Self-Authorship as a Means to Develop Athletic Training Students’ Professional Identity

Research Design

We used a concurrent mixed-methods design to characterize the self-authorship of professional-level MAT students in athletic training. The concurrent nature of the investigation allowed the findings from the qualitative interview to provide depth and context to the findings of the quantitative survey. This study was deemed exempt research by the Indiana State University Institutional Review Board.

Recruitment and Participants

We recruited athletic training students enrolled in professional MAT programs and in the final year of their program. All participants had to have completed an immersive clinical rotation to be included, as the theoretical foundation for inclusion of immersive clinical experiences is to socialize students to the profession. We used a 2-pronged recruitment approach due to the potential for sampling bias with both approaches. We sent a recruitment email through a web-based platform (Qualtrics) to all program faculty of Commission on Accreditation of Athletic Training Education-accredited programs (N = 416) in good standing at the end of 2022. We also used the National Athletic Trainers’ Association (NATA) research service to contact student members directly. A random sample (N = 2781) of those who were categorized as noncertified students in the NATA database was generated by the NATA, and recruitment emails were sent to this random list. The recruitment email to students contained the purpose of the study and a link to the initial survey. The initial survey included informed consent, demographic questions, self-authorship assessment, and an additional question for students to opt into the semistructured interview. All participants indicated consent to participate and then navigated the survey. The Figure includes a breakdown of recruitment procedures for this project.

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A total of 286 participants opened the survey. There were 104 students who were eligible for the survey and who completed it entirely. The participants averaged 24 ± 3 years old (range, 20–40 years), with most identifying as women (n = 78), followed by men (n = 24) and transgender (n = 2). Most participants identified as White only (n = 84), followed by Asian (n = 10), Black (n = 6), or mixed race (n = 4). Table 1 includes the demographic characteristics of the participants.

Table 1.Patient Demographics for Quantitative Survey

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After completing the survey, participants had the option to complete the semistructured interview. Twelve participants (10 women and 2 men, age = 24 ± 2 years, White = 8, Asian = 3, Pacific Islander = 1) completed the follow-up interview. Table 2 includes the demographic information of participants from the interview portion. There was a total of 10 different athletic training programs represented by the 12 participants.

Table 2.Demographic Data for Qualitative Interview

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Instrumentation

Semistructured Interview.

At the end of the SAQV2, participants had the option to engage in a follow-up interview (Table 3) that focused on meaning-making to further investigate factors influencing participants’ self-authorship. The interview was constructed from previous investigations in self-authorship, exploring interviewees’ perceptions on meaning-making and crossroads experiences.^13,14 The interview script was sent to 3 expert qualitative researchers (age = 37 ± 9) as external reviewers for content validation and review. The experts were asked to ensure that the questions aligned with the research question and aim of the study. Based on the feedback, we made minor grammatical changes and clarification on terminology to be appropriate for the intended audience. The interview was semistructured to allow the researcher to probe and ask follow-up questions as appropriate depending on the participants’ responses. The script consists of 7 parent questions and 8 planned follow-up questions.

Table 3.Interview Protocol

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Researchers conducted the qualitative interviews via the video conferencing software Zoom and transcribed the audio recordings using artificial intelligence (Otter.ai). Once the interview was concluded and the transcript was produced, the primary investigator deidentified the transcript. Each participant was given a pseudonym to protect their identity, and all references to specific athletic training programs or other identifiable information were removed. The primary investigator sent the deidentified transcript to participants to ensure the accuracy of their responses. Interviews were continued until data saturation was achieved where the common themes were repeated, and no new insights were derived from additional interviews.

Data Analysis

Qualitative Analysis

We used the consensual qualitative research approach to analyze the responses during the interviews.¹² A 3-person coding team was used. This approach allowed the proper representation of participants’ experiences and meaning-making processes. In the first phase of coding, investigators read a subset of the transcripts multiple times to gain familiarity with responses and participants. During this initial review of transcripts, investigators made notes and developed commentary of responses of interest or commonalities and reduced notes into core ideas. The coding team met to compare notes, and initial themes were identified. During this meeting, the initial codebook was constructed by building a consensus among the team, which represented the responses of the participants and core ideas identified. Next, the data analysis team applied the initial codebook to a subset of new and previous transcripts. At the end of this phase, the coding team met once more to ensure the congruency of the codebook and consistency in applying the codebook across analysts. Minor revisions to the codebook were made to consolidate similar categories. In the next phase, the primary researcher applied the codebook to all transcripts, and the other members of the data analysis team internally audited the coded transcripts and discussed disagreements. After the multiphased approach was completed, the transcripts, codebook, interview script, and purpose of the study were sent to an external reviewer with experience in qualitative research to ensure accuracy and integrity of the coding process. The frequency designations were general (n = 11–12), typical (n = 6–10), and variant (n = 2–5).¹⁵

Researcher Reflexivity and Mitigation

The primary investigator has 8 years of research experience in quantitative, qualitative, mixed-methods, and database research. The primary investigator has explored their own meaning-making process and integrated these concepts into their regular teaching and mentoring roles. To ensure trustworthiness in the analysis, we first used member-checking, allowing participants the opportunity to ensure that their responses were accurately portrayed in the transcription process. Second, we used regular structured team-reflexive discussions during data analysis. Finally, external reviews were performed by experts in qualitative research that were not members of the research team.

Quantitative Results

Overall, students scored high on the SAQV2, with a mean score of 113.16 ± 10.18 (range, 87–129) out of a possible 135, indicating greater levels of self-authorship. The average score for each construct is presented in Table 4. There were significant differences in SAQV2 scores between age groups (P = .005), with a mean rank SAQV2 for traditional-aged students of 55.03 and for nontraditional-aged students of 36.17 (Table 5), indicating that traditional-aged students reported higher levels of self-authorship. There were no significant differences in SAQV2 mean scores based on gender identity (man or woman, P = .75) or cultural ethnicity (White or non-White, P = .37).

Table 4.Overall Self-Authorship Questionnaire Version 2 Scores and Construct Scores

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Table 5.Self-Authorship Questionnaire Scores by Age Group (Kruskal-Wallis Test)

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Traditional-aged students scored significantly higher than nontraditional-aged students in the Interpersonal leadership (P = .016), self-efficacy (P = .002), and knowledge creation (P = .011) constructs (Table 5). These results indicate that students of traditional master’s age perceive to have higher interpersonal leadership, self-efficacy, and knowledge creation than their older counterparts, suggesting higher perceived self-authorship.

The only significant difference between White and non-White students was in the interpersonal leadership (P = .047) construct, where White students scored significantly higher than non-White students, indicating a higher perceived interpersonal leadership ability for White students (Table 6). There were no significant differences in construct scores between gender (P ≥ .09; Table 7).

Table 6.Self-Authorship Questionnaire Scores by Cultural Ethnicity Group (Kruskal-Wallis Test)

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Table 7.Self-Authorship Questionnaire Scores by Gender Group (Kruskal-Wallis Test)

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Qualitative Results

Through consensual qualitative research analysis, 3 domains emerged with 8 categories: Developing Trust, Growing/Maintaining Confidence, and Creating Identity (Table 8).

Table 8.Domain, Categories, and Frequencies

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Developing Trust.

The first domain that was identified involved actions by the student or preceptor that led students to develop trust as a provider and trust in their patient care skills. The development of trust in oneself and in others is a key component of self-authorship and professional identity formation. The actions that led to the development of trust included giving the student autonomy and the use of feedback as a form of clinical teaching. We classified autonomy in 2 ways: patient care and procedural. The actions that were classified in patient care were instances where students were afforded the opportunity to make clinical decisions about direct patient care under the supervision of their preceptor. The actions under procedural relate to those actions in clinical practice that are not directly linked to patient care, such as administrative, custodial, organization of supplies, etc. All the participants in our study described the use of autonomy related to patient care to further their trust in themselves to make clinical decisions (Table 9). Others described the use of autonomy in patient care to develop trust between themselves and their preceptor. The use of autonomy with direct patient care was described as a major benefit to the intrapersonal and interpersonal development of trust, which can be linked to the intrapersonal and interpersonal domains of self-authorship.

Table 9.Supporting Evidence and Quotes for Developing Trust

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Procedural.

Like patient care, participants also described the preceptor’s use of autonomous completion of procedural tasks to develop trust. The procedural tasks included patient care documentation, communicating with coaches, custodial duties, field set up, and organizing the health care space. Although not all participants described opportunities to do procedural tasks autonomously as a way to develop trust, this was a general response. Other participants described feeling trusted to set up the playing surfaces for events or similar custodial tasks that allowed them to see the full scope of work.

Feedback.

The use of feedback was typically described by the participants in this study and included feedback from their preceptor for patient care decisions and performance. Feedback is an effective tool to help students understand what they did well and where they can improve in the future. Participants described different forms of feedback, including affirmative feedback, corrective feedback, or negative feedback. However, there were instances where participants described the use of negative feedback to deter their trust.

Growing/Maintaining Confidence.

The growth and maintenance of confidence is a crucial component to a professional identity as well as moving toward authoring one’s own life. Participants described multiple situations that helped them grow or maintain their confidence as providers, including rule following, questioning authority, questioning knowledge, and debriefing (Table 10).

Table 10.Supporting Evidence and Quotes for Growing/Maintaining Confidence

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Rule Following.

The first stage in developing self-authorship is following external formulas, otherwise known as rule following without question.⁸ Participants described multiple formulas or external sources of rules that they use, including textbooks, a rigid exam process, and authority figures. Generally, participants described the use of textbooks or course materials as the first source of evidence they use when making decisions clinically. However, some participants described the use of a structured approach to follow for clinical exams. When describing authority as the source of evidence, participants described when they relied on their preceptor to make decisions or dictate care. Interestingly, some participants shared when rule following would not be a viable option for their current context. In Self-Authorship Theory, the moment when students describe frustration with following rules is called the crossroads, where they encounter an experience that does not align with their current formulas. The student is forced to then rely on the ability to adapt and solve problems. Although following external formulas is necessary to learn new skills and build confidence, students must move toward questioning to self-author their approach to patient care.

Questioning Authority.

The ability to see knowledge as contextual and not fixed or finite grows from students’ abilities to question authority and current knowledge. Participants typically described the questioning of authority either directly or indirectly. Direct questioning of authority referred to instances where students verbalized their questioning to their preceptors. Indirect questioning referred to when participants internally questioned preceptor decisions but did not express the questioning to their preceptor. Many participants also described that when preceptors curated an environment that allowed them to ask questions openly, students felt more comfortable asking questions directly to their preceptor about decision-making. Some participants had difficulty describing instances when they disagreed with a preceptor directly. When participants described instances of indirect questioning of authority, it usually resulted from disagreement in clinical decisions.

Questioning Knowledge.

The ability to question the knowledge that one possesses is an ideal pivot point to move from seeing knowledge as a fixed item to be possessed to seeing knowledge as contextual and fluid. Participants typically were able to share how they have questioned previous knowledge and applied their new perspectives to care, ultimately building more confidence in patient care.

Debriefing.

Debriefing has been described as a powerful clinical teaching tool to help students learn from experiences, which may grow or maintain their confidence in clinical practice. Participants in our study typically debriefed with their preceptor to grow confidence. Similarly, the ability to use debriefing to identify when participants could improve performance was described.

Creating Identity.

The final domain we identified was how participants created an identity, which encompassed both a personal and professional identity (Table 11). This domain included acquired attributes that students described learning through their socialization and education in athletic training. The domain also included how the students described their internal attributes that have led to the development or reinforcement of their professional identity. Students described how they learned to develop their identities through social learning and clinical teaching (instructional strategies).

Table 11.Creating Identity Quotes

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Acquired Attributes.

The first acquired attribute that students described was being holistic in their patient care. Participants in our study recognized that an important identity component for being an athletic trainer is considering the whole patient in their decision-making rather than focusing on the injury alone. All but 1 participant in the study discussed the importance of being holistic in their patient care. Further, some participants shared their perspective on helping patients beyond sport-related activities and considering the long-term impact of injury on the health-related quality of life of their patients. Participants typically described being collaborative as part of their professional identity. Participants described collaborating with other health care providers, preceptors, coaches, parents, and the patient themselves. An important aspect of developing a professional identity is the ability to identify and describe the roles, responsibilities, and characteristics of the profession that they are entering. The participants described recognizing themselves within the profession of athletic training, which also meant they were able to see some of the struggles of the profession There were instances where participants identified aspects of the athletic training profession that pose challenges. Burnout and compassion fatigue have impacted all health care, specifically because of the coronavirus disease 2019 pandemic. However, burnout has challenged athletic training for decades, and participants were able to recognize that combatting burnout and compassion fatigue would be important to their identity.

Internal Attributes.

All but 1 participant (n = 11) in the study described or demonstrated curiosity as an internal attribute consistent among athletic trainers. When considering the progression of self-authorship from external formulas to self-authoring, curiosity is an important aspect to move toward self-authorship. Participants also described curiosity as necessary to becoming a life-long learner and to avoid complacency. All the participants described being humanistic in their approach to patient care and that being an important part of their professional identity. Participants similarly described that putting patients’ decisions and feedback as a primary driver for decision-making was critically important to their philosophies.

Instructional Strategies.

Generally, participants described how they were introduced to the profession that was consistent with social learning theory. The social learning theory suggests that behaviors can be learned through observation and interaction with others.¹⁶ All the participants in this study were introduced to the profession of athletic training through the observation or interaction with other athletic trainers. Participants also described interactions with athletic trainers when they were patients to learn about the athletic training profession. Participants described how their preceptors’ active engagement in clinical teaching helped them to create or reinforce their identities. Other participants described the use of probing questions as a method their preceptor would use as a form of clinical teaching.

Observation

One developmental experience that has demonstrated effectiveness in promoting self-authorship and a professional identity in medical education is observation.^20,21 By observing positive behaviors of preceptors and mentors, MAT students can begin to develop and reinforce attributes that will build into a strong professional identity. Specifically, observation of teaching faculty related to patience, empathy, respect, and teamwork led medical interns to model their behaviors in a similar pattern.²⁰ In our study, students described internal and acquired attributes of themselves that influenced their identity creation as an athletic trainer. Positive attributes, such as being humanistic, collaborative, and curious, can be modeled for students early on by preceptors and athletic training faculty to start building a positive professional identity. When students have positive modeling of professional behaviors, they can more easily see how to integrate these behaviors into their professional identity. As athletic training programs are considering clinical sites and preceptor selection, the professional identity and behaviors of the preceptor should also be factored in as these are what students observe.

Yet, passive observation alone is not sufficient to develop meaning-making as this reinforces students to rely on external guidance of observed behaviors from the preceptors. Athletic training programs should be training preceptors to integrate more active observation where students are asked to reflect and challenged on their reflections, allowing students to move past external guidance toward internal meaning-making of their own. For instance, if students are never challenged to express how their role in the health care system aides in their professional identity, and preceptors are not integrating students into these experiences at their clinical site, students will not be able to internalize their role and limit their professional identity development. Rather, preceptors should allow students to engage in these conversations with other providers and then use debriefing as a means to reinforce the positive aspects of identity formation as a collaborative provider.

Early on in a student’s development of their professional identity and meaning-making exploration, they are more likely to mold their beliefs and identity to fit their surroundings. Therefore, the modeling of negative behaviors or characteristics by preceptors and mentors can equally influence students’ professional identity formation.^20,22 In our study, all but 2 participants described some level of burnout or compassion fatigue as an acquired attribute. If preceptors are negatively modeling how to cope with burnout, students can internalize these behaviors and limit persistence in the profession. In previous medical literature, when learners are exposed to negative traits, such as unprofessional behaviors or mistreatment of others, students were able to acknowledge how they would avoid integrating such traits into their development.²⁰ However, this requires space for feedback, self-reflection, and support to reject negative behaviors and not internalize them. Preceptor deselection should also be considered when identifying clinical experiences for students if preceptors are not modeling positive professional behaviors that would lead to a strong professional identity.

Progressively Autonomous Experiences

All the participants indicated that when preceptors gave them autonomy in either patient-care or procedural tasks, these experiences helped develop trust in their knowledge, skills, and abilities as future athletic trainers. Similarly, previous research has shown that when medical students are given the opportunity to be involved in the management of patient cases, such as taking a history or participating in a decision-making process with a physician, it increased their sense of usefulness, confidence, hope, and interest. Preceptors who provide students with more autonomy in their clinical education have the opportunity to greatly impact students meaning-making of patient care knowledge and shape their identity as a future athletic trainer. Granted, students should be given a level of autonomy that is appropriate for their current knowledge and skills. Yet, this level of autonomy should not be stagnant but progressive in nature, and programs should take an intentional approach to helping preceptors implement these progressively autonomous experiences.²³

Through understanding procedural skills such as sanitation and competition set up, students should be given as many opportunities to engage in direct patient care as possible. When students are engaged in direct patient care in authentic clinical work environments, they are introduced to new and often stressing environments.²⁰ These new and stressing situations allow students to confront their own abilities, interests, and need for growth. When students are able to experience these challenging moments with the supervision of a preceptor, they are introduced to what is known as the crossroads moment, whereby students are challenged to move from solely following external guidance to more internal foundations.²⁴ When students experience these crossroads moments as they have been given progressively autonomous experiences with real patients, they are able to move through crossroads moments and internalize their own meaning-making as they are required to manage patients. Furthermore, students can see themselves as capable of working as a future clinician, thereby strengthening their professional identity.

Feedback and Debriefing

Once students are given progressively autonomous experiences, students should be given feedback, and debriefing should occur. Participants in our study found that the use of feedback developed trust with their preceptor, and debriefing reinforced their confidence as a future athletic trainer. Feedback, although it can take many forms, is the route through which an instructor provides a response to a student’s performance in learning. Traditionally, in clinical education within athletic training, the feedback is corrective in nature on where students can improve.¹⁹ Although there may be times where instant feedback is required to avoid harm to a patient, preceptors should allow students to engage in the patient encounter fully before providing feedback. No participants in our study described a preceptor intervening to avoid a negative clinical outcome for the patient, which may be related to participants not wanting to share a negative image of themselves. Importantly, as preceptors are delivering feedback, it is imperative that the feedback be candid and empowering so that the student can see the usefulness and applicability of the feedback to improve performance in the future. Again, simulated experiences are a great way to initiate the first 2 steps in this process in providing autonomy and feedback without the possibility of danger to a real patient.

Debriefing was described by all but 2 of the participants in the interview as a means for developing confidence as a provider. After another bout of engagement by the student with the adjusted level of autonomy, a more formal debriefing should occur. Although some smaller debriefing during the feedback intervention may occur, preceptors should adopt the practice of introducing more formalized debriefings to allow students the opportunity to reflect on and discuss their performance.²⁵ A recent review demonstrated nurses’ feelings on debriefing as they entered the profession and found that those who did not receive formal debriefing as a part of their transition felt that it would have helped them in decision-making and entry to the profession.²⁶ Further, this review found that nurses who did experience debriefings felt that it strengthened their learning and provided a positive environment for learning. The simplest form of debriefing is the “Diamond Debriefing” method, which allows learners to make connections between their performance and their areas for improvement. Preceptors can use Diamond Debriefing to provide structure to their debriefing methods and maximize the time and impact that debriefing can have. The last step of the Diamond Debriefing model asks the students to identify their own action steps to establish a road map ahead.²⁵ These action steps should be developed in consultation with the preceptor and include increasing degrees of autonomy.

Finally, after the debriefing session, preceptors should outline and identify specific contexts where the students can take on more independence and autonomy with patient interactions or procedural skills. This ongoing process would lead back to the initial stage and allow for continual collaboration and growth of the students as they progress throughout their clinical experience. This section has primarily focused on patient-care autonomy as this experience is more difficult to manage, with the implementation of progressively autonomous opportunities for students. However, the process for providing increasingly independent performance of procedural skills should follow a similar approach.

To provide a comprehensive clinical example, as students demonstrate competence with procedural skills, preceptors would best serve students by allowing the student to begin developing an initial care plan for a patient (eg, intervention selection, modality settings, and exercise prescription) without direct input from the preceptor. The preceptor should then review the decisions from the student and question the student on their decision-making. This instance could provide an opportunity for feedback and debriefing where the student and preceptor have a respectful and honest dialogue about disagreements and clinical philosophy, thereby demonstrating the questioning of authority in a positive manner to strengthen the student’s professional identity.

Integration of Self-Authorship to Didactic Education

Previous literature has shown that students primarily value clinical education and devalue education in the didactic setting.¹⁰ Self-authorship should be integrated into didactic learning to further enhance the professional identity of students and help provide experiences that more closely reflect clinical education. First, integration of the learning partnerships model presents an opportunity for educators and learners to engage in dialogue that is both supportive and challenging.²⁷ Learning partnerships place students in collaborative environments where they are required to articulate their own perspectives and challenge their own assumptions. Requiring students to articulate their decision-making and challenge their beliefs can foster more self-authorship and strengthen their professional identity.

Athletic training educators can use a more interactive approach to case-based learning by shifting case study assignments to grand round presentations and allowing students to develop a presentation on how they would manage a simulated case study or presenting an actual case they have helped manage with a preceptor in clinical education. Having students present their decision-making, intervention selection, and management of cases forces them to internalize their decision-making, moving them closer to authoring. Alternatively, having students question their peers and themselves allows for more crossroads moments where they are confronted with understanding their own meaning-making. Finally, the regular integration of reflective practice for students through journaling to help reflect on their beliefs, decision-making, values, and experiences can help them strengthen their professional identity. Specifically, these reflective practices should be grounded in prompts and experiences that draw on aspects of professional identity, such as the professional norms, values, and beliefs of that athletic training profession.

Limitations and Future Directions

This study was not without limitations. First, although the SAQV2 provides valuable information on perceived self-authorship of participants, the assessment is self-perception, which can lead to inflated scores. Additionally, the Self-Authorship Theory is a continuum where individuals are constantly shifting, and a cross-sectional assessment many not fully capture the development of self-authorship. Second, the qualitative interview allowed participants to expand on their survey responses and provide rich data in experiences. However, this focused on the students’ perceptions and recall of lived experiences. Future research should explore observed behaviors, decision-making, and meaning-making for MAT students. Additional research should investigate the influence of clinical education curriculum grounded in Self-Authorship Theory on the development of MAT students. Finally, future research should explore the self-authorship and professional identity of practicing athletic trainers to compare to those transitioning to the profession.