the preceptor's abilities as a clinical teacher. Preceptors report⁷ much of their training is centered on programmatic policies and accreditation requirements, along with learning from what others do as preceptors. Preceptor training, particularly that for immersive preceptors, should go beyond surface-level policies and instead focus on how the preceptor can expand on being an effective clinical teacher and mentor in order to support student persistence and retention in athletic training.^16,17 Preceptors have noted^5–7 their role as mentors and their importance in helping students to see the full picture of athletic training clinical practice. However, we must adjust our training to ensure that preceptors have the tools necessary to be effective clinical educators to ensure the optimal learning environment for students, especially for the immersive clinical experience.

CONCLUSIONS

The CAATE requirement for immersive clinical education experiences allows programs to be innovative in their curricular design and to minimize some of the prior barriers to selection and deselection of preceptors and clinical sites. This educational technique encourages programs to facilitate student advocacy through a process of identifying preceptors who meet the students' learning needs, including mentorship; facilitating progression toward autonomous clinical practice; and aligning with future career goals. These components are essential to a successful immersive clinical experience. Historically marginalized students may be most advantaged in this type of clinical education model because they can identify preceptors who mirror their own demographics, promoting their persistence and retention in higher education. Programs that are using a process whereby students select their own immersive clinical sites and preceptors should consider the lens through which they are establishing their approach. Supporting historically marginalized students in their identification of a demographically concordant preceptor may be one strategy for programs to demonstrate compliance with DEI Standard 1.¹