Programmatic Efforts to Provide Progressively Autonomous Clinical Education Experiences
In previous research, athletic trainers (ATs) have identified the formal coursework and clinical experiences of their professional program as contributing to preparedness for autonomous practice. However, new graduates have reported a perceived lack of skills necessary for practicing autonomously. The purpose of this study was to evaluate how programs provide progressively autonomous clinical education experiences and the role of these experiences in preparing future ATs. Qualitative study. Virtual interviews. A sample of 17 program administrators (program directors = 12, coordinators of clinical education = 5) representing 16 master of science in athletic training programs participated in this study. Each program completed a virtual interview guided by a semistructured interview protocol. A 3-person data analysis team identified emerging domains and categories through a multiphase approach. Member checking, multiple researcher triangulation, and auditing were used to establish trustworthiness. Four domains emerged from participant responses: (1) curricular design, (2) preparatory experience and outcomes, (3) preceptor role, and (4) assessments. We found that intentionality in curricular design to promote progressive autonomy was beneficial in facilitating transition to practice through improved knowledge, skills, and confidence. Due to the importance of clinical education in AT preparation, preceptors played a critical role in creating opportunities for learning in the clinical environment. However, the degree to which experiences were autonomous and the effectiveness of the student in those encounters were rarely measured. Limitations outlined by participants included accreditation and program length. The development of knowledge, skills, and confidence through intentionally selected clinical experiences and guided by preceptor feedback are critical to establishing an autonomous practitioner. However, the program’s evaluations were predominantly traditional practice assessments and informal feedback, instead of an assessment of readiness for practice.Context
Objective
Design
Setting
Patients or Other Participants
Main Outcome Measure(s)
Results
Conclusions
KEY POINTS
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Opportunities for autonomy in clinical education play a significant role in transition to practice for athletic training students.
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Programs must develop autonomy through knowledge and skills learned didactically, which are then practiced and progressed through clinical education.
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Objective and validated measures are available in the literature and should be integrated to better assess readiness for autonomous practice.
INTRODUCTION
Professional socialization is a process by which an individual develops an understanding of the required knowledge, skills, values, and attitudes of a professional role.1,2 The professional socialization process is further divided into anticipatory and organizational socialization, both contributing to an individual’s ability to learn the roles and responsibilities of the profession.3–7 Recruitment into the profession and formal academic preparation are anticipatory factors that occur before becoming an autonomous practitioner. Within athletic training, anticipatory socialization occurs when a student is enrolled in an athletic training program and engaging in the clinical and didactic learning opportunities allowing them to advance their knowledge, skills, and abilities.3,4,6 Organizational socialization occurs after graduation when the newly credentialed athletic trainer (AT) is introduced to their professional role within a specific job setting with the goal of continuing within the profession.1,3,6,8 The period of time when an AT is moving from student to professional is referred to as transition to practice,9 a process critical in establishing professional identity and establishing oneself as an autonomous practitioner.9
The anticipatory socialization experiences provided by athletic training programs have been studied from the perspective of the student and the newly credentialed clinician.3,7,10 Key components of anticipatory socialization in athletic training programs include mentorship, diverse and immersive clinical education experiences, and guided autonomy.6,7,11 Early-career ATs identified their professional education as influential on their transition to practice.4,12 However, new graduates have indicated they may lack the necessary skills needed for autonomous practice including communication, decision making, and rehabilitation.8,10,11
Both didactic coursework and clinical education within athletic training programs contribute to the transition to practice period.4,12,13 Clinical education has been noted as the primary reason students are prepared for their career.6 Specifically, clinical experiences that encourage students to make clinical decisions and having been provided feedback were identified as being beneficial to their transition.4,13 Clinical education provides students with the opportunity to concurrently apply classroom concepts to patient care under the supervision of an AT.3,6 Clinical education is intended to improve students’ confidence and the ability to fulfill their role as an AT.6,10 Allowing athletic training students to engage in the roles and responsibilities of the profession with appropriate autonomy helps to facilitate student confidence.10 Furthermore, the ability to be progressively more autonomous in clinical education is critical for socialization to the profession of athletic training.3,10,12
An autonomous AT is able to make independent health care decisions per their credential, while practicing under and in collaboration with their supervising physician per regulatory guidelines.14 Standard 15 requires that a program’s athletic training clinical experiences and supplemental clinical experiences provide a logical progression of increasingly complex and autonomous patient-care and client-care experiences.15 With previous research having focused on transition to practice from the perspective of the newly credentialed AT and employers, there is a need for research within the programmatic perspective in relation to anticipatory socialization and the intentional creation of progressively autonomous clinical practice experiences.7,8,10,11 The purpose of this study was to evaluate how programs provide progressively autonomous clinical education experiences and the role of these experiences in preparing future ATs.
METHODS
Design
This study used a phenomenological design and was guided by the Standards for Reporting Qualitative Research.16 Semistructured interviews with program directors (PDs) and coordinators of clinical education (CCEs) were performed to assess the role of progressive autonomy in clinical education. This project was deemed exempt by the Indiana State University Institutional Review Board.
Participants
Participants were current PDs or CCEs at professional master’s in athletic training programs accredited by the Commission on Accreditation of Athletic Training Education (Table 1). To be included in the study, the PDs and CCEs had to have held their current position for a minimum of 1 year and their program of employment had to have graduated at least 1 class. Inclusion and exclusion criteria were evaluated through an eligibility screening tool hosted as a survey through Qualtrics.
PDs and CCEs for professional master’s programs were recruited to participate in the study via email. The email addresses used to contact PDs and CCEs were curated from publicly available information on institutional websites based on the list of Commission on Accreditation of Athletic Training Education–accredited master’s programs. The recruitment email included an invitation to participate, the informed consent document, and the eligibility screening tool. Follow-up emails were sent 2 weeks after the initial email. In total 240 emails were sent during the recruitment period. Participants who indicated they were eligible on the confidential screening tool and wanted to contribute to the study were contacted by the primary investigator (PI) for an interview. A total of 17 participants representing 16 programs completed interviews, at which time data saturation was met. Participants from 1 of the 16 programs specifically requested to have the PD and CCE for the program do the interview together, to best capture their approach to program delivery.
Instrumentation
The research team developed a 5-question semistructured interview script guided by the purpose of the study and previous research on transition to practice (Table 2).17 The interview script was developed by the PI (B.E.C.) and internally reviewed by 2 other members of the research team (J.P.Y., L.E.E.) with experience in athletic training education and qualitative inquiry (Table 3). The script was externally reviewed by 2 experts with athletic training education and qualitative research experience (E.R.N. and J.B.). Minor changes to the interview script were made in the sequencing of questions. However, no changes were made to the content. The PI piloted the interview script twice with individuals who met the inclusion criteria, but responses were not included in the analysis. No changes to the interview script were made after the pilot interviews. The interview script was guided by 2 themes: mentorship and progressive autonomy. For the purpose of this article, we focused specifically on progressive autonomy.
Data Collection Procedures
The PI provided participants with meeting information via email. All interviews were conducted over Zoom Video Communications, Inc, audio recorded, and transcribed using Zoom’s transcription software. The PI gained verbal consent from participants to record the interview both before beginning the recording and again after recording began. The interview script (Table 2) was used for the duration of the interview. By using a semistructured approach, the PI was able to ask participants for clarification or further information after the guided questions.18 The average interview period was 32 ± 7 minutes. The recordings and transcripts were deidentified and saved directly to cloud storage with multifactor authentication. Member checking was completed by the research team sending the participants their interview transcript via email and providing 15 days for each participant to verify the accuracy of the transcript.
Data Analysis and Trustworthiness
Data were analyzed using consensual qualitative research. Multiple measures were taken to ensure trustworthiness of the data, including member checking, multianalyst triangulation, and an external auditor. Once all the interviews were completed, 3 members of the data analysis team began reviewing interview transcripts using an inductive approach. The use of multiple reviewers in consensual qualitative research facilitates multiple perspectives while eliminating researcher bias.19,20 In the first phase of data analysis, 5 interview transcripts were independently read and reviewed by each member of the data analysis team (B.E.C., J.P.Y., L.E.E.). Each team member independently developed a domain list that accurately reflected the identified concepts within the data regarding progressive autonomy in athletic training education. The analysis team met to compare their list of domains to create the primary codebook. The primary codebook was then applied by each independent reviewer to 2 transcripts reviewed in phase 1 and 3 transcripts that had not yet been reviewed (Figure 1). The team met again to determine if the codebook accurately reflected both the old and new transcripts (Phase 2). Minor adjustments were made to the primary codebook through group consensus. To start the third phase, the PI (B.E.C.) applied the consensus codebook to all 16 transcripts. The coded transcripts were then divided between the 2 other members of the data analysis team (J.P.Y., L.E.E.) and checked for accuracy. A final meeting was held to ensure that each code was confirmed by two-thirds of the data analysis team. To ensure the trustworthiness of the data beyond member checking, we audited the analysis by sharing the interview script, consensus codebook, and 4 transcripts with an auditor (E.R.N.). The auditor determined that the consensus codebook was representative of the data and no changes were required (Figure 2). Interview quotes have been selected to substantiate the analytic findings. Frequency counts (Table 4) were calculated, and categorical labels were assigned based on how often a category was discussed as a group.20 Categories were assigned as general if identified in 15 to 16 cases, typical if identified in 8 to 14 cases, variant if identified in 3 to 7 cases, and rare if identified in only 2 or fewer cases.20
Citation: Athletic Training Education Journal 19, 1; 10.4085/1062-6050-013.23
Citation: Athletic Training Education Journal 19, 1; 10.4085/1062-6050-013.23
RESULTS
Two overarching themes emerged from the data, including progressive autonomy and mentoring. For the purpose of this article, we focused on the domains related to progressive autonomy: curricular design, preparatory experience and outcomes, preceptor role, and assessments. The frequency counts of coded domains and categories are provided in Table 4. Each theme is discussed with supporting quotes from participants.
Domain 1: Curricular Design
Participants indicated that curricular design was a way to facilitate progressive autonomy and therefore transition to practice. Specifically, 2 categories emerged among participants’ responses: using an integrated approach and the length of immersive experience.
Integrated Approach
Participants noted that both didactic and clinical education play a significant role in the development of an athletic training student. Derek stated:
I would say if you thought about athletic training education, our true intent is to prepare individuals for successful professional practice. I think in order to do that there has to be a lot of intent and intentionality behind how a curriculum is established in terms of the didactic component, but I think there also needs to be an equal amount of diligence and intentionality regarding individual students and the clinical assignments and their placement.
In both the didactic and clinical components, participants noted the importance of experiential learning opportunities being integrated into the curriculum. Standardized patients, simulations, and objective structured clinical examinations (OSCEs) were recognized as being intentional in providing students with practice experience. Tara commented:
It’s just giving students opportunities and experiences, so making it realistic. We do a lot of standardized patients and simulations so we can get students some of that experience. I think that’s how we tie that in, making sure it’s not just sitting and learning. Athletic training is a hands-on field. You can’t just sit in the classroom and learn and not practice and do things.
Many participants described how the curriculum intentionally progressed through their programs, moving from basic foundational knowledge to synthesizing concepts and skills over the course of the program. This multilayered approach was seen between semesters, but also between didactic and clinical education. The process of building upon knowledge and experiences based on the appropriate level of development is referred to as scaffolding.21 David described the use of scaffolding:
The whole idea of [clinical education and athletic training education] is just growing autonomy and each semester building on itself. So what we have in our program is a 5-semester program and really, the idea is, how does it grow from one sequence to the next, how do you use what you’ve learned last semester in the next semester and build upon that and within that then, how do you match up what you’re doing didactically with what you’re doing clinically.
Length of Immersive Experience
Participants explained that the value of the immersive experience, particularly exceeding the 4-week minimum, aided in the development of progressive autonomy. Elliot mentioned how a year-long immersive clinical experience prepares students to transition to practice:
As the student progresses in their experience and because they’re around for a full year of immersion, the students are actually getting more and more responsibility and transition to autonomous practice almost naturally. So that has been probably one of the biggest benefits of our immersion experience.
Participants described immersive clinical experiences as opportunities for students to gain exposure to all domains of athletic training and prepare them for independent practice. Ellie commented:
They’re understanding the full role of what a clinician does from the time they get there in the morning until the time they leave at night, and it’s really helped, especially, our new graduates who are coming into the field make that transition a little smoother. They understand what the responsibilities are for an [AT] because they have had to be one [in clinical education].
Having immersive experiences that parallel the reality of the profession was also noted by Casey, who said:
By the time they’ve graduated they don’t have that really, really steep learning curve of “I’ve only worked this job for 30 hours a week and covered practice and now here I am full time in the job doing 40 hours a week and I’m scheduling appointments and I’m running treatment sessions and things.” I think the addition of the immersive clinical rotation in our profession has allowed, or the requirement for it I should say, has encouraged giving them autonomy and then as a result made the transition to practice a lot smoother for our students.
Progressive autonomy can be helped through a program’s curricular design. Specifically, integration within the curriculum and the use of scaffolding can reinforce student learning and allow for more autonomous experiences. The immersive experience is supportive of progressive autonomy by allowing students to apply knowledge and engage in socialization.
Domain 2: Preparatory Experience and Outcomes
Participants acknowledged that the goal of progressively giving autonomy offered important preparatory experiences to develop knowledge and skills that led to confidence for students as they transitioned to practice. Clinical education experiences that offered progressive autonomy also offered chances to develop knowledge and skills and the confidence to perform them.
Knowledge and Skills
After establishing a foundational level of knowledge in athletic training, Olivia described how she encouraged students to engage with as many patients as possible:
I want them to get their hands on every patient or athlete that they can and get those patient [repetitions] in so they can build their confidence. They’re seeing all the things that they should see as an [AT] and that will, in the end, build their confidence, their critical thinking skills and decision-making skills. Those are the biggest ones for sure.
Melinda described how students can begin practicing skills early in their athletic training education:
Even as early as their first placement they’ve been taught how to take a history. So even if they can’t do anything else, they’re autonomously taking a history on every patient that walks through the door. Because through that independent practice being willing to make mistakes and learn from them is how we all grow.
Confidence
As students acquire and develop skills over the course of the program, they also begin to build confidence. Participants noted that with practice comes confidence, which will assist in the transition to practice after graduation. Abby explained:
They should start to feel autonomous as they’re going through, but ultimately in that final semester they should feel completely autonomous because if they don’t, then they’re going to lack that confidence. And then when they get out, and they hopefully get certified and go into that first job they’re going to be like “Holy cow. What do I do?” and they’re going to be really nervous and maybe question a clinical decision when they’re out there alone and they don’t have someone.
One of the contributing factors to building confidence reported by participants was the ability to practice in a safe environment. Penelope stated:
I think if students don’t utilize that safety net while they’re in their clinical experiences, they won’t have the feedback that they need to be able to move on as a clinician on their own. I think that one of the biggest things with transition to clinical practice is confidence, so I think in the clinical experiences and with those preceptors it’s vital that they work on their confidence and skills as they continue on in the program.
When provided with opportunities to engage in progressively autonomous experiences, athletic training students were able to improve their knowledge, skills, and confidence. These preparatory experiences and outcomes can facilitate transition to practice.
Domain 3. Preceptor Role
Throughout the interview process, preceptors were identified as being critical in offering progressive autonomy. This indicates a need to more intentionally select, prepare, maintain, and deselect those who did not provide progressively autonomous experiences.
Selection
For participants who described the use of specific selection criteria for prospective preceptors, a large emphasis was placed on experience, expertise, and setting, with some mention of autonomy. Emily explained:
We do want them to be certified for at least 2 years minimum, but we like them to be at least 2 to 5 years, so they’ve developed who they are as a clinician. You want them at their site for a minimum of 1 year. We also want to see what their contemporary expertise is to make sure that it matches with what we’re looking for each student, so we have [potential preceptors] fill out the table. And we also want to make sure that who their patients are match what our needs are for students… We want to make sure that the patients that they are seeing are a wide variety, but also that our students can engage their skills and learning and they’re not going to be flies on the wall.
Matching students to specific preceptors was also indicated as being important in facilitating more autonomous experiences over the course of the program. Casey stated:
I think our director of clinical education does a great job of assigning the clinical sites and picking and selecting preceptors that we know are going to give a student the autonomy that we’re hopeful they’ll get. It’s always based on what the student is interested in in the setting. We can really work, one on one, with the preceptors and make sure that the preceptors are understanding of the expectations that we have for the student.
For immersive clinical sites specifically, preceptor selection is important in ensuring that the site follows accreditation standards and there is appropriate autonomy for the student to engage in. Donald stated:
I think matching our second year [student]s appropriately with their preceptors and clinical sites to give them a little bit of autonomy is important. We try to guide that through our program.
Preparation
After selection, programs provide training for preceptors. Training can include a number of administrative tasks such as ensuring accreditation requirements of a site and preceptor are complete. Although preceptor preparation was described by all participants, specific training on appropriate levels of autonomy for students was infrequent and variable. Spencer outlined the steps taken by his program:
Utilizing articles again that address the timing and importance of transition to practice. We discuss teachable moments, knowing what the student is competent at during that point in clinical education and allowing autonomy with those skills/tasks.
Penelope described how her program incorporates ongoing communication to prepare preceptors:
We have videos that explain what progressive autonomy looks like. We also send [an email] each semester with the classes that the students have been in and the skills that we expect them to have done and we have the students give their current syllabi to their preceptors when they start their rotation.
Appropriate preceptor preparation is especially important for those students at immersive sites, who are expected to engage in more autonomous patient care. Casey described how:
The preceptor training differs depending on the type of rotation that the preceptor will be supervising. So, for the early integrated rotations it’s about [the students] observing and just exposing them to as much as possible. And if they get to participate in some stuff at the end that’s great, that’s a bonus. But by the immersive rotation it’s less about the exposure and more about [the students] doing it.
Maintenance and Deselection
Maintenance and deselection of preceptors is an ongoing process. Evaluations are one way to determine if a preceptor or site is used again. Ellie explained:
If we’re seeing some lower scores in certain areas on our preceptor evaluation, we will do either remediation or we will make the decision not to use that clinical site again.
When students are not able to engage in autonomy, Donald suggests having a direct conversation to address the concern. If there is no resolution, Donald stated:
The last thing is not being hesitant to remove a student from a clinical site or move the clinical site because a preceptor is not giving those [autonomous] experiences.
Due to the importance of clinical experiences, preceptors play a significant role in athletic training student education. Preceptor selection and preparation that facilitates progressive autonomy can best prepare students for transition to practice. Maintenance and deselection practices can ensure that students have autonomous experiences.
Domain 4. Assessments
Programs offered a range of methods to measure whether progressive autonomy was occurring in the clinical experience and whether students had sufficient opportunities to practice autonomously before graduation. Participants described the use of practice assessments and informal feedback; some used encounter-based metrics to assess student preparedness.
Informal Feedback
Informal feedback was often described as casual conversation with students checking in on how they were progressing. Informal communication between program administration and preceptors throughout the year to help facilitate student learning was identified by Caitlin, who explained:
We can have conversations with our preceptors about our experiences with the students and maybe identify certain weak areas. We try to get the preceptor as much information as possible about where the students are academically so they know where they should go with them.
Other forms of informal feedback came from the students themselves. Emily stated,
Honestly, autonomy comes out in conversation too just because [the students] kind of brag about it. I hate to say it, but they kind of do because they’re like “I ran out on the field into this!” Especially for the young first-year because they’re like “I got to do this,” which is exciting. I love seeing that in their eyes because they’re so excited about it.
Practice Assessments
Aside from informal feedback, practice assessments are another way that autonomy and the potential for transition to practice can be assessed. Practice assessments varied from evaluating professionalism to the use of the Athletic Training Milestones.22
Several participants identified the use of OSCEs as a practice assessment incorporated into the program. Aaron describes the OSCEs as a way to “get our students tested within a clinical experience.” Olivia further explained how they are strategically placed in the program’s curriculum:
One [OSCE] in their first year, and then the other one is in their second year right before they sit and take their certification exam. They are the 2 highest-stakes [evaluations] that we have in our program that looks at their autonomous practice.
Objective structured clinical examinations and standardized patients are also included in Spencer’s curriculum and measured by the Dreyfuss model, which is a model used to evaluate a student’s competence in autonomous clinical practice before graduation.23 Spencer stated:
We expect students to be at level 3 or competent prior to graduating for their clinical skills. We use simulation, high fidelity and low fidelity, and we also use standardized patients within our program, OSCEs, etc, to help develop skills that [students] may not be seeing clinically, like maybe cardiac arrest.
Rather than a thesis or project, Spencer assessed students through the creation of a professional portfolio that was a culmination of the previous 2 years of their education. He explained:
They highlight their patient encounters, how they’ve grown from day 1 as a new student to graduating as an entry-level clinician. They must display their quality improvement project and plan their professional development plan with 1-, 3-, and 5-year goals. They really must talk about their reflective medical practice and how that’s grown every semester. And then they do a final reflection of how they’re ready for transition to entry-level practice.
Encounter-Based Metrics
Encounter-based metrics were quantitative measures of the number and type of encounters ensuring sufficient opportunity for autonomy. One participant, Abby, described how “performed” competencies indicated autonomous practice whereas “assisted” competencies were when the preceptor was making the decisions and “observed” was just watching. However, there were no strict benchmarks set for student autonomy:
It’s not like I say, “Oh, you need to have 80% of your procedure codes at perform to graduate.” We don’t have a hard line like that.
Melinda, on the other hand, provided insight into how encounter-based metrics guided clinical placements for the program:
We use that data to give us metrics and when we determine if a site is a first-year site or a second-year site or an immersion site. Currently our immersion sites must be more than 65% independently performed patient care. First-year sites have less than 40% independently performed patient care. Those are the metrics from this last year, but we’ll look at that data again at the end of this year.
Another way that patient encounters were used to assess autonomy was through regular reflection and summary of a select group of encounters. This approach still used encounter-based metrics but was less clearly defined. Jason explained that he could check on student autonomy through monthly summaries:
We don’t keep track of every patient encounter, but we have students try and summarize their top 4 or 5 [patient encounters] for the month.
Measures to evaluate student autonomy varied among programs. Conversations provided informal feedback related to student experiences in clinical education, whereas standardized patients were one way of formally assessing readiness for autonomous practice. The incorporation of encounter-based metrics provided insight for student experiences at clinical sites, but its use was not consistent across programs.
DISCUSSION
As in previous research,4,12,13 our study demonstrated that allowing athletic training students to engage in appropriately autonomous experiences is important for readying them to practice. Participants broadly reported an intentional program emphasis on integrating progressive autonomy into curricular design. The use of scaffolding was indicated in multiple responses, either explicitly or implicitly. Scaffolding, a concept based upon connections between foundational and new material, is a means for knowledge and skill acquisition.24 The use of scaffolding in athletic training education is evident in the connection between didactic and clinical education as well as across the length of the program.25 Study participants also made connections between scaffolding and the resulting progressive autonomy through immersive clinical experiences. Specifically, immersive clinical experiences, beyond the 4-week minimum, were recognized as being influential in providing opportunities for engagement in progressive autonomy. The efforts to intentionally integrate progressive autonomy into both didactic and clinical education are congruent with previous literature indicating its ability to support the socialization process.6,26 Curricular design should include the intentional development of progressive autonomy over the program to best facilitate anticipatory socialization to the professional of athletic training. The use of scaffolding in curricular design provides students with repeated exposure to the knowledge and skills needed for the profession. Additionally, providing immersive clinical experiences with a longer duration could allow students to have experiences that mirror those of the profession.
Participants acknowledged the parallels between progressively autonomous practice in clinical education and the process of transitioning to practice. Progressively autonomous clinical experiences offered chances to develop knowledge and skills and the confidence to perform them. Participants stressed the importance of gaining experience through repetition. Student confidence was frequently recognized as the result of becoming progressively autonomous in performing skills required of the profession. Increased confidence over the length of a program is concurrent with the growth of knowledge and skills ultimately leading to the student being autonomous at the point of graduation. The environment in which students develop was noted as being particularly beneficial because it provided what many called a “safety net” to make mistakes and learn from them. Previous research12 has also identified that direct supervision between preceptor and students can assist in developing the student’s confidence and responsibility while still being able to intervene when necessary. Supervision should also be adapted to the specific student, allowing more advanced students to have more responsibility.12 Increased responsibility could lead to increased autonomy within clinical education. Programs should provide an environment in which students can implement skills in a stepwise progression ultimately leading to autonomous practice. Preceptor education regarding the didactic components of the students’ education and the progression of knowledge and skills over time could help facilitate appropriately autonomous experiences.
Preceptors play an influential role in the implementation of program design and the ability to offer autonomous experiences for students. The practice of preceptor selection, preparation, and maintenance is evident in all programs, though approaches vary. Our study indicated similar concepts to previous research indicating accreditation compliance and strategic choice as being the drivers in preceptor selection.17 However, there is a need for preceptors to have the qualities of an educator, professional, and leader, including providing adequate learning opportunities for students.27 Offering progressively autonomous experience was rarely recognized as a criterion for preceptor selection and was introduced rather through preceptor preparation, though still infrequently. Although a lack of progressively autonomous opportunities for students was noted as a means for deselecting preceptors, participants also described only a few ways their programs were objectively measuring this quality. Preceptors should be objectively evaluated to best capture the level of autonomy practiced by students. In many clinical education tracking systems, students denote when experiences are observed, directed, or autonomous, and this may offer the program information to drive preceptor retention.
Across program curricula, no singular measure was identified for evaluating autonomous practice before graduation. The use of informal feedback, practice-based assessments, and encounter-based metrics were most often described. Within health care education, competency-based education has been integrated to improve preparedness to practice.28 Entrustable professional activities and milestones are recognized as conduits to integrating competency-based education and measuring readiness for autonomous practice.28,29 Specifically within health care education, students need provocative moments in which they are challenged to engage in the practice of athletic training, including the decision-making required of patient care. These crossroads moments, part of self-authoring,30 align with the milestones for developing progressive clinical behaviors, those specifically detailed in the Athletic Training Milestones.22 The Athletic Training Milestones have been validated as an effective tool for assessing competence and growth of the knowledge, skills, and behaviors associated with being an AT.22 The Athletic Training Milestones can therefore be integrated into professional program curricula as an objective measure of an athletic training student’s readiness for autonomous practice,19 just as the Athletic Training Milestones can be used after graduation and throughout an AT’s career to maintain competence or develop as a specialist in the profession.19
LIMITATIONS AND FUTURE RESEARCH
Our study presents the perspectives of program administrators representing 16 athletic training programs with varying characteristics. Although generalizable, individuals who do not have an affinity toward preceptor development may not have been represented due to self-selected participation. Results of this qualitative study were from the perspective of program administrators and did not reflect the experiences of athletic training students currently or previously enrolled in these programs. Future researchers could evaluate current students’ perspectives on what their respective programs are doing to facilitate progressive autonomy and readiness for practice. Due to the importance of clinical education in transition to practice, examining the role that preceptors specifically play in offering progressively autonomous experiences may be advantageous. Future research could also analyze the perspectives of recent graduates regarding the impact of programmatic design on easing their transition to practice.
CONCLUSIONS
The transition from student to newly credentialed AT is critical for establishing professional identity and oneself as an autonomous clinician. Program administrators have identified the importance of progressive autonomy in helping future ATs transition to practice. Curricular design and program intentionality relative to preceptors created greater opportunities to ensure progressively autonomous experiences. However, programs predominantly used traditional practice assessments and informal feedback to assess student readiness to graduate, which may not effectively measure a student’s readiness for autonomous practice.
Methods flow chart.
Codebook diagram.
Contributor Notes