A Theoretical Model of Transition to Practice for Athletic Trainers

Participants

A purposive sample of 14 graduates (7 men, 7 women, age = 25.6 ± 3.7 years) from 9 professional master's athletic training programs took part in this qualitative study. We evaluated professional master's students to ensure that the results would expand current knowledge, given that undergraduate professional programs may no longer accept students after 2022.¹⁸ Therefore, by 2025, professional programs will no longer exist at the undergraduate level, and no undergraduate students will be eligible to take the Board of Certification examination. At that time, all new clinicians will be products of professional master's programs, which may make the findings of transition-to-practice research conducted among undergraduates less relevant. To recruit participants, we sent emails to the program directors of all accredited professional master's programs and asked that they forward the emails to students in the last semester of the program.

Participants were followed from their last semester in graduate school through their first year of autonomous practice as ATs and represented institutions in 7 of the 10 National Athletic Trainers' Association districts. They were employed in diverse settings, including high schools (n = 5), colleges (n = 6), performing arts (n = 1), or professional sports (n = 2). The sample size was determined by data saturation and occurred by the 14th participant. Data saturation is signified by redundancy in the data, indicating that further data collection would yield similar results.¹⁷ In other words, as data are collected, new data are constantly compared; when interviews yielded similar responses and the researcher memos become repetitive across interviews, the data are considered saturated. We collected the data so that we could understand the contexts for the experiences described. The purpose of our study was not to determine differences in experiences but rather to identify participants' shared experiences.

Data-Collection Procedures

Upon receiving approval from the institutional review board, we conducted and audio recorded the semistructured phone interviews. The interview guides (Table) were developed based on the current transition-to-practice literature in the athletic training and nursing fields^2,5 and were specific to each of the 3 data-collection timepoints. The interview guides were then reviewed by outside researchers familiar with the transition-to-practice literature. This review was followed by a small pilot study (n = 3) to ensure clarity and flow. The pilot study resulted in a resequencing of questions but no changes in content. We did not include the pilot data in the analyses.

Table Preliminary Interview Guides^a

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Interview data were collected longitudinally at 3 timepoints: (1) during the participants' last semester, usually within 3 weeks of graduation, (2) 4 to 6 months after beginning autonomous clinical practice, and (3) 10 to 12 months after beginning autonomous clinical practice to ensure that the entire transition was represented. These timepoints were selected to support the longitudinal nature of the study but also to align with past explorations^{5,14,16,19–21} of the longitudinal nature of transition to practice, which used similar timepoints. The broad, open-ended questions were designed to gather rich detail on the lived experiences of the participants. We used probing to clarify responses, gain further insight, or both. Interviews were transcribed verbatim. The data were generated from more than 20 hours of interviews.

Data Analysis and Credibility

Our data analysis followed the systematic approach as outlined by Corbin and Strauss¹⁷ and occurred in stages. First, we used open coding to develop themes. We attempted to saturate each theme and build properties, or subcategories, within each theme. These subcategories represented different aspects of each theme.¹⁷ Open coding was conducted using a constant comparative approach to show possible continuums within the themes.¹⁷ The result was a coding paradigm through which we identified the central phenomenon (ie, the transition to practice). Two researchers (B.F.K. and T.G.B.) then performed axial coding, returning to the data to gain insight into coded themes that related or helped to explain the central phenomenon.¹⁷ Finally, we performed selective coding to connect the themes, creating a conceptual map of the process of transition to practice.¹⁷

The 2 researchers independently completed these analyses and then shared their findings. Any differences were negotiated until the final theory incorporated the abstract analytical schema that best fit the data.¹⁷ This schema graphically represents the integration of concepts and themes into an interconnected process: a theoretical model.¹⁷

Several methods were used to establish credibility. Peer evaluation was a critical component and occurred throughout the study. Before data collection, a peer performed an instrument review to improve the study design. On completion of the data analysis, the peer was provided with 2 coded transcripts and the presentation of the results for verification. The peer was selected based on content expertise in both ATs' transition to practice and qualitative research design. Expertise was determined by the peer's published studies on the transition to practice and grounded theory but was independent of the data-collection process and initial analyses. We discussed all suggestions made by the peer until we agreed. A process journal was used to track the evolution of thought and ensure credibility.²² The process journal was then used to communicate the findings and theory development to other researchers for validation.²² Additionally, because all of the authors and peer experts were ATs who had experienced the transition from student to autonomous clinician, the process journal allowed reflexivity to occur organically throughout the analysis.

Clash of Cultures: Causal Conditions

The phenomenon of the transition to practice begins as individuals become aware of the distinction between who they have been (athletic training students) and who they must become (professional ATs). The data suggested that the psychological process of transition was initiated by the conflict that occurred as newly credentialed ATs became aware of the differences between the cultural norms and expectations they faced as students learning in educational clinical settings and those of professionals in clinical settings. Specifically, newly credentialed ATs became aware that, even with the confidence gained as athletic training students, educational clinical cultural norms and expectations were limited. As they were exposed to the professional cultural norms of employers, coworkers, and patients, our participants became aware of the ways in which they had been protected as students from some of the responsibility for ensuring patient safety. The resulting incongruence created a culture clash between educational clinical cultural norms and professional cultural norms.

Transition to Practice: Phenomena

The next stage of the transition process explains how the newly credentialed ATs derived meaning from the experience produced by the clash of cultures. We will depict how the causal conditions were experienced and given meaning. The data suggested that new ATs in transition experienced this clash of cultures in feeling overwhelmed by chaos, self-doubt, and fear.

Coping Strategies

The next stage in the transition process was the coping strategies used to deal with the transition. Our participants relied on a variety of techniques, which appeared to occur organically in response to their new situations. The themes that emerged were trial and error, self-compassion and self-reflection, and search for support.

Outcome: Rhythm Amid the Chaos

Using coping strategies, the newly credentialed ATs found their rhythm amid the chaos. Ava recognized that she “definitely has gotten into a better rhythm and [am] just enjoying all of the opportunities that this job provides me.” She found confidence in this rhythm Olivia echoed the sentiment: “I was nervous a lot, but I think that kind of goes with any new job, but I think, once I got my rhythm here at [employer's name], definitely the nerves went away.”

Each participant found rhythm in a variety of ways. Mason explained, “I've gotten into way more of a rhythm with my life. I used to be pretty disorganized.” Lucas similarly found planning critical: “Finally getting [a documentation routine] sorted out” helped him find rhythm. Once this occurred, Lucas was better able to manage his day:

I come in. I get everything cleaned up and start taking care of all my disinfectant protocols and things like that at the beginning of the day. Then at the end of the day, I can get charts set up for the next day. It took me an awkwardly long time to get that figured out, even though I knew exactly what I needed to do. It's like silly things trip you up.

Elijah also found relief in rhythm as his self-reflection led him to spend more time planning:

So I was kind of making stuff up on the fly and testing things out, but now I get home, and I sit down, and I plan stuff out. It helps quite a bit in terms of getting organized and having a flow for the next day or for the next week or so.

Clash of Cultures

The clash of cultures begins the transition process. Specifically, cultural differences exist in the expectations of athletic training students and ATs. These cultural differences reflect the distinct purposes of the clinical student and the professional AT. The primary purpose of clinical education is to provide “a logical progression of increasingly complex and autonomous patient-care and client-care experiences” so that “students can experience the totality of care provided by an [AT].”^23(p7) Conversely, ATs' responsibilities extend beyond patient care²⁵ and may include additional obligations as determined by the employer. In short, clinical ATs are not paid to allow athletic training students to be the primary health care providers. However, these findings do support the conclusions of previous researchers^14,26 who suggested that having a greater breadth of clinical experiences facilitates the transition process.

The clash of cultures experienced by new practitioners creates cognitive dissonance between the expectations of clinical practice versus the reality and results of the uncomfortable experience of transition. These findings are similar to those in the nursing transition-to-practice literature.⁵ Clarke and Springer⁵ found that new nurses described the chaos of the shock of a “typical day” that was never typical. Moreover, new nurses experienced “stress from not knowing” related to missing something important that could result in patient harm or death and not being adequately prepared.⁵ Given the similarities in the students' clinical experience and transition to practice for nurses and ATs, it seems logical that both groups would experience these feelings.

Coping with Transition to Practice

The coping strategies used by transitioning ATs in our study mirrored those identified in the current athletic training literature as well as in the nursing and physician residency literature.^2,5,6,10,27 Specifically, newly credentialed clinicians found it critical to seek support and self-reflect to ease the transition to practice.^2,5,6,10,27 It could be argued that this search for support and self-reflection is required to develop a personal community of practice. Cruess et al⁶ proposed that it is the learning that occurs through social interactions that allows the voluntary joining of a community of practice for medical students. This learning process begins peripherally and allows the new clinician to identify and develop characteristics of the community (ie, the profession),⁶ which suggests that the transition to practice is a concept with significance beyond education and employers as a developmental process influenced by the entirety of the profession. Simply stated, all ATs are members of the athletic training community of practice and, therefore, play a role in the transition to practice of new clinicians.

In our proposed model, peripheral participation in the community of practice is seen in the new clinicians' search for support and internalizing of the information gained through self-reflection and expressed through trial and error. Cruess et al⁶ described this internalization in their stages of the development of a professional identity in medicine, which they adapted from the Kegan stages of identity formation.²⁸ Cruess et al⁶ stated that the responses of individuals will vary, but “serious personal negotiations” are critical to the acquisition of the new identity. Accordingly, the final stage of professional identity development manifests as

An individual who is able to understand relationships in terms of different values and expectations. The external values of the professional become internal values. Reason is in full control over needs, desires, and passion.⁶

It is important to note that our model cites trial and error as a critical component of the transition process. Our findings mirror those of transition in other health professions and business.^29–32 This suggests that there may be value in educational processes that promote the use of trial and error when appropriate. Educational experiences in which value is placed on the errors (mistakes) made in reaching a desired outcome as opposed to the outcome itself may teach beneficial skills for the transition to practice. Error-based learning is not a new concept, as researchers^33–35 suggested that errors had a positive effect on knowledge and academic achievement and better equipped employees to manage on-the-job errors with emotionally controlled responses.

It should be noted, however, that the outcomes of error-based learning are influenced by personal beliefs and the environment. Individuals who held positive beliefs about errors and their effect on learning were more likely to have positive outcomes.³⁶ Moreover, a climate in which errors are viewed as a learning tool improves outcomes for students.³⁴ Therefore, it could be presumed that both educators and employers should communicate the value of mistakes in professional development, especially during the transition to practice. Students and new clinicians should understand that mistakes occur in clinical practice. Instead of promoting feelings of self-doubt, fear, and shame, students should be empowered by opportunities that allow for the appropriate correction of mistakes made by students and new clinicians, thereby reframing mistakes into a natural component of instead of an alternative to success.

Although our theory is not exhaustive, it is informative and aids the profession in understanding how the development of professional identity affects new AT graduates and their subsequent transition. Notably, our results indicated that discussion of the transition-to-practice process needs to move beyond the current implications related to education and employment settings and expand to the role all ATs play in the development of young athletic training professionals.

Transition to Practice: A Process

Ultimately, through the transition, new ATs find their rhythm amid the chaos. These findings are similar to those in the nursing transition literature⁵ and describe the point when clinicians no longer feel that they are posing or pretending to be professionals and are able to embrace their professional identities. As such, the transition process can be viewed as a critical part of developing a professional identity. Therefore, the proposed model should be seen as a map of transition in which the goal of the educational process and employer onboarding should be to provide the tools necessary to navigate the transition process, not avoid it. Conceptually, this aligns with the result of Mazerolle Singe et al¹⁵ that new clinicians need to live the experience of transition.

We performed this study to better understand the process of transition and build a viable theoretical model to explain the process. Through this work, we identified what is often thought to be dysfunctional behavior as a normal part of personal and professional development. As such, it is a process that should not be minimized or eliminated but understood. Our findings provide a framework for the reevaluation and adaptation of educational and employment processes to help the individual develop the necessary skills to transition successfully.

Limitations and Areas of Future Research

Although these findings have expanded our understanding of the transition to practice for new ATs, several limitations of our work should be considered. The goal of the study was to develop a general theory that represented the broader process of transition. As is frequently the case in qualitative research, the results are unique to the investigators and participants. From a quantitative perspective, small sample sizes commonly limit generalizability, but given the inductive nature of qualitative research, this is not the case here. Future researchers may wish to explore the transition process in specific specialties or settings to determine if differences exist. Additionally, investigators should evaluate the efficacy and efficiency of educational and organizational mechanisms identified as supporting the transition.