Newly Credentialed Athletic Trainers' Perceptions of Their Transition to Practice

Participants

Inclusion criteria were having passed the Board of Certification (BOC) examination between the months of January and September and being currently employed as an AT full or part time. The survey was completed during October and November, which included the participants' first 3 months of employment. We chose that time frame to capture individuals who had 3 months of work experience. We recruited participants via an e-mail from the BOC that was sent to all 1835 ATs who were certified between January and September; the e-mail was distributed in October to capture the newly credentialed ATs. Participants who were not employed as ATs were excluded from the study. After removing surveys that were incomplete or from individuals who did not fit the inclusion criteria, data from 332 participants (18% response rate) were analyzed.

Procedures

The Ball State University Institutional Review Board approved this study. In mid-October, an e-mail was sent by the BOC to those ATs certified between January and September. The e-mail contained information regarding our purpose, the inclusion criteria, an invitation to participate, and a link to the survey. Reminder e-mails were sent 1 week and 2 weeks later to increase participation rates. Those ATs who qualified for the study and were willing to participate completed the survey on the online platform Qualtrics (Qualtrics Lab, Inc, Provo, UT) using the Web link located in the recruitment e-mail.

Instrumentation

We developed the survey using results from interviews with supervisors of newly credentialed ATs,¹¹ interviews with GA ATs,^12,13 and the previous literature²² examining the transition to practice of medical students. The survey was part of a larger instrument that also examined orientations provided to newly credentialed ATs.¹⁴ The construct items were developed through an iterative process, with the research questions in mind. We reviewed qualitative research^11–13 examining the experiences of ATs, from both GA ATs' and supervisors' perspectives, to develop questions related to orientations and the transition to practice. Using these questions as a guide, we adapted questions from a validated survey examining the transition to practice of medical students.²² The questions were grouped into constructs based on the transition-related topic developed from the earlier studies (ie, comfort level, mentorship and support, or organizational transition). The instrument was then reviewed by a statistician and 5 athletic training educators with experience in survey research for content validity, and minor modifications were made. The instrument was pilot tested with 7 newly credentialed ATs for clarity, and minor modifications were made. Internal consistency for each section of the survey was established using a Cronbach α (comfort level α = 0.79, mentorship and support α = 0.83, and organizational transition α = 0.77, values that demonstrated good internal consistency). The minimum target sample size of respondents was 148, which yielded a power of 0.95 for detecting a large effect (f = 0.40).²³

The survey consists of demographic questions (eg, age, gender, employment setting, type of professional program), questions related to the individual's current role (eg, orientation provided, mentor provided, policies and procedures manual provided), and 3 constructs with questions related to the individual's feelings and experiences during the transition into the new role (eg, ability to adapt to the role, feelings of nervousness, access to a mentor, and understanding of organizational policies and procedures). Additional questions at the end of the survey asked if the individual had ever considered leaving the profession of athletic training. The 3 transition-to-practice constructs examined were feelings of comfort, feelings about mentorship and support, and feelings about the organizational transition. The comfort construct consisted of 9 questions that addressed the feelings and comfort levels of the new ATs as they made the transition from students to independent practitioners. The mentorship-and-support construct contained 5 questions that explored the support and mentorship the new clinician received from his or her supervisor or assigned mentor. The organizational-transition construct had 4 questions that investigated components of the transition to the organization and the level to which the new AT felt he or she was oriented to the organization. Questions in the 3 constructs asked the participants to indicate their level of agreement with statements related to their feelings on a 4-point Likert scale (1 = strongly disagree, 2 = disagree, 3 = agree, 4 = strongly agree).

Data Analysis

Data from the survey were analyzed using SPSS (version 23; IBM Corp, Armonk, NY). Descriptive statistics (frequencies, means, and standard deviations) were calculated for each individual survey item. Mann-Whitney U tests and Kruskal-Wallis (H) tests were used to determine if differences in characteristics (eg, supervisor, work setting, and job title) affected how the newly credentialed ATs were oriented into their role and their feelings and perceptions regarding their transition to practice with respect to each construct. The level of significance was set at α < .05. A Bonferroni correction was used to account for multiple comparisons. Independent variables were work setting, job title, assigned supervisor, receiving policies and procedures manual, duration of orientation, and perception of whether orientation prepared the participant for the role. The dependent variables were feelings and perceptions regarding transition to practice for each of the 3 constructs: comfort level, mentorship and support, and organizational transition.

Comfort Level

The majority of participants either agreed (48%) or strongly agreed (31%) that they were nervous at the beginning of their job and that the transition from student to independent practitioner was stressful (68.1%). Despite being nervous and having a stressful transition, most new ATs felt well prepared (78.7%) and ready to begin (81.7%) their job. The majority felt comfortable and ready to communicate with patients (85.9%) and other staff members (80.2%) but not as well prepared to communicate with physicians (70.8%; Table 2).

Comfort levels did not differ among settings (H = 5.64, P = .228), job titles (H = 4.88, P = .087), whether the participant was assigned a mentor (U = 8593, P = .121), whether the participant's supervisor was an AT (U = 10 988, P = .937), types of professional programs (U = 6488, P = .279), or number of ATs in the setting (H = 21.21, P = .325). The duration of the orientation process had no effect on comfort level (H = 7.96, P = .336). However, those who felt orientation adequately prepared them for their roles had higher comfort levels than those who did not (U = 7717.5, P < .001). Respondents who received a policies and procedures manual when beginning their role had higher levels of comfort than those who did not (U = 7285, P = .024). Participants who identified they were more likely to consider leaving the athletic training profession reported lower comfort levels (U = 12 934, P < .001).

Mentorship and Support

Most participants (79.2%) agreed or strongly agreed they could go to their mentors or direct supervisors anytime they had questions and 78.6% also felt their supervisor genuinely cared about their transition. However, about one-quarter of supervisors and mentors (27.6%) did not provide resources to address challenges or assist in the transition to professional practice. The majority of participants (74.1%) felt they had peer support to help with the stress of their job (Table 3).

Mentorship and support did not differ based on job setting (H = 7.62, P = .106), job title (H = 2.801, P = .833), or number of ATs in the setting (H = 23.72, P = .207). Respondents who were assigned a mentor reported better perceptions of mentorship and support (U = 6250, P < .0001) and were less likely to consider leaving the athletic training profession (U = 12 311, P < .0001). Men experienced greater feelings of mentorship and support than women (U = 9325, P = .024). Feelings of mentorship and support and the comfort level were moderately positively correlated (r = 0.50, P < .001).

Organizational Transition

A slim majority of participants (54.3%) felt their supervisor adequately explained administrative procedures during the orientation process; however, most (75.7%) felt they were adequately oriented to the values and beliefs of the organization. Participants demonstrated better perceptions of organizational transition if they received a policies and procedures manual (U = 7129.5, P < .001), felt the orientation adequately prepared them for their roles (U = 4039.5, P < .001), and were assigned a mentor (U = 7821, P = .004). Job setting (H = 7.37, P = .118), job title (H = 11.53, P = .073), athletic training supervisor (U = 11 692, P = .351), and the number of ATs in the setting (H = 24.11, P = .192) had no effect on the transition. Respondents who had better perceptions of their transition were less likely to consider leaving the athletic training profession (U = 12 065, P = .007; Table 4).

Comfort Level

The comfort level of newly credentialed ATs was similar across settings, job titles, types of professional programs from which they graduated, and duration of orientation as well as whether they were assigned a mentor. This shows that despite all these variables, new clinicians had similar feelings when entering their new roles. Although they felt prepared, new clinicians also felt nervous to begin their roles. This is not surprising given that interviews with newly credentialed ATs revealed many were excited to begin their careers, and even though they may have felt nervous, they also felt prepared for their roles.¹ New ATs are practicing independently for the first time and are responsible for making the ultimate decision for the first time.¹ Having the ultimate decision-making power is nerve racking and stressful. This nervousness was not limited to new ATs; new nurses also faced challenges when making patient care decisions.²⁴ As newly credentialed ATs transition, many feel they know what to do, but it takes time and practice to develop confidence in their roles.

Our results also showed that the transition was stressful for new ATs. Many new ATs cited role ambiguity as a source of stress during the transition.²¹ This role ambiguity is related to uncertainty about certain policies, procedures, administrative duties, and their role. One way to help new ATs understand their role is through thorough orientation and continued onboarding. Participants who received policies and procedures manuals and felt orientation prepared them for their roles were more comfortable in their roles. Onboarding is the formal process of supporting new employees as they are integrated into their new organization, providing new employees a means by which they can understand the expectations of the position, organizational processes, and the beliefs and values of the organization.^15,25 As new employees are oriented into their roles, they familiarize themselves with the organization, policies and procedures, and other staff. Inadequate orientation and onboarding procedures add stress during the transition.^26,27 Often, new clinicians are consumed with administrative challenges and their own performance instead of focusing on patient care²⁸; however, as they become more comfortable in their roles and better understand policies and procedures, they are able to focus on the needs of their patients. For nurses, a period of support through gradual and continued onboarding allowed them to assimilate into their setting more effectively,²⁴ thereby decreasing stress. Employers ought to provide thorough orientations and sustained onboarding to new employees to combat the stress associated with the transition to practice. Orientations assist new employees in understanding the policies and procedures associated with one's role, which can help decrease role ambiguity. Although new ATs are still nervous to begin their roles, if they have a good understanding of policies and procedures, they can focus more on patient care instead of spending time focused on learning administrative policies.

Mentorship and Support

Mentoring is a crucial part of the transition to practice for newly credentialed ATs and assists with learning and professional development,^11,29,30 and new ATs desire mentorship and support as they transition.⁵ Fortunately, our participants felt they could seek help and support from their mentors; however, the vast majority (71%) were not assigned a mentor. Successful socialization and transition to practice in the health care professions, such as athletic training, largely depend on the extent of the mentoring and support provided to new clinicians.¹² Mentorship is an essential and vital aspect of the development of new ATs. Additionally, mentorships can enhance patient care through evaluation, review of patient cases, providing feedback, intervention when necessary, development of professional communication skills, and scheduling learning opportunities based on the individual needs of the new clinician.^11,31 New ATs seek feedback from their mentors on topics such as patient care, decision making, communication, and networking.²⁹ Mentors can also provide reassurance and validation to new ATs. When supervisors actively mentored athletic training GAs, fewer GAs were unsuccessful in their roles.¹¹ Although participants in our study had been employed for only approximately 2 to 3 months, which was not long enough to adequately determine success or failure, individuals who perceived higher levels of mentorship and support were less likely to consider leaving the profession. Prior researchers²¹ demonstrated the benefits of mentorship in the transition to practice, despite mentor inaccessibility being cited as a challenge during this time. Our results indicated that most new ATs felt they could go to their mentor or supervisor anytime they had a question.

Interestingly, having an assigned mentor did not affect the comfort level of newly credentialed ATs, notwithstanding the correlation between feelings about mentorship and feelings of comfort. We anticipated that newly credentialed ATs who were assigned mentors would have a higher comfort level because of the perceived support. This could be because of the formal nature of an assigned mentorship. Often, informal mentorships that evolve organically are more beneficial than formal mentorships.³² In a recent study¹⁶ exploring the development of mentoring relationships for new ATs, most mentor-mentee relationships were found to be informal, initiated by the new AT and reciprocated by the mentor. We noted that the majority of participants did not have assigned mentors. Those who were not assigned a mentor may have sought a mentor informally or already had mentors from earlier experiences, which may have helped their comfort levels during the transition. New ATs in the secondary school setting often reached out to former preceptors and mentors from their professional education experiences to serve as a resource or support system.⁵ Additionally, the study took place in the first 3 months of employment, so our participants may have lacked adequate time to fully develop a relationship with an assigned mentor.

Another surprising result was the absence of differences in perceptions of mentorship and support among job settings and titles. We anticipated that GAs would receive more mentorship and support, as would newly credentialed ATs in the collegiate setting. Graduate assistant ATs are often assigned a formal mentor¹³; however, the extent of mentoring varies among supervisors and institutions.^11,13 Many supervisors of GAs reported having formal mentorships in place to enhance the socialization of the GAs in the collegiate setting and assist with professional development.¹¹ Yet interviews with GAs in the collegiate setting indicated that the mentorship largely depended on the personal characteristics of the mentor, not the formal or informal nature of the mentorship.¹³ Some GAs who had been told they had a formal mentor did not actually receive any mentoring, whereas other GAs who developed informal mentoring relationships with their supervisors or other ATs reported receiving great mentoring and support. For the mentoring relationship to work, new ATs need to be committed to developing and investing time and effort in the mentorship process.¹¹ When GAs were not invested or interested in putting time into the relationship, the mentor no longer actively sought opportunities to provide formal mentoring.¹¹ Mentoring can be extremely beneficial to new ATs; still, the new AT must be invested to reap the positive benefits. If not assigned mentors, new ATs should actively seek and be involved in forming relationships with mentors.^21,33

Organizational Transition

Organizational transition demonstrated the lowest score of the 3 constructs. The newly credentialed ATs may feel comfortable performing clinical skills in their role even if they do not completely understand the administrative aspects of the role. Our results showed that many basic administrative procedures (eg, ordering magnetic resonance imaging, physician referral, documentation) were not always adequately explained to new ATs. One of the challenges associated with transition to practice is role ambiguity, in which new ATs are unsure about basic organizational and administrative expectations or expectations of their role.²¹ A great deal of stress associated with the transition can be attributed to role ambiguity and role overload during the transition.³⁴ As new clinicians transition to their roles, they are initially so overwhelmed that they are focused on themselves, understanding their role, and how they are adjusting.²⁸ However, after the first 6 months, they are able to focus on patient care and their patients' needs rather than their own transition needs. For newly credentialed ATs, some of the stressors associated with role ambiguity are inadequate explanations of documentation or physician referrals, ambiguous role expectations, and insufficient access to protocols, such as the emergency action plan and concussion protocols.¹ These are easy challenges to overcome, but they can cause a great deal of stress. Having a basic understanding of organizational policies and procedures can alleviate unnecessary stress associated with the transition to practice. These topics can be readily addressed before employment so that new ATs are able to focus on patient care.

One way to assist new clinicians through the transition to practice is by offering an orientation and onboarding process to provide support. Onboarding is a formalized process of supporting new employees as they are integrated into their new organization; it provides new employees a way of understanding the expectations of the position, organizational processes, and the beliefs and values of the organization.^15,25 As part of the onboarding process, orientation is often used to assist the new employee in understanding the roles and responsibilities, expectations, policies and procedures, and organizational values associated with the position.^5,11,14 In this study, feelings of transition to the organization were higher among participants who felt orientation had prepared them for their role. Additionally, those who better understood their roles were less likely to consider leaving the profession of athletic training. Furthermore, the onboarding and orientation process can assist new ATs by improving employee morale, retaining employees, and reducing stress.³² At a minimum, employers should provide formal orientations to welcome new employees, supply information on the organization's mission and vision, and explain the new employee's place in that mission.³⁵ The employer should also specifically outline the new AT's role and the expectations of the AT. This can make employees feel valued and give them a sense of purpose and ownership within the organization.²⁴ Other items that should be included in the formal orientation are specific procedures, such as physician referrals, ordering diagnostic tests, and documentation. Resources, such as a policies and procedures manual with detailed expectations, should also be provided to assist newly credentialed ATs in understanding institutional policies, as our results showed that individuals who received manuals felt better about the organizational transition than those who did not receive this resource. Although orientations may address workplace information, they will not necessarily address an individual's transition-specific needs.⁵ Despite not addressing each transition need, having a basic understanding of organizational policies and procedures could alleviate unnecessary stress associated with the transition to practice.

Limitations and Future Research

Our work provides a snapshot of newly credentialed ATs' perceptions as they transition to practice. However, we examined the transition at only 1 point in time, when the individuals had been in their roles for approximately 3 months. Future investigators should repeat this study among individuals at different time points in their transition. Additionally, longitudinal research to examine the type and extent of mentorship and support provided to newly credentialed ATs is warranted to determine what these new clinicians need from mentorship experiences to enhance their comfort levels during the transition process.

Another limitation is that all of our participants were newly credentialed ATs, regardless of setting or level of educational programs. Thus, individuals who graduated from professional baccalaureate programs and who were employed as GAs were included. As the profession continues to evolve, the educational model transitions to the master's level, and educational competencies and clinical experiences develop, the transition experience may change. Our results showed no difference related to the level of education, but the majority (74%) of our participants graduated from professional baccalaureate programs. Moreover, the instrument was developed based on research among GA ATs and medical students. We did not find any differences among participants based on job setting, yet this is a limitation. As baccalaureate programs are phased out and more literature on the transition to practice for ATs in all settings becomes available, our instrument can be adapted and the study repeated among postbaccalaureate students who graduated under the new educational standards.

We explored only comfort, feelings of mentorship and support, and feelings of organizational transition. We did not ask about job satisfaction or retention. However, these are vital components of the transition to practice, and future authors should explore the influence of the transition on these variables. Although we asked if participants had ever considered leaving their jobs, we did not follow up on retention rates. Our aim was to gain an initial look at the transition to practice and, therefore, we asked about comfort only in a general sense. Future researchers should assess comfort with specific athletic training skills and then repeat the study to see how comfort levels evolve. Finally, we did not address patient care or patient safety. Future investigators should examine patient outcomes of newly credentialed ATs to determine the effects of challenges associated with the transition to practice.