Creating Progressively Autonomous Experiences in Athletic Training Clinical Education

Key Points

• Progressive autonomy is a critical component to clinical education. Preceptors in our study described limited training on creating progressively autonomous experiences with athletic training students.

• The implementation of immersive clinical experiences offers an opportunity for progressively autonomous practice, yet programs appear not to have maximized this opportunity through effective training.

• Programs are expected to offer regular and ongoing training of preceptors, which should include strategies for assessing student competence and progressively offering opportunities to autonomously practice during clinical education opportunities.

Clinical education is a critical component of a student’s professional preparation and involves the formal acquisition, practice, and evaluation of clinical competence through classroom, laboratory, and clinical experiences in health care environments.^1,2 Clinical education offers an opportunity to leverage experiential learning theory, which is guided by Kolb’s Experiential Learning Theory.³ Kolb’s theory includes 4 modes for student development: concrete experience, reflective observation, abstract conceptualization, and active experimentation.³ Each of the modes from Kolb’s theory plays a crucial role in a student’s experience in clinical education where they are given concrete experiences followed by ample time to reflect and conceptualize. The level of active experimentation, which is synonymous with opportunities for autonomous practice, is crucial in the development of competent health care professionals.

Many health care professions require some form of immersive clinical education for students.^1,4–10 Clinical education experiences are meant to be progressively autonomous to hone and develop skills under the supervision of a preceptor who is already established into the field.^1,4–14 Progressive autonomy is the practice of allowing greater degrees of autonomy to students, based on their skill, education, and experience levels.¹³ Offering progressively autonomous experiences allows the students to have the supervision they need during their clinical education, from the early stages when their clinical reasoning and skills are low, then transitions into more hands-on practice as their skills develop.¹⁴ Reported benefits of progressively autonomous clinical experiences are increased confidence, development of clinical decision-making skills, a sense of responsibility and patient ownership, readiness for independent practice, and development of professional identity.^4,5,13 The benefit of a progressively autonomous experience as opposed to pure observation or complete autonomy has been observed in multiple health care settings and professions.^14–17 Within athletic training education, it has been shown that students who strictly observed were likely to implement fewer professional core competencies than those who assisted.¹⁷ Those who assisted also implemented more core competencies then those who performed independently.¹⁷ The Commission on Accreditation of Athletic Training Education (CAATE) has established that programs must offer students clinical experiences that are progressively more autonomous over the course of the program.¹⁸ However, the degree to which athletic training students are offered autonomous clinical experiences has not been well researched.

Athletic training preceptors and athletic training students have both identified that 1 characteristic of an effective preceptor is to give responsibility and autonomy.⁸ However, it is unclear if athletic training students are being appropriately provided with progressively autonomous clinical experiences as there have been conflicting reports on this subject.^8,19–21 Athletic training students have expressed frustration, indicating that they were not receiving enough autonomy to hone their clinical skills.^8,20,21 In some cases, athletic training students were not being allowed to have meaningful patient interactions.²⁰ Programs have also indicated that they do not train preceptors differently for immersive clinical experiences, suggesting that they are not well equipped to maximize these experiences in creating autonomous practitioners.²² The purpose of this study was to investigate the experiences of athletic training preceptors and how they provide athletic training students with a progressively autonomous clinical experience.

METHODS

Participants

To be included in this study, participants must have been athletic trainers who have filled the role of clinical preceptor for a CAATE-accredited institution for a minimum of 4 weeks, the minimum number of weeks for an immersive clinical experience, within the past 2 years. To identify eligible preceptors, we contacted clinical education coordinators (CECs) using emails acquired from the publicly available websites for programs and the Commission on Accreditation for Athletic Training Education profiles. A total of 286 CECs from CAATE-accredited programs were contacted, of which 36 preceptors from those programs responded indicating their interest in participating in the interview. Nineteen participants responded to follow-up requests and completed the interview (Table 1). Participants were, on average, 32 ± 5 years old, with an average 8 ± 5 years of clinical practice and an average of 5 ± 3 years of experience as a preceptor (range, 1–10 years).

Table 1.Participant Demographics

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Instrumentation

We used a Qualtrics survey to gather participant demographic information, including age, education level, years of experience as an athletic trainer, years of experience as an athletic training preceptor, and job setting (Table 1). The survey allowed preceptors to share contact information for the semistructured interview. We developed a qualitative semistructured interview protocol (Table 2), and it was externally reviewed for clarity, relevance, and structure.^23,24 Questions were designed to investigate preceptor perceptions about creating progressively autonomous learning experiences and strategies they use to implement progressively autonomous experiences. We sent the interview protocol to content and qualitative interview experts who provided feedback on script structure, clarity, and quality. We incorporated the expert feedback into the interview script, and 2 practice interviews were conducted before data collection occurred.

Table 2.Interview Protocol

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RESULTS

During data analysis, 2 domains emerged: Preparation and Implementation (Figure). Both domains were further broken down into categories. Categories within the Preparation domain included Perceived Importance, Personal Development, and Lack of Programmatic Development. Categories within the Implementation domain included Initiative and Confidence, Progression, Execution, and Assessment (Table 3).

Table 3.Frequencies for Categories

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Preparation

Preparation represents factors that influenced participant training and preparation to deliver a progressively autonomous experience.

Perceived Importance.

Perceived Importance refers to how participants viewed incorporating progressively autonomous clinical experiences for their students. All participants described that incorporating progressively autonomous clinical experiences was important to the development of the student to some degree. Mary, when asked about the role that progressively autonomous experiences play in clinical education, responded,

I think that it helps to prepare athletic training students to be clinicians on their own. Progressive autonomy really helps the students to grow in their confidence and grow into their independence and truly helps to prepare them for the careers that they are signing up for.

Typical responses included the belief that progressively autonomous clinical experiences provided a safe space for students to make mistakes while learning and were important to students’ educational progression. Progressively autonomous clinical experiences were reported to be extremely important to develop students into practice-ready athletic trainers following graduation. Supporting quotes for the Perceived Importance category are found in Table 4.

Table 4.Perceived Importance Quotes

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Personal Development.

Participants spoke about the actions that they took to prepare themselves for the role of preceptor and provide a progressively autonomous experience for their students. Many preceptors reported that their personal experiences as a student influenced much of their personal development for providing a progressively autonomous clinical experience. Participants in our study commonly leaned on their experiences when they were students in shaping how they allowed students to progressively engage in autonomous practice. Laura replied,

I think it plays a big role, just from my own experience. As a student, I felt like I learned the most and grew the most as a clinician when my preceptors allowed me to go as far as I could with my knowledge.

Additionally, some reported that military experience, experience being a coach, and postprofessional education also helped prepare them for the role of preceptor. Several participants mentioned taking continuing education courses on preceptorship to help develop themselves. Supporting quotes for the Personal Development category are found in Table 5.

Table 5.Personal Development Quotes

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Lack of Programmatic Development.

All participants reported that they received some form of preceptor training from the athletic training programs. However, all but 1 of the participants reported that they had never received training from the program on how to provide a progressively autonomous clinical experience. Expanding on program training when discussing preceptor training Derrik stated,

When it comes to progressive autonomy? No, there wasn’t a training that they go through, but most of it is talking about the requirements of the program and expectations of the student. They do not really cover autonomy specifically. I guess you could get a gist of that in that conversation, but a lot of it is making sure that the preceptors are guiding [the students], trying to define their skills and things like that and help them with anything that they may be a little bit more nervous about or apprehensive about. Those are the kind of the things that we typically talk about during those trainings.

Participants expressed limited programmatic development relative to assessment of the student’s readiness to practice more autonomously. Preceptors felt that training on student assessment was lacking, and they reported feeling ill prepared on how to assess if a student is ready to progress and be more autonomous. Haley responded about training on assessment,

I don’t think there really is. I think that’s a little bit of a trial by fire, especially when you’re in the thick of it in the season, and they’re traveling, and they’re getting games and practices, and this that the other. Hey, can you do this? And they get that frozen look on their face? Okay, no, we’re not ready for that. Then in the downtime you back track [and say] let’s talk about that moment.

Implementation

The Implementation domain encompasses the strategies that preceptors used to provide their students with progressively autonomous clinical experiences. The strategies included how decisions are made on how much autonomy to provide, day-to-day execution, and how they assess students about their readiness to be more autonomous.

Initiative and Confidence.

Preceptors did not describe a formal baseline assessment to know how much autonomy to give a student at the beginning of a clinical experience. Rather, preceptors described using the student’s initiative and confidence as a means of assessing readiness for more autonomous experiences. Speaking on the importance of confidence, Kate replied,

If you feel comfortable enough to do something, I’m going to let you try it. I may be behind the bushes watching you while you’re trying it, but if you want to try something [I will let you try it]. How else are they going to learn if we do not trust them enough to do something?

The importance of students taking initiative was also commonly reported. Preceptors reported making decisions on what they felt comfortable allowing students to do based on how much initiative the student demonstrated and how engaged they were in the learning process. Supporting quotes for the Initiative and Confidence category are found on Table 6.

Table 6.Initiative and Confidence Quotes

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Progression.

Preceptors described the student’s progression in their program as an important data point to determine the level of autonomy to give a student. Meaning, preceptors used the length of time the student was in the program and curricular map as a means of making decisions on the level of autonomy they would provide the student. Kate, when talking about student expectation stated,

There are different expectations for first year versus second year [students], and I have initial expectations even before the student orientation. Where, if it’s a first-year versus a second-year, I know that a second year would be a lot more comfortable taking more initiative as opposed to a first-year student that would probably not take that amount of initiative. I have these preconceived lines where I think each student will fit in, and then once we meet with them, we discuss what previous clinical experiences they have had. What classes have they taken? What are they comfortable doing?

Others reported having students who are further along in the program’s chronology teach and assist those that do not have as much experience. Using this method, preceptors reported being able to help more advanced students solidify their learning through teaching as well as giving beginning students the ability to learn from someone who can easily relate to where they are in the program. Supporting quotes for the Progression category are found on Table 7.

Table 7.Progression Quotes

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Execution.

Execution is the specific strategies and day-to-day methods preceptors were using to provide students with a progressively autonomous clinical experience. Many participants reported the importance of establishing open lines of communication, setting expectations early, and establishing goals with students. Daren provided the following example of opening clear lines of communication to set expectations and establish goals:

I start with a pre-email, letting the student know my expectations through that semester, and how that’s going to go so that way they can get in the right frame of mind. It covers how many sports, how many athletes, what’s expected, pitfalls that I’ve seen in other students to help them get their mind right and then a consent for weekly homework assignments that aren’t graded. I just like making sure my students think. When they get here, we do a prerotation meeting before anything happens, and I go over their goals, and we establish smart goals. And then, once patient interaction starts in the beginning, I’m really involved, but I don’t really step in.

Some preceptors implemented planning strategies to identify patient cases that would be appropriate for their students to take based on their current skill set. Part of this planning frequently included involving the student in the decision-making process. Tasks would be assigned to patients based on their comfort and knowledge levels. In settings where patients had scheduled appointments, the preceptor would assign the student to take the lead on the patient’s care. When it came to situations where students made mistakes when offered an autonomous experience, preceptors described using a debrief after the encounter to provide feedback in a safe space. Supporting quotes for the Execution category are found on Table 8.

Table 8.Execution Quotes

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Assessment.

Assessment refers to how preceptors are evaluating the progress of their students to determine if the level of autonomy a student has is appropriate. Most of the assessment strategies shared by preceptors were subjective in nature. Participants reported working with students to gauge progress and skill development and make decisions on adjusting autonomy based on these perceptions. Another commonly used assessment tool was a proficiency or core competency checklist derived from the 2012 educational competencies (which are no longer part of the CAATE 202 standards).²⁵ Conner stated,

Every program I work with does it a little bit differently. But in general, it is the proficiency checklist. [For example] with ultrasound, they need to make sure that they identify all the indications, counter indication, and set up. Understand why we’re doing the treatment, and they need to do that in a supervised fashion. Once we’re confident that they can do that [they will be] checked off in an athletic training room. Then we’ll allow them to perform that treatment. That is a real basic example but working into something [more complicated] like covering a game by themselves, we’re going to need to make sure that they can pretty much do all aspects of the job at that point. An acute on field evaluation coach communication, handling the weather, just everything that goes into it.

Using checklists had reported problems. Grading scales were not always made clear, and training was limited on how to apply the grading scale to students. Preceptors reported having to guess how to apply the grading scale. Supporting quotes for the Assessment category are found in Table 9.

Table 9.Assessment Quotes

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DISCUSSION

We sought to explore the experiences of athletic training preceptors and how they provide athletic training students with progressively autonomous clinical experiences. Clinical education in athletic training should prepare athletic training students for autonomous clinical practice following certification.^1,26 A critical component of ensuring students are able to practice without supervision is preceptors providing progressively autonomous experiences to students.^5,26,27 Establishing strong mentor/mentee relationships between preceptors and students and providing quality progressively autonomous clinical experiences has been shown to help prepare students for the workforce.²⁷ Athletic training programs should continue to develop preceptors as mentors and foster positive mentee/mentor relationships for athletic training students.

Our results indicate that preceptors believe that providing progressively autonomous experiences to students is an important part of being a preceptor. The benefits of autonomy described by our participants align with other research on the subject; however, our findings also indicate that programs are not adequately training athletic training preceptors to assess students’ readiness to progress.^4,5 All but 1 participant reported that there was a lack of training on how to provide a progressively autonomous clinical experience. Insufficient preceptor training is a theme that has also emerged in other studies.^28,29 Although participants reported that programs are providing training to preceptors, much of this training is reportedly focused on providing basic information on the role of the preceptor. Most of the participants found that these trainings were helpful for new preceptors but that they were not helpful for more experienced preceptors.²⁹ Participants also believed that the lack of training led to inconsistent assessment strategies. It is possible that these inconsistencies may partially account for the reported frustration among athletic training students, including recent graduates, about inconsistent levels of autonomy.^20,21

To ensure that preceptors are identifying when an athletic training student is ready to progress to more autonomous practice, athletic training programs should develop specific training that includes the importance and benefits, measurement and assessment tactics to ensure readiness, and strategies to implement these more autonomous opportunities when they are ready. Learners benefit from understanding the “why” behind an expectation, and preceptors are no different. Programs must clearly communicate an expectation that as students demonstrate readiness to progress, their preceptors should be giving them more opportunity to practice autonomously. Training could include high-quality simulations that preceptors either participate in as part of their training or video examples that preceptors respond to and receive feedback on.³⁰ Simulation would offer the preceptors a safe place to learn about how to assess readiness and communicate evolving expectations based on the students’ performance and ability to make more autonomous decisions. Simulations provide a method to teach preceptors how to allow for experimentation while also maintaining safe patient care.

All participants in this project shared strategies they used to create more opportunities for autonomy with their students. Preceptors should establish good lines of communication early and communicate expectations from the start.^8,31 Providing quality feedback is also critical to developing athletic training students.^8,31,32 Debriefing provides a valuable tool to deliver feedback and address mistakes in a safe controlled space that can help students develop.^1,33 Athletic training programs should train and have preceptors practice delivering high-quality feedback and fostering meaningful debriefings as a part of training.³⁴ Debriefing is an important tool as part of experiential learning, for both reflective observation and abstract conceptualization. As such, it is important that the debriefing occurs regularly during clinical experiences especially after difficult situations or encounters.

Training should also include methods to track the progress of students and address when problems arise. Poor assessment of student progress allows for gaps in student knowledge to occur that can go unrecognized.^5,35 Our findings suggest that assessment of student autonomy is inconsistent in both Preparation and Implementation. Much of the assessment was subjective and based on student characteristics. Athletic training programs and preceptors should focus student assessment in a manner that focuses not only on performance in a single instance but on how those assessments can be used to tailor the autonomy given to a student. For instance, preceptors can use validated tools such as AT Milestones to track student progress.³⁶ Following the student assessment, the program faculty and preceptors should collaborate to identify where students need more autonomy or more focused supervision for that particular skill/behavior. This proposed approach allows for better collaboration between the program and the preceptor than the approaches described by our participants where preceptors are simply using the chronology of the student in the program to identify the level of autonomy they should be given. Finally, programs should be evaluating whether the clinical environment and preceptor are offering a high-quality progressively autonomous clinical experience and deselecting clinical experiences for immersion if they are not sufficiently offering the time and space for learners to experiment and reflect.

CONCLUSIONS

As the athletic training profession continues to grow, it is continually important that new athletic trainers are adequately prepared for independent clinical practice following graduation and certification. Progressively autonomous clinical experiences are critical to the development of autonomous clinicians in athletic training practice. Properly providing progressively autonomous clinical experiences prepares students to transition into practice. Preceptors in our study described limited training to provide autonomy for athletic training students. First, athletic training programs should establish clear communication and expectations for preceptors related to creating autonomous opportunities over the course of a clinical experience. Preceptor training should also include instruction on effective methods for assessing student readiness, tracking progress, addressing problems in real time, and debriefing to shape the direction of student progression. Athletic training programs should also provide examples of high-quality applications of progressively autonomous clinical experiences that should be shared with preceptors as part of their training.