Factors Influencing Athletic Trainers Pursuing Residency Training Open Access

• Athletic trainers pursued residency training to advance their practice skills, based on personal factors, as well as to develop a specialty.

• Residency programs can improve recruitment strategies to better match clinicians to programs based on their goals and motivations.

• Central messaging regarding residency training and postprofessional pathways needs to improve to clearly define residency training and its role in specialty development to consumers and mentors of those that may pursue residency training.

In athletic training, the need for specialization through postprofessional-level education has emerged.^1–3  The need for specialists has encouraged athletic trainers (ATs) to pursue additional training or other professional development to cultivate advanced practice skills beyond those gained during their professional preparation. Residency training is a postprofessional pathway through which health care professionals can develop specializations within a specific discipline. In athletic training, residency programs are designed to provide ATs with advanced training and experiences within a specific area of clinical focus.²  Previous research^1–3  regarding residencies show the effectiveness of residency-trained ATs in delivering quality health care, improving outcomes, and increasing physician satisfaction and patient throughput. As the profession of athletic training has grown and demanded ATs with specific areas of clinical experience and knowledge, several residencies have surfaced to develop advanced clinical specialists. The Commission on Accreditation of Athletic Training Education (CAATE) recognizes 8 approved residency specialty areas, as follows: prevention and wellness, urgent and emergent care, primary care, orthopedics, rehabilitation, behavioral health, pediatrics, and performance enhancement. As of March 2020, there are 10 CAATE-accredited residency programs.⁴ 

Previous research^5–9  has focused on motivators for other postprofessional pathways in athletic training as well as other health care fields. Researchers have investigated the motivators that influenced ATs to pursue the Doctorate in Athletic Training Degree.⁵  Research has been conducted in other health care disciplines, such as surgery^6–9  and nursing,¹⁰  to identify motivators and barriers to individuals in these respective fields. Motivation research in medical education has identified factors such as mentorship,¹¹  autonomy,^12,13  and the expectation of a particular result due to their actions¹⁴  as factors contributing to the motivation of health care residents. Although the Strategic Alliance encourages the development of accredited residencies, specializations, and specialty certifications,¹⁵  current research lacks information or investigation regarding motivation or participation in specialty clinical training for ATs. Therefore, the purpose of this study was to identify the motivating factors that influence ATs to pursue residency training.

We used a qualitative semistructured interview and consensual qualitative research approach to explore motivating factors that influenced ATs to pursue athletic training residency training. We used the Standards for Reporting Qualitative Research¹⁶  to guide both project development and presentation of data. The Consensual Qualitative Research approach was chosen to identify, explain, and provide context to the experiences that the residency applicants had regarding pursuing residency through a recorded, transcribed, and coded phone interview.^17,18  The university institutional review board deemed this project “exempt” before we conducted any interviews or participant recruitment. Participants provided informed consent before recording each interview.

Participants were included if they were ATs who had applied to and interviewed with at least one of the CAATE-accredited athletic training residency programs. It was possible that participants had interviewed at more than one residency program, and it was also possible that they had interviewed with residency programs that had not been CAATE accredited. Participants were not excluded if they had not been selected or if they had not chosen to enroll in a residency program because of their application. ATs who had already started their residency training were excluded because of the potential for their motivations to change with a greater understanding of programmatic goals. To recruit participants for the study, the program directors of each of the 10 CAATE-accredited athletic training residency programs were contacted by email in March 2020; the email explained the goals of the study and the desired participant population. The program directors were then asked to send the recruitment message to final interview candidates for their programs. Additionally, the research team used criterion sampling to recruit potential participants via social media postings, confirming eligibility for the project before conducting the interview.

Twelve residency candidates (8 females, 4 males; age 26 ± 3 years; years of athletic training experience = 3.5 ± 3 years) who met the inclusion criteria were interviewed before data saturation was achieved. Demographic information for each participant, including the participant pseudonym used to protect participant identity, is displayed in Table 1.

A semistructured interview script (Table 2) was established that consisted of questions regarding how the participants learned about residency programs, what factors motivated them to pursue residency training, and areas in which the applicant felt that the residency programs could improve. The interview script was created by the primary and senior investigators. With permission, we used the interview script from a previous study⁵  exploring motivators to pursue a Doctor of Athletic Training (DAT) degree to guide the development of this interview script. After the script was developed, it was revised and validated by peers who are experts in both qualitative research and residency content. The primary investigator conducted 2 pilot interviews to refine the script. The 2 pilot interviews were done with ATs who had either already completed a residency program or were already matriculating in a residency program. After the pilot interviews, one question was added to the interview script, which was used to identify how the participant would describe the purpose of athletic training residency training.

The procedures for this project are represented in Figure 1. Potential participants contacted the primary investigator via email expressing their interest in the study. The primary investigator provided the potential participants with the informed consent document and invited them to schedule a Web-based teleconference interview. The participant then confirmed their enrollment status. Any questions regarding the study were answered before starting the interview. When the interview began, the primary investigator reviewed the purpose of the study, informed consent, and information regarding member-checking and withdrawal. Each interview lasted approximately 25 minutes, and participant interviews were recorded via Zoom (San Jose, CA) in a private room to ensure that the responses were confidential. At the end of each interview, the primary investigator deidentified the transcripts and created a pseudonym for each of the participants. The deidentified transcripts were then sent to the participant to check for accuracy (ie, member checking). Data collection continued until the research team reached saturation with 12 interviews.

Once all data were accurately transcribed and confirmed for accuracy, 3 members of the data analysis team (D.J.D., C.E.W.B., L.E.E.) used a Consensual Qualitative Research approach to complete the data analysis.^17,18  Comparison¹⁹  was used throughout data analysis to ensure consistency among the investigators. Four transcripts were individually coded to identify domains, subdomains, and categories.²⁰  The data analysis team then met to establish a preliminary codebook. The team then checked the codebook against 2 transcripts from the first step and 2 new transcripts. The team met again to establish a consensus codebook. Once consensus was reached regarding the codebook, the transcripts were divided evenly (4 each) among the members of the data analysis team. Each member analyzed their assigned transcripts using the consensus codebook and coded the applicable domains, subdomains, and categories. We internally audited the coded transcripts by verifying the coding with one other member of the data analysis team. Any discrepancies were discussed by the data analysis team, and a two-thirds majority was used to confirm a code. After the analysis was reviewed and confirmed, an external auditor (M.J.R.) served to confirm and verify the accuracy of the information that was collected and reviewed. The data analysis team included the primary investigator (novice qualitative researcher) and 2 expert qualitative researchers (L.E.E., C.E.W.B.). The external auditor, an experienced qualitative researcher, served in this role based on previous experience with qualitative research and familiarity with postprofessional educational pathways.

Once the consensus codebook was confirmed by the external auditor, cross-analysis of the coded information was performed by the primary investigator to ensure all coded material was appropriately aligned with the codebook. We then calculated the frequency of responses.^17,18  With respect to the 12 transcripts analyzed, a category was labeled general if all or all but one participant case was coded, typical if 7 to 10 participant cases were coded, variant if 4 to 6 participant cases were coded, or rare if 3 or fewer participant cases were coded.¹⁷ 

Four domains emerged: (1) support to pursue, (2) personal influencers, (3) professional influencers, and (4) future recruitment considerations (Figure 2; Table 3). With support to pursue, ATs described the resources, individuals, and events that led to their exposure and an increase of knowledge about residencies. The personal influencers described by the participants included factors that stemmed from their personal lives: specifically, the participants improved respect, work/life balance, and financial standing as a result of completing a residency program. The participants also discussed professional influencers like self-improvement, specialty training, a change of professional setting, as well as a team-based approach to care that they hoped would change their professional life as a result of completing a residency program. Professional influencers also included a subdomain in which potential residents aimed to gain advanced practice skills in clinical care, scholarship, and leadership. Future recruitment considerations focused on the participants' feedback regarding central messaging, modes for recruitment, clinician experience, and setting limitations.

All participants described mentors (including program and clinical educators), with knowledge of residencies, as a primary source for learning about the existence of residency programs. Edward stated that:

Other participants learned of, or were exposed to, residencies through direct residency contacts. These contacts included previously established colleagues with direct knowledge of a residency, electronic communication with program administrators, or interactions at educational conferences/events with ATs associated with a residency program. Gordon described his initial interaction with residency-trained ATs through a colleague of his with whom he already had a relationship:

Participants also initiated contact with residency faculty to garner more information regarding the programs. Barbara described her experience as follows:

All the participants also highlighted the importance of Web resources to improving their knowledge and understanding of residencies. However, some participants were able to discover more resources than others. The NATA, CAATE, and Athletic Trainers in the Physicians Practice Society (ATPPS) Web sites, as well as the program-specific Web sites for each residency, served as common sources of information. Leslie described her data-retrieving process by noting, “I used the NATA website and the CAATE website to find out what programs they offered and what made up those programs.” Tabitha also stated that she found the program-specific Web sites to be valuable tools with which to uncover more information: “I looked into their website. Once I looked at all of the specialties I then realized where I preferred to go.”

Personal influencers were factors that were driven by personal reasons, feelings, and motivations to seek residency training. Participants were hopeful a residency would improve work/life balance compared to their current or previous job setting. Harvey described his work/life balance and how the residency would impact it by saying:

Participants also hoped residency training would improve their experience of feeling respected. Bruce said:

Bruce goes on to say, “I think a big part of it [completing a residency] is the respect of my current peers and those that I work with right now and having the support of physicians.” Jada also spoke to how residency training can bolster ATs' perceptions of being respected and valued by stating “It [residency] is allowing us as athletic trainers to demonstrate our work and value in areas other than just soccer fields and basketball courts.” Harvey spoke more to personal respect and trust:

Edward also spoke on the importance of being a clinician who can provide consulting to other peers:

Financial considerations also played a role in the participants' choice to pursue residency. Ivy spoke of some of the potential financial issues with which someone could be faced when trying to identify residencies that they are interested in: “I think even my selection of the residency program that I chose had a lot to do with cost of living in certain areas and what I could afford.” Harvey, a consistent proponent of pursuing residency training for personal reasons, also spoke to the idea that graduates may make more money upon completion of the program: “It's been shown that most ATs that follow the residency program [pathway] start their salary at a higher rate than those in a more traditional setting.”

Participants identified self-improvement as a clinician as a professional influencer for pursing a residency. Bruce described his desire as follows:

Since several athletic training residency programs are located in the physician practice setting (especially those with an orthopaedic focus), the setting of the residency played a role in participant reasoning to pursue the residency. Gordon spoke to his desire to work with a new patient population: “I just want to experience a different patient population, besides college athletes, that I've been exposed to for the past few years.”

Participants also indicated that specialization was an important professional influencer for pursing residency training. Leslie stated:

As a result of working within the physician's practice setting, many residents also described a desire to take a more team-based approach to health care. Gordon explained his desire to work with interprofessional teams:

Harper also described a desire to pursue a team-based approach to care through collaboration by stating:

As a subdomain of professional influencers, participants recognized that some program benefits came from studying in any postprofessional pathway. Specifically, they identified that they would develop advanced practice skills in clinical practice, scholarship, and leadership. Participants indicated they wanted to develop clinical skills specific to the residency program's focused area of practice. Renee identified specific orthopedic-based skills that she was seeking to gain from residency:

Several others, like Harvey, also discussed how residency programs can be used to improve skills for which they have foundational knowledge, such as orthopedic clinical examination skills:

Another component of residency training is the opportunity to participate in activities related to scholarship. Using outcome measures and other clinical tools, residents can advance their scholarship through data collection, quality improvement, and research activities. Tabitha discussed her excitement to participate in scholarship activities as a part of her residency program: “I know that through the program that I am a part of we will be doing research and doing more outcomes-based research within the residency.” Renee also stated:

Finally, Barbara described her desire to prepare for a position of leadership in the profession, specifically as a clinical teacher:

Ivy identified that scholarship and leadership were areas in which she was not seeing herself grow, supporting her professional influence to pursue a residency:

Most participants stated a concern that there is not enough general understanding of what residency training is and what it entails. There is a concern that the term “residency” is used interchangeably with other words, such as “fellowship” and “internship,” causing confusion as to the real meaning of residency. Bruce described this uncertainty as follows:

There also seemed to be a general misunderstanding as to the role of residency programs. Some clinicians believed that residency training is another program to help young professional transition to practice. However, Barbara identified that this is not the purpose of residency:

Several participants also indicated that more can be done to promote residency programs, to explain what being a resident means, and to explain the pathway through different modes of recruitment. Some residencies are doing presentations at local universities and conferences, which participants like Selina stated were important in their motivation:

Participants indicated that the perception that residency training is limited to one setting (physician practice) and requires experience in a specific setting was problematic. They indicated it was important for programs to speak about the transferability of the skills learned in a residency program, regardless of training setting. Edward states:

The purpose of this study was to identify the motivating factors that influence ATs to pursue residency training. In this study, 4 domains and 1 subdomain emerged that were recurrent among participants. Participants indicated they had both personal and professional reasons to pursue a residency. Among the professional reasons, participants were influenced by professional factors that impacted their ability to provide care in a specific setting that was team-based. They had a desire to engage in learning that led to specialization and self-improvement, Most of all, they wanted to advance their skills in clinical practice, leadership, and scholarship. The participants also had supportive factors that helped them learn more about residency program opportunities and provided recommendations for future recruitment considerations. These findings illuminate what motivates ATs to pursue residency training compared to other forms of postprofessional education and draw connections to specialization development in other health care professions.

In this study, we found that most ATs learned about residency programs through mentors with a knowledge of residency or through direct contact with an individual involved in a residency and then further discovered pertinent information through Web resources. Research in physical therapy residencies highlights that expert training is an accepted pathway, and the method by which to pursue this pathway is taught as part of the learner's professional-level education.^21,22  This, however, was not clearly or consistently communicated to participants seeking athletic training residency through their professional-level education. Since anecdotal evidence suggests there is a knowledge gap about the value of residency training and postprofessional pathways among mentors who guide early career ATs, further research should seek to identify areas to help improve central messaging. Without the influence of mentors and direct residency contacts who had a knowledge of residency, most ATs stated that they would be unaware of the existence of residencies.

Participants also indicated needing to use multiple Web resources to find the information that they needed to understand the position of a resident. While this did not deter ATs from pursuing residency training, it shows that there is need for more concise central resources from the profession. This central messaging should be designed to adequately explain what a residency is, for whom residencies are targeted, and how residency impacts the career path of an individual. The resources developed already should also be shared to improve their reach (Table 4).

The participants who were pursuing athletic training residency training described that while they had social support from friends and family, they considered the financial implications (cost and future benefit) as well as hoped-for improved work/life balance and respect anticipated to result from residency training. Similar to ATs pursuing the DAT degree, financial considerations were seen as a barrier to some because of the cost of living and attending the program.⁵  While one does not have to pay to be a resident, some participants described having to take a pay cut in order to participate in the program, which can impact decision-making of potential residents when considering a program. Residents also described a desire to improve their work/life balance compared to that associated with their current or previous positions. When compared to those pursuing a DAT degree,⁵  there is a drastic difference in the participants' opinion of how further education would change their work/life balance. For those pursuing the DAT degree, work/life balance was seen as an initial challenge⁵  that would negatively impact their current balance while completing the degree. This may be due to the current state of DAT programs, which are nonresidential and add additional responsibilities to one's current clinical practice, versus the integrated learning environment offered within a residency. When participants described discontent with their current positions, they saw residency as a path to potential improvement, especially because they considered a residency in the physician practice setting as a setting with more work/life balance, one offering a more traditional schedule.

Another key factor for participants was their desire to increase their internal feeling of respect in their workplace and their desire to develop respectful relationships with other providers. This demonstrates a similar desire to achieve respect shown in both other postprofessional athletic training pathways and other health care professions. DAT students described a desire to improve professional advocacy and to gain respect for their profession as a whole.⁵  Athletic training residency candidates reported an idea of respect that was more consistent with that identified by medical students and surgical residents^7,9 ; by gaining greater respect among their peers, they then foster further their internal motivation through a feeling of respect as well as through serving as models for the profession of athletic training.

The participants demonstrated a desire to pursue specialization, engage in self-improvement, take a team-based approach to patient care, and change the setting in which they work. For other professions, such as surgical residents⁹  and physical therapy residents,^21,22  the focus of the residency program was not to provide an avenue to change the place in which they worked but rather to develop expert-level knowledge in the specific area of focus that they chose.

Development of specialization was also a primary influencer for participants who wanted to practice at the top of their license and engage in skills to be as effective and efficient as possible within a new setting. Residencies are expected to be one avenue for specialty certification in athletic training and incorporate both clinical and didactic education in the development of clinical specialists. Several participants in the study applied to residency programs of differing specialty areas. In residency training for physical therapists, it is suggested that clinicians do not pursue a specialty unless they are completely invested in that focused area of practice.²³ 

Participants also discussed the desire to work with and learn from multidisciplinary teams and specialists to provide higher quality, team-based care to their patient panels. In nursing residencies, nurses viewed residency as an avenue for improving interprofessional practice and a multidisciplinary team approach to care.¹⁰  Residency-trained ATs have also been shown to improve team-based outcomes that have been shown to increase success and throughput in a sports medicine clinic.³ 

As part of postprofessional education, participants anticipated advancing their practice skills. Like surgical residents⁹  and physical therapy residents,^21–23  athletic training residents seek the development of skills within a specific discipline to develop a specialization. Currently, most participants seek to develop skills related to orthopedic evaluation and assessment. The development of these skills within the physician practice setting is also consistent with literature^1–3  regarding the effectiveness of athletic training residents within the setting. Moreover, the skills cited by the participants were consistent with those detailed in the 2020 BOC Orthopedic Practice Analysis²⁴ for an orthopedic specialty. This redundancy in motivator, standard of program delivery through accreditation, and specialty certification demonstrate alignment and further reinforce that residency serves as the industry standard in the pathway of developing ATs for specialty certification.

Previous research²⁵  on specialization in athletic training highlights the importance of continued education and pursuit of knowledge within a specialty area, similar to the desires of participants to be more engaged in clinical scholarship. Residencies serve as an opportunity for clinicians to not only gain the knowledge of how to become a specialist but also give clinicians the responsibility for maintaining their specialization and continuing professional development upon completing the training.

Participants described a lack of consistent and accurate central messaging through which to define residency. The 2012 “Future Directions in Athletic Training Initiative”¹⁵  describes the use of standardized language to describe the nature of residency. There appears to be a disconnect among what residencies are, the role they play in the postprofessional pathways, and the scope of athletic training positions. Currently, programs that are CAATE-accredited or are pursuing accreditation are the only programs required to use standardized language to define residency and fellowship. The Strategic Alliance should continue to encourage adoption of these standard definitions and actively work to help those who are misusing the term residency to refine their offerings and pursue accreditation. Consumers need clarity and consistency from the professional organizations to define the scope and purpose of the residency pathway within athletic training.

Participants also described having mixed information on the target applicant for residency programs. Some thought residency training was a means of improving transition to practice; however, literature¹  describes residency as a way to develop specialization within a specific focus. Mentors are likely to be in the strongest position to guide early career ATs into postprofessional pathways. Messaging that emphasizes the distinction between residency training and transition to practice would be helpful to improve mentorship aimed at guiding early career AT next steps after professional training. Since the participants in this study described the importance of direct residency contacts in their motivation and pursuit of residencies, experts across the spectrum of postprofessional education should be encouraged to educate both professional-level students as well as credentialed ATs about the postprofessional opportunities available to them. Currently, the field of physical therapy offers dedicated resources that outline and explain the goals of residency training using common language to explain the pathway.^22,23  This common language unifies the profession by delineating postprofessional pathways as well as preventing the creation of positions that claim to be residency training but that lack the standards necessary to uphold the standards of the pathway through accreditation. Greater use of standardized language as well as pathway role delineation can reinforce the purpose of residency within the scope of athletic training.

Participants also described a limitation that the clinical setting of a residency may be a limiting factor. This perception may be a result of the limited research in residency effectiveness, in that the only setting where evidence exists is physician practice.¹  Continued proliferation of residency programs beyond the physician practice setting are needed, and those programs should be actively focused on publishing and publicizing their effectiveness at training clinical specialists in their focused areas of practice. The “Future Directions of Athletic Training^” Initiative¹⁵  calls for the development of more residencies across the different specialty areas.

We originally aimed to recruit participants who interviewed and secured a position in a CAATE-accredited residency program. Because of the COVID-19 pandemic, some residency programs were unable to fill residency positions and we were forced to adjust the recruitment strategy to those who interviewed. Although we used comprehensive recruitment strategies that accessed all potential programs, not all programs are represented within the sample. The nature of qualitative research is exploratory; future research should seek to generalize these findings among current and former residency-trained ATs. In addition, continued research should seek to understand interest among ATs currently enrolled in professional programs for residency training, including understanding of residency training and specialization.

ATs who pursued residency programs described personal and professional influencers in pursuing residency training. Participants also identified supportive resources that helped them better understand residency training and provided suggestions for how the athletic training professional and residency programs can improve recruitment strategies. Participants expressed several concerns regarding central messaging regarding the role, purpose, and goals of residency training. This lack of consistency can be a limiting factor for the growth of residencies because ATs may lack the knowledge of this pathway as well as understanding related to the outcomes of this pathway. Central messaging from professional organizations must clearly align and reinforce the role of residency in developing specialization.

We would like to thank Nicholas “Nick” Pfeifer, Jefferson Jackson “JJ” Wetherington, and Bonnie Van Lunen for their contributions in reviewing our interview script. Their knowledge and experience with residency education were valuable to the project.