Challenges Faced by Preceptors Serving in Dual Roles as Health Care Providers and Clinical Educators

Participants

There were 17 (3 males, 14 females) certified athletic trainers serving as preceptors in cohort 1. They came from 1 of 2 separate athletic training programs (ATPs) in the northeast region of the United States. This group represented both on-campus and off-campus clinical education sites. The participants had an average of 8 ± 3 years of clinical experience and 6 ± 2 years of experience as a preceptor. Thirteen of the preceptors worked at the college level. The remaining 4 worked at the secondary school level.

Twenty-four participants serving in the role of the preceptor were in cohort 2. These had an average of 9 ± 6 years of clinical experience and 5 ± 3 years of experience as a preceptor. Like the preceptors in cohort 1, they were employed in the collegiate (12) and secondary school (12) settings. Cohort 2 represented 7 CAATE-accredited ATPs from the East Coast.

Data Collection

Data collection began once institutional review board approval was secured, and occurred during the fall semester of 2011. Participants in cohort 1 were engaged in a recorded telephone interview, which followed a semistructured format. The interview guide was developed based on a review of the literature regarding preceptor development and socialization, and used open-ended questions (Table 1). Before piloting, the content was reviewed by 3 certified athletic trainers who were currently preceptors. The pilot study served to establish interview flow and question interpretability. Data from the pilot study were not included in the final analysis. All transcripts were transcribed verbatim by the researchers.

Table 1. Cohort 1 Structured Phone Interview Questions

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Participants in cohort 2 were asked to journal their responses and thoughts to a similar, but independent, set of questions via Question Pro, a secure Web site designed for research and data collection purposes. Data collection with cohort 2 began during the fall semester of 2011. Similar to the interview guide for cohort 1, we developed a set of questions based upon our experiences as instructors, our knowledge of the preceptor role, and the existing literature on professional development and socialization. The questions were purposely slightly different than those used in cohort 1 to triangulate the findings gleaned from the telephone interviews. This interview guide was also reviewed by a peer for content, writing style, and clarity of the questions. All changes were made before piloting and subsequent data collection (Table 2). Feedback from the piloting process also allowed us to make any final changes to the interview guide to enhance the clarity of the questions.

Table 2. Cohort 2 Asynchronous Interview Questions

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In contrast to the personal telephone interview used with cohort 1, the online data collection process used with cohort 2 allowed participants more time to reflect upon their question responses. It also gave us the ability to access a more diverse group of preceptors. This balance of depth from cohort 1 and breadth from cohort 2 provided data saturation across a diversified sample and allowed methodological triangulation to fully understand the participants' experiences.⁹

Data Analysis

We coded all transcriptions independently, and data were analyzed via a grounded theory¹⁰ and general inductive approach.¹¹ We borrowed principles from both strategies to help uncover the most dominant themes from the data sets, while allowing analysis to be guided by the purpose of the study. Data analysis took place in 3 distinctive steps. First, we read the transcripts in a general approach to gain a sense of the data. Second, comparable with the steps of open coding in a grounded theory study, we broke the data down into discrete parts and compared them for similarities. The final step combined the concepts of axial and selective coding by identifying major categories and subcategories and linking those major categories to one another with the intent of identifying central categories and themes.¹⁰ The 3 aforementioned steps were conducted independently by the primary researchers before comparing findings generated by the analysis process.

Data Credibility

We secured data credibility by including: (1) data triangulation; (2) multiple investigator triangulation; and (3) peer review. Data triangulation was accomplished by evaluating data from 2 separate cohorts of preceptors collected with 2 separate methodologies (telephone interviews and online asynchronous interviewing). The data collected by different means allowed for corroboration between independent sources. Data coding was independently completed by the first 2 authors following the grounded theory and general inductive processes as previously presented. The emergent themes and supporting data were exchanged between the authors for confirmation. The authors were in complete agreement before conducting the peer review. Our peer, an AT educator who was trained in qualitative methods and analysis through his doctoral studies, reviewed the final presentation of the findings as negotiated upon by the first 2 authors. The peer was provided with the emergent themes and supporting quotes for review as identified by the authors. Following the same analysis procedures, the peer confirmed the findings as presented. After the peer review, the themes were agreed upon and finalized by both authors and the peer.

Role Strain

Preceptors discussed the role strain that they often felt when trying to function appropriately as both educators and health care providers. For example, when asked about challenges that are associated with serving as a preceptor, Lauren stated the following:

I would say probably just having the time to just sit down and go over stuff that they [the students] specifically want to go over. We try to do that but sometimes it's really hard, especially during the fall term when we've got kids in here the whole time and then we have to get out to practice with folks. I really try to make sure that if they want to go over something we can go over that. But sometimes it's just hard to have that time to just sit down and do it.

Participants were also cognizant of the increased demands associated with serving as a preceptor. Sally shared, “Our jobs get harder and harder every year with the paperwork requirement. You know, the expectations of being a [preceptor] along with all the other things.” It appears that documentation of necessary paperwork, such as student evaluations, can be an additional source of stress for the preceptor, contributing to role strain.

The busy nature of providing health care to numerous patients made mentoring during real-time experiences difficult as well. Preceptors often spoke about a lack of ability to provide feedback to ATSs when they were completing evaluations. Janet summed up this theme by stating the following:

The biggest challenge is having time to do competencies and overseeing all the eval[uation]s that they do especially when I'm busy seeing athletes as well. It's always a challenge to observe eval[uation]s and make real-time corrections in hand placement, and so forth which I feel is really important.

Another preceptor agreed that primary role time constraints were an issue, as they often reduced the time available for clinical instruction and student-centered learning. He said, “On occasion, with my very busy schedule, I find it difficult to spend the optimal one-on-one time that I would like to spend with each student.” Despite their best efforts, preceptors did not always feel that they could meet all of the ATSs' educational demands and provide appropriate health care for their patients. This inability to devote themselves fully to both roles was often a source of frustration for preceptors.

Working Conditions

Preceptors indicated that their general working conditions made their roles as educators more challenging at times. Preceptors felt frustrated with their workload and lack of compensation, which made it difficult to approach their job with excitement and provide ATSs a valuable learning experience. One source of frustration was the volume of patients that preceptors were faced with as health care providers. For example, when asked about challenges associated with her career, Bridget stated:

The challenging part is the patient volume and the students can see that. It's not that hard to treat everybody, but obviously that treatment equals documentation. With treatment plus documentation, the volume is really the thing.

Terry, a preceptor serving in a traditional dual role as a clinician and classroom educator, added:

Being both a clinical AT and a professor, I believe the biggest challenge for me is to make sure I balance my time between doing class work and actually helping the students during their clinical experience. Instead of bringing work home with me, I sometimes get it done during practices, so that takes away from my time spent with the athletic training students. I think they understand, but it's still a frustration to me.

Long and unconventional hours associated with the job were another source of frustration for preceptors, which made it difficult, at times, to focus on educational tasks. Amy summed up the challenges associated with working as both an athletic trainer and preceptor with the following statement:

There are a lot of negatives. The hours are too long. We don't have enough staff. We're expected to pick up when other staff can't get their stuff covered. We don't get paid enough. Did I mention that already? There is no room to grow in the university setting. And, our jobs get harder and harder every year with the paperwork requirement. We have to deal with all of that in addition to the expectations of being a [preceptor].

Lack of compensation or incentive was discussed as another source of frustration. The time and effort necessary to be a good preceptor, although frequently rewarding, was often viewed as upsetting because of the lack of appreciation. One preceptor shared,

Lots of time and effort with no compensation. It adds to our workload significantly if you do it correctly and involve the students versus just letting them be wallflowers. Tuition assistance would be great, more variety of CEU [continuing education unit] options etc. Even better, being a [preceptor] should be worth CEUs!

This viewpoint of compensation was shared by several participants. Alison agreed that it would be nice to have CEU opportunities stating the following,

Honestly, [I wish I were] compensated for my time. I wish there were more opportunities for CEUs through the university. Taking classes would help with NATA recertification and teacher recertification.

Preceptors expressed frustrations with numerous aspects of their jobs. These frustrations were amplified, at times, by the demands associated with serving as a preceptor.

ATS Interactions

Athletic training student interactions, supervision, and motivation were other challenges discussed by the participants. For example, some preceptors struggled with allocating tasks or patients to ATSs as part of their learning experience. Mary, a younger preceptor, stated the following:

It was challenging to balance my role as a [preceptor] and my role as a newly certified athletic trainer. The tendency is to want to finally be able to have autonomy with your team but you quickly realize that you have to allow students to learn and engage in the athletic training process as well.

Charles agreed, indicating that his most significant challenge was “letting go of control and letting someone else handle the athletes.” Providing adequate supervision while still fostering an appropriate learning environment was another student-centered issue discussed by the preceptors. One preceptor said,

I struggle with the strictness of the direct supervision expectation. I feel like the AT students are not getting the full experience if we are constantly looking over their shoulders and acting like their “security blanket.” I've been dealing with that struggle for a few years and I understand to a point why the rule is in place. The AT is responsible for the well-being of the athletes, I understand that. I find other ways of letting the AT students make decisions. That way, their confidence grows and their ability to problem solve hopefully improves.

Whereas difficulty providing adequate supervision and timely feedback was discussed by a number of preceptors, others struggled when trying to determine how much autonomy to give their ATSs. One preceptor discussed his difficulties with allowing more hands-on skill integration during clinical instruction, saying,

I had to learn not to intervene during a student's evaluation, and to offer my opinions, insights, or critiques only after he/she had come to a conclusion about their assessment. I learned to deal with this when I realized that it is the best way for the students to learn.

A second challenge associated with student interaction was related to the individual personalities of preceptors and ATSs. For example, 1 preceptor, when asked about challenges in clinical instruction, shared, “[I struggle with] students that are not willing/able to get involved and do not learn from their mistakes.” Another preceptor also struggled with low ATS motivation levels. She stated, “[My challenge centers on] students [who are] not willing to give it 100 percent on their rotations.” Another preceptor discussed the development of relationships with their ATSs and navigating personalities. She said,

Some students are easier to work with than others. The most difficult challenge of being a [preceptor] is to figure out ways to get the very best out of every student. I want them to reach their fullest potential which can be difficult at times.

Another preceptor shared a similar challenge: “You have to learn that you aren't going to get along with every kid and get through to every kid. It doesn't mean you can't teach them, though.”

Role Strain

Despite caring for their ATSs and acknowledging the benefits associated with the reciprocal learning that often occurred,⁸ preceptors indicated that their role was not without its challenges. Role strain, consistent with the work of Henning and Weidner,⁶ occurred because of multiple roles within the workplace, and was the primary challenge for our participants. The clinical athletic trainer's role has been reported as stressful because of work hours, the patient-to-health care professional ratio,^12,13 and the challenge of balancing the conflicting responsibilities of clinician and educator.¹⁴ The time commitment for each individual role can be taxing; when combined, these time commitments can become overwhelming and lead to role overload or conflict.¹⁵

Our results indicate that because of the role strain that often occurred, providing appropriate feedback to students was a common challenge associated with serving as a preceptor. Feedback has been highlighted as important to the overall learning experience;¹⁶ therefore, student learning has the potential to suffer in instances where preceptors are unable to provide adequate feedback because of conflicting roles. Limited interactions with preceptors has also been shown to decrease clinical integration, which has implications for socialization and persistence of ATSs.³ Therefore, there is a need to identify strategies for making time to regularly interact with ATSs in meaningful ways. A portion of these interactions should focus on providing students with feedback that is both timely and constrictive in order to allow ATSs to engage more fully in the clinical education experience.

The role of educator also appears to complicate the job of the practicing athletic trainer at times, which has implications for burnout and job attrition.¹² Preceptors who are not satisfied in their jobs are less likely to make efforts to foster appropriate learning environments for ATSs. Preceptor dissatisfaction can lead to negativity, which could negatively influence ATSs' perceptions of the field and overall educational experience. Poor interactions between students and preceptors hinder education.¹⁷ Therefore, we speculate that preceptors who are not invested in their students' education are not well suited to serve as preceptors. It then falls to the clinical education coordinator to carefully select clinical sites and match students and preceptors thoughtfully. Among the preceptors who remain in that role, however, it seems important for them to continue to seek out ways to balance their roles as clinician-educators.

It is interesting to note that 9 of the 41 preceptors interviewed in the current study were masters-level graduate students, and therefore relatively inexperienced as preceptors. These preceptors had particular difficulty trying to navigate their way through having new job responsibilities, serving as clinical educators, and trying to find their professional identity. Difficulty balancing new responsibilities to patients and students often predisposes new preceptors to role strain.⁶ Furthermore, such challenges can lead to role incompetence,⁶ potentially decreasing the quality of the learning experience or damaging the preceptor-ATS relationship. Because the use of relatively inexperienced athletic trainers as preceptors does not seem likely to change, it is important for ATPs to pay special attention to their socialization and provide additional support when needed.¹⁸ Preceptors who feel supported as both clinicians and educators would be most likely to approach their roles with enthusiasm and positively affect their ATSs.

Working Conditions

Participants cited working conditions as another barrier to serving as effective educators for their ATSs. Despite advances in our profession and improvements in our salaries and working conditions,¹⁹ it appears that preceptors do not feel that they are paid the respect that they deserve, and that their salaries do not match their value as a health care provider and educator. Compensation and work overload have been linked to job dissatisfaction, a factor also contributing to burnout in athletic training.^20,21 Athletic trainers from numerous settings have reported moderate to high levels of stress and burnout.^20,21 The added responsibility of supervising ATSs can potentially increase an AT's stress level, which in turn can decrease job satisfaction.¹² Athletic trainers who struggle with their own working conditions might not be well suited to take on the additional responsibility of serving as a preceptor. Although preceptors are necessary to help ATSs develop a full understanding of professional demands,⁴ preceptors who do not cultivate a strong clinical learning environment risk ATSs' not becoming clinically integrated, which increases the chance of ATS attrition.³ Research has also indicated that graduates of ATPs are often frustrated by the perceived working conditions associated with professional practice.²² Athletic training students supervised by preceptors who struggle with their own working conditions are less likely to appreciate the positive aspects of a career in athletic training. In these cases, student learning and socialization may suffer, necessitating student removal from the clinical site. In cases where students remain in clinical placements with preceptors who do struggle with their working conditions, students could potentially benefit from infusing their own energy into the learning experience. Preceptors have indicated that working with students often motivates them and keeps the experience fresh and exciting.⁸ Therefore, preceptors and students working together to learn in a collaborative and exciting environment could overcome the negative aspects associated with some working conditions.

ATS Interactions

According to the CAATE standards, the requirements for direct supervision are as follows:

Students must be directly supervised by a preceptor during the delivery of athletic training services. The preceptor must be physically present and have the ability to intervene on behalf of the athletic training student and the patient.^5(p12)

Similar standards for direct supervision have been in place since 1987; however, elimination of the internship route to certification in 2004 caused the most dramatic change in supervision practices.²³ Despite the fact that these standards have been in place for many years, some preceptors still struggle with appropriate direct supervision practices. Numerous authors^23,24 advocate supervised autonomy, in which the ATS is allowed to provide patient care and make decisions, but the preceptor is still able to intervene as needed. Some of the confusion over direct supervision could be addressed during preceptor training and also during initial meetings between preceptor and ATS at the beginning of the clinical learning experience. Preceptors who have an understanding of the ATS's skill level, strengths, weaknesses, and goals will have an advantage when determining how best to supervise them. Being knowledgeable about the student's expectations and objectives will also help both parties form a stronger relationship, which is important to the overall educational experience.

Clinical education coordinators do their best to match up preceptor and ATS personalities in order to facilitate the development of an appropriate learning environment; however, our participants did report some difficulty forming working relationships with ATSs. Some preceptors perceived a lack of motivation among their ATSs, straining the learning relationship. This perception could partially be due to generational gaps between preceptors and ATSs, with more experienced preceptors expressing this perception more often than younger counterparts. Before educational reform, ATSs were required to complete a minimum of 1500 clinical hours to stimulate learning²⁵; now, clinical education emphasizes learning quality over quantity.²⁴ This shift in focus from counting hours to tracking educational outcomes may lead older preceptors to perceive their ATSs as unmotivated when they aren't physically logging as many hours as students did in the past. Current students are also burdened by higher academic demands on their time due to expanding competencies.²⁶ Although they may want to spend additional time at their clinical site, they may feel pressured to complete their academic coursework first and have difficulty balancing these competing needs. Preceptors who recognize that students may be preoccupied with academic requirements while completing clinical experiences may be able to help them budget their time and approach the experience with vigor, and ultimately improve the ATS-preceptor relationship.