Exploration of Anticipatory Socialization and Transition to Practice: Multistakeholder Perspectives

• Novice athletic trainers (ATs) are described as being knowledgeable, energetic, and moldable, but struggle with self-confidence, communication, and health care administration tasks.

• Regardless of experience level, many ATs described how reciprocal learning helped them learn new skills, concepts, or strategies to navigate clinical practice.

• Professional program faculty and preceptors play a critical role in preparing novice ATs by ensuring that students get a variety of clinical experiences, practice professionalism and interprofessional skills, and engage in ATs' daily tasks.

Anticipatory socialization in athletic training is the process by which students obtain the requisite knowledge, apply it to clinical practice, and develop professional behaviors in preparation to enter the profession.^1,2  Completing immersive clinical rotations, learning to provide care for diverse populations, experiencing multiple employment settings, and engaging in daily responsibilities of athletic trainers (ATs; eg, clinical documentation, communication with coaches) while enrolled in a professional program have been identified as effective strategies to ease students' transition to practice.^2–6  However, fragmentation of hours spent in the clinic while balancing classes and supervision standards may prevent students from fully realizing the roles of ATs. In a recently developed theoretical model of transition to practice for ATs,⁷  an initial culture clash between educational and professional cultural norms was identified. Students realized they had been shielded from some responsibilities of ATs and lacked the skills to manage conflict that resulted from others' ignorance of ATs' scope of practice and interprofessional power struggles. The clash led to self-doubt and feeling overwhelmed, but eventually resulted in the development of coping strategies and ultimately finding their own rhythm of clinical practice.

It is well established that the transition from student to autonomous clinician can be a stressful time for novice ATs.^8–13  Whereas supervisors described novice ATs as knowledgeable, their interpersonal skills and ability to apply their knowledge to clinical practice were deemed lacking.^14,15  Novice ATs also felt academically prepared to enter the workforce, but reported they initially felt nervous, lacked confidence, and had difficulty making autonomous decisions.^1,3,8  To mitigate the barriers, it has been recommended for supervisors to establish a mentor program and conduct a structured onboarding or orientation process.^12,15  Organization-level support is needed; however, professional program-level planning of curriculum delivery and strategic scaffolding of clinical education to promote anticipatory socialization of students is also essential. Much of the literature on the transition to practice of ATs is from the perspectives of novice ATs and supervisors separately. Therefore, to build on previous work on the anticipatory socialization of students, we investigated multiple stakeholders' perceptions of and experiences with novice ATs as they enter the workforce. The following research questions guided this study: (1) What are novice ATs' strengths and contributions to the workforce? (2) What factors facilitate or impede novice ATs' transition to practice? (3) What do stakeholders identify as areas of need for novice ATs?

We followed the consensual qualitative research tradition^16,17  for this qualitative study. The approach was used to investigate multiple perspectives and gather a deeper understanding of novice ATs' characteristics, their professional preparation, and their transition to practice. The consensual qualitative research design was used to limit individual biases while analyzing and presenting the data, which added to the credibility of the study.^16,17 

To gather the perspectives of multiple stakeholders, we interviewed 10 faculty and 8 preceptors (age = 43 ± 10 years, experience in their role = 11 ± 12 years), 16 supervisors (age = 52 ± 11 years, experience in their role = 14 ± 11 years), and 17 novice ATs (age = 26 ± 5 years, experience = 9.5 ± 5 months, bachelor's degree = 5, master's degree = 12). The inclusion criteria for novice ATs were having obtained their credential within the past 2 years and practicing as ATs. These criteria were used to focus on ATs' initial transition to practice as they learn to adapt to their environment and function as autonomous clinicians. Faculty, preceptors, and supervisors were included if they were currently serving in their particular role and frequently interacted with students and/or novice ATs. Because data collection started right before and continued through the COVID-19 pandemic, participants who met the inclusion criteria before the start of the pandemic were included because they would be asked to reflect on their current and past experiences regarding novice ATs' transition to practice.

The University of Lynchburg Institutional Review Board deemed this study exempt. The National Athletic Trainers' Association (NATA) survey service facilitated purposeful recruitment of novice ATs, faculty, preceptors, and supervisors. The NATA randomly selected 500 novice ATs, 852 ATs designated as faculty (accounting for all NATA members who identified as having an academic appointment), and 2000 ATs across all settings to email. The email contained a link to a survey that included the purpose of the study, research team contact information, and items about demographics (eg, employment setting; NATA District; years of experience; role as a novice AT, faculty, preceptor, supervisor) and contact information if interested in participating in our study. We also used a snowball sampling strategy by asking participants at the end of the interview to share the study email or contact information with potential participants who met the inclusion criteria and added diversity to the group (eg, geographic region, employment setting, professional program level). Of the 51 interviews conducted, 4 novice ATs and 2 preceptors were recruited through snowball sampling. To gather multiple stakeholders' perspectives, we developed interview guides based on the available literature on transition to practice.^3,8,10,18  The guides were peer reviewed with 2 qualitative researchers with extensive experience publishing manuscripts on ATs' transition to practice and 2 practicing ATs who supervised novice ATs. The interview guides were tailored to each group of participants, and then piloted with 2 individuals from each group (novice ATs, faculty/preceptors, supervisors). Minimal to no revisions were made to items in the interview guides based on the pilots, and pilot interviews were not included in the analysis. Core questions or interview items for each group are provided in Table 1.

Potential participants were divided into 3 groups (supervisors, faculty/preceptors, novice ATs) based on their responses within the initial recruitment survey and then contacted by a member of the research team. Each member of the primary research team (T.M.K., T.G.B., A.B.T.) was assigned a group and conducted all interviews from that group to ensure consistency. As interviews occurred, the research team confirmed that data saturation had been met through the repetition of key concepts within and across groups but continued with a few additional interviews that had already been scheduled. Participants had the option to complete the interview on a telephone or computer (camera on or off) and provided informed consent to be interviewed and for the interview to be recorded for transcription purposes. The interviews were transcribed verbatim and deidentified before analysis. Participants were sent a copy of their transcript to review for accuracy, and transcripts were deemed ready for analysis upon receipt of revisions or after a 2-week period had passed. Only minor grammatical or wording revisions were made to a few transcripts, and no new information was added at that time. The Figure illustrates the data collection and analysis process used for this study.

Based on the consensual qualitative research tradition,^17,19  the primary research team individually analyzed 3 transcripts from one group of participants to identify potential codes. They met to establish an initial codebook and then analyzed 2 additional transcripts. They met again to discuss codes, to identify themes and subthemes, and finalize the codebook. To complete the analysis, one researcher coded the remaining transcripts for a participant group and the other researchers cross-checked the codes using a rotating internal audit process.^17,19  For example, T.G.B. analyzed all remaining novice AT transcripts, then T.M.K. and A.B.T. confirmed consensus of all codes. If 2 researchers had different codes for a quote, the third researcher served as a tiebreaker. The rotating internal auditing process followed a similar approach used in athletic training research among experienced qualitative researchers.¹⁹  The analysis process was repeated for each participant group.

After the confirmation of codes, the primary research team sent an external auditor the final codebook, 2 or 3 blank transcripts, and 2 or 3 coded transcripts for each participant group. The external auditor, an AT with prior experience in qualitative research and as an external auditor, confirmed the coding schema and coded transcripts. Another research team member (S.M.L.) viewed the selected quotes and confirmed that the quotes represented the assigned theme/subtheme, presented perspectives across groups, and included a variety of participants within groups. Table 2 presents the frequency of participant quotes for each theme and subtheme. Coded frequencies were labeled as general (90%–100% of all participants), typical (51%–89%), variant (11%–50%), or rare (1%–10%).¹⁶  To establish credibility and trustworthiness, we used multianalyst triangulation, member checking, rotating internal auditors, and an external auditor as described above.^16,17,19 

Four themes emerged regarding the anticipatory socialization of students and their transition to practice. The themes include the following topics: (1) personal characteristics and behaviors, (2) knowledge and skills, (3) program preparation, and (4) reciprocal learning. Additional participant quotes for each theme are provided in Table 3.

The first theme emerged from participants' descriptions of how personal characteristics and behaviors either facilitated or impeded novice ATs' transition to practice.

Novice ATs were described as moldable and eager to enter the profession. Bob (supervisor) stated, “They're enthusiastic. They're willing to get it done. They're not stuck in a preconceived mode that this is the way I've done it, so I don't want to change. They're a little bit easier to mold.” Similarly, Julia (novice AT) described the benefit of a fresh perspective:

John (novice AT) described his excitement and said,

Similarly, Alicia (preceptor) shared,

The perceptions of being energetic and more relatable to younger patients were also mentioned as a benefit to hiring novice ATs. Erin (novice AT) related her energy to clinical practice by stating, “I think because we are young. And I know for me personally, I like moving around with the students. So, if I'm showing them a rehab [exercise], I'll do it with them sometimes.” Dan (novice AT) believed being young and the way he interacted with patients made him more approachable. He explained,

Similarly, Elsbeth (faculty) shared, “I think they can easily relate to the athletes who are their age. I think they have an energy and enthusiasm that older, more seasoned ATs may have lost.”

Several participants also described how professional demeanor and behaviors were deemed problematic in some novice ATs. Owen (preceptor) reflected on his many years of experience and explained,

Similarly, Dan (novice AT) shared, “Maybe just being on time and that sort of professionalism.” Twyla (supervisor) noticed additional problematic behaviors in some of the novice ATs she supervised, and stated, “Being present in the moment. And I think that's one of the things that some of the young professionals are missing out on. You know they're there on the sideline, but they're on their phone.” Additionally, a few supervisors also commented on intertwined personal characteristics and professional behaviors. Eric (supervisor) elaborated:

Conversely, novice ATs may have a different view of professional behaviors and work-life balance. Julia (novice AT) asserted,

Another factor described to impede novice ATs' transition to practice is a lack of confidence or fear of making mistakes. Cary (faculty) summarized this by sharing, “A lack of confidence in their skills. As educators we see that they have the skills and we understand they have the skills, but sometimes their lack of confidence may lead to some issues.” Likewise, Stephanie (novice AT) said,

Steven (novice AT) agreed with this sentiment and admitted, “I wish I would've just known how to kind of be more confident with it all. I think that's my biggest issue. I don't think it's a lack of knowing, I think it's just a lack of confidence.” Eric (supervisor) attributed the lack of confidence in many novice ATs to the fear of making a mistake. He elaborated,

Similarly, Gwen (supervisor) explained, “It's a fear thing, and I don't know if they're fearful of upsetting someone or fearful of what the feedback might be. I'm not quite sure what that trigger is.”

The second theme included 2 subthemes regarding the strengths and areas for improvement in novice ATs' knowledge and skills.

Overall, participants acknowledged that novice ATs have the necessary knowledge and skills to enter the workforce. Johnny (supervisor) shared, “They excel with their book knowledge.” It was also purported that novice ATs graduate with a better understanding of general medical conditions, emergency management strategies, and how to integrate evidence-based practices. Patti (faculty) provided specific examples of additional skills currently integrated into professional programs, such as “wound closure, airway adjuncts, and rectal thermometry.” Will (preceptor) shared, “They may be very well versed in different manual therapy techniques, whether they have been Graston trained or Postural Restoration Institute or Mulligan.” Glenn (preceptor) elaborated:

Similarly, Stephanie (novice AT) agreed with learning knowledge and skills that differ from the curriculum ATs may have learned in the past. She said:

Participants commonly identified the need for improvement in novice ATs' interpersonal skills, such as communication and conflict management. Like many novice ATs, Paul (novice AT) struggled communicating with parents, coaches, and administrators. He explained,

Lana (preceptor) identified how the method of communication could also be problematic: “Everyone can get themselves into trouble with a quick text, so they have to learn how to prioritize and strategically use those types of communication based on the situation.” Similarly, Diane (faculty) said, “It's more the soft skills, the interpersonal relationships, dealing with people, that sort of thing rather than the actual clinical ones.” Alicia (preceptor) added, “I'd say conflict management. I think it scares them to be the bad guy.”

Other areas for improvement included health care administration tasks and clinical decision-making. Jake (supervisor) said, “They're weak in the administrative/organizational skills. They're not taught how to do insurance claim forms, but I wasn't either.” Christina (novice AT) admitted,

Julia (novice AT) reflected:

However, Jason (novice AT) still identified a need to improve on his ability to do a quick evaluation and “be able to make a decision on the go.” Patrick (supervisor) also noticed some challenges with novice ATs' clinical decision-making: “Their ability to come up with the correct decision in a somewhat timely manner.” Roland (supervisor) attempted to explain why novice ATs struggled in these areas and said, “Just that lack of clinical experience. You know, they spent so much time in the classroom, you know, book smart. But then they're still a little bit behind the curve of how can I apply it?” Likewise, Julia (novice AT) explained, “The young professionals might be a little bit unprepared, just because they haven't had the chance to do some of those things yet.”

The third theme pertained to the perceived effectiveness of the preparation novice ATs received while completing their professional programs.

Several participants engaged in practices to enhance students' preparation to successfully fulfill the roles and responsibilities of ATs. Faculty had developed assignments that connect with clinical experiences or had modified practical exams to encapsulate authentic patient encounters from start to finish. For example, Lana (faculty) explained,

Although it was uncomfortable for Becca (preceptor), she included her students in difficult situations to demonstrate how to adapt in the clinical setting:

Preceptors, supervisors, and students also described ways to address common challenges novice ATs encounter. Glenn (preceptor) shared how he had changed his practice as a preceptor:

Jason (novice AT) valued the opportunity to work autonomously, but with the support and trust of his preceptors. He elaborated:

Related to authentic clinical practice, Emily (novice AT) explained,

Michelle (novice AT) believed her immersive clinical rotation helped her feel prepared and confident in her new job: “I would just be able to implement everything I learned there and really I was there all day, every day. So I really got comfortable.”

Many participants felt students needed more clinical experience to develop confidence and to execute all the duties of ATs. Moira (supervisor) shared, “[Students] need more real-world experience in a variety of things… because a lot of athletic trainers are not necessarily working in a traditional setting.” Similarly, Ed (novice AT) learned about creative problem-solving and suggested students would benefit from an opportunity to work in lower-income neighborhoods:

Roland (supervisor) was concerned whether novice ATs had enough opportunities to make autonomous decisions as students. He stated,

Grace (preceptor) also believed students need more practice working through problems on their own without routine validation or troubleshooting suggestions from preceptors. To better prepare students to make autonomous decisions, her suggestion for preceptors was to “let [the student] fail and struggle through getting to what they think is the solution, and if they can't then help them problem solve, as opposed to giving them the solution.”

Additionally, inconsistencies in the quality of clinical experiences and limited tracking of specific types of patient encounters were discussed. Steven (novice AT) reflected how working autonomously was a shift and shared how his preceptor would often take over injury evaluations. He said,

Owen (preceptor) highly regarded the importance of preceptors, but also proposed future considerations for coordinators of clinical education:

To ensure students get the types of experiences they need, Patti (faculty) suggested:

Collectively, participants described strategies that faculty can integrate into the classroom, preceptors can use with their students, and students can embrace throughout their education.

In the final theme, stakeholders described how they valued the exchange of knowledge, lessons from experience, and different perspectives among all ATs. Whereas it was anticipated that novice ATs would continue to learn from others, novice ATs also contributed to an atmosphere of lifelong learning and were excited to share new information. For example, Caitlin (preceptor) explained, “There is always something to learn from anyone. That's what I tell my students also. They think they are learning from me, but I'm learning from them also. It's not only that I'm the mentor.” Similarly, Ray (supervisor) stated:

Some novice ATs and supervisors also described how reciprocal learning translated into clinical practice. Mary (novice AT) shared:

Erin (novice AT) said:

Twyla (supervisor) also enjoyed the interaction with novice ATs and reflected on her clinical practice:

Overall, several stakeholders acknowledged the valuable contributions novice ATs made to the workforce and respected that learning could be reciprocal, not based on years of experience or level of education.

The purpose of the study was to investigate multistakeholder perceptions of and experiences with novice ATs as they enter the profession. Whereas the findings are similar to those of previous studies on transition to independent practice, the inclusion of novice ATs, supervisors, faculty, and preceptors within the same study is unique. We found that novice ATs were academically prepared but would benefit from additional development of interpersonal skills and a holistic experience of athletic training clinical practice during their professional education. Stakeholders also valued the exchange of skills and strategies to navigate clinical practice that occurred through reciprocal learning.

Novice ATs were described as being energetic, eager, and moldable to their environment, but were also described as lacking self-confidence. Reports of lack of self-confidence among novice ATs are not new^8,15 ; however, multiple stakeholders in our study confirmed that confidence continues to be challenging for novice ATs. Interestingly, the lack of confidence may be intertwined with the fear of making mistakes, which may impede their ability to act or make independent decisions without supportive feedback they are accustomed to receiving.²⁰  Novice ATs have described the initial months of employment as being stressful and feeling nervous,⁸  and may also experience heightened anxiety and other mental health concerns like recent nursing²⁰  and medical school²¹  graduates. However, prior experiences managing a variety of situations with increasing autonomy and decreasing reliance on preceptor feedback over time may help bolster students' confidence before their transition to practice.^3,13  Additionally, preceptors and supervisors should encourage students to engage in healthy lifestyle behaviors, to seek help when necessary during their professional preparation, and to continue these practices for long-term well-being.²⁰ 

Many supervisors, faculty, and preceptors in our study also described a lack of professionalism in novice ATs, such as problematic attire, arriving late, and lack of initiative. As part of the socialization process, it is important for students to observe and embody characteristics and behaviors that align with professional expectations and norms.^15,22  Whereas program directors have stated they most frequently evaluate dependability and responsibility, they less frequently evaluate if students had a positive attitude and perseverance or the concept of being givers and takers.²³  Managing time commitments is essential for work-life balance, but differing values placed on interpersonal interactions and being a team player may partially explain the disconnect between novice ATs' and supervisors' and educators' perceptions of professionalism. For example, supervisors and preceptors commented on novice ATs' unrealistic job expectations (eg, unwilling to go the extra mile, preconceived notions of appropriate work hours), which novice ATs described as being necessary to improve work-life balance across the profession. Reflective journaling and class discussions can be incorporated into professional programs to establish professional expectations²⁴  and to better prepare students for open dialogue with supervisors to prevent misunderstandings.

Novice ATs were described as having a strong academic foundation, which is similar to supervisors' perceptions of novice ATs' textbook knowledge.¹⁵  In the current study, novice ATs' expanded clinical skill set (eg, varying types of manual therapy, diagnostic tools) and knowledge base (eg, recognition and management of emergent conditions, wound closure, general medical examination skills) were also identified because they surpassed content taught in professional programs in the past. However, interpersonal skills, familiarity with completing administrative tasks, and clinical decision-making skills were reported challenges for novice ATs. Collectively, these interwoven skills may ultimately affect job performance, job effectiveness, and novice ATs' job satisfaction. For example, recent graduates in health care often prefer to communicate in mediums that do not require face-to-face interaction, which may affect their ability to articulate a message to administrators or effectively convey information to patients.^20,21  Difficulty navigating a new organization or communicating with coworkers may also affect novice ATs' ability to complete administrative tasks, particularly if they had limited experiences with clinical documentation or insurance billing as students. Adapting and responding to new situations can be challenging for novice ATs; therefore, preceptors can explicitly share how they manage new encounters or conflict so that novice ATs' first experiences with critical conversations are not as new employees. Role-playing through uncomfortable conversations, practicing with low-stakes cases, and engaging in frequent communication with parents or coaches can better prepare students for the role of ATs and improve their interpersonal skills.⁴ 

Similar to novice ATs in previous reports,²⁵  stakeholders in our study believed that professional programs adequately prepared novice ATs with the requisite didactic knowledge, but that more clinical experience was needed. As immersive clinical education becomes commonplace, the transition to practice may become less daunting for novice ATs. Immersive clinical experiences have been associated with novice ATs' improved confidence from living the role of ATs and knowing they have already successfully managed challenging experiences.^2,6  Role integration can begin during any clinical education experience by engaging students in communication with stakeholders, assisting with completing insurance claims and clinical documentation, or problem-solving strategies to address complex clinical problems. As students gain more clinical experience, preceptors can shift from giving suggestions to asking open-ended or pointed questions and encouraging reflective journaling to develop students' clinical decision-making and confidence.²⁶  Similarly, faculty can develop application-based assignments that bridge didactic and clinical education, such as completing the BOC Facility Principles²⁷  at their clinical sites to learn about appropriate policies and procedures, discussing with preceptors how social determinants of health affect health care,²⁸  recording patient encounters and evaluating the worth of their provided services, or reviewing the new employee checklist²⁹  to facilitate transition to practice.

Similar to previous reports,^30,31  ATs across levels of experience described the benefits of learning from one another. As part of the evolution of education in health care programs, novice ATs in our study were described as being able to share their familiarity with evidence-based practice and application of advanced manual therapy skills. Additionally, newer techniques, such as Thessaly test or laser treatment, have also been reported as topics preceptors have learned from students.³⁰  Even with advancements in athletic training education, supervisors and preceptors continue to recognize the value of reciprocal learning more often than novice ATs, which suggests novice ATs may not realize the contributions they make to staffs or the perceived value of their knowledge and skills. Students' and novice ATs' lack of confidence to teach others is likely linked to their familiarity with teacher-centered learning³¹  and not disrupting hierarchical structures. Regardless, our findings indicate a value placed on lifelong learning and an acceptance of reciprocal learning, which will strengthen ongoing development of all ATs. More importantly, engaging in reciprocal learning validates students' and novice ATs' knowledge and skills and can improve their confidence, which in turn may better facilitate their transition to practice.³⁰ 

We recruited participants via an email blast from the NATA's survey system; therefore, it is possible that our enrolled participants (ie, educators, preceptors, supervisors) were more likely to self-identify as someone who supports novice ATs and that they had different perceptions than other stakeholders. To reach data saturation and representation across districts, we used snowball sampling, which may have also included individuals with similar perspectives and led to a positive bias. Our sample of novice ATs included students from bachelor's and master's programs, which provides a current snapshot of transition-to-practice perspectives but may not be indicative of transition to practice once all novice ATs have graduated from a program at the master's degree level. Additionally, these participants were not triads (novice AT, their educators, their supervisor) that described specific collective experiences together; however, researchers can use this recruitment strategy in future studies to capture these experiences.

To continue to understand and prepare novice ATs for autonomous clinical practice, researchers should explore factors of the immersive clinical experience that may affect students' preparedness, such as the timing of the immersive rotation within the program, number of weeks, balance of supervision and autonomy, or preceptor mentorship style. Researchers may also discover valuable insight from conducting a longitudinal study that tracks students' experiences during their immersive rotation and into their first job. Lastly, future researchers should reevaluate novice ATs' transition-to-practice experiences after all professional programs have transitioned to the master's level and have fully integrated the 2020 Commission on Accreditation of Athletic Training Education standards.

Novice ATs are perceived to be moldable, eager, and academically prepared to enter the workforce. Many stakeholders touted novice ATs' advanced content knowledge and clinical skills, which extended beyond the level of education obtained in the past. They also valued the exchange of knowledge and skills through reciprocal learning, which fostered ongoing professional development for all ATs. However, novice ATs' lack of professionalism, limited experience with administrative tasks, and underdeveloped interpersonal skills were described as areas for growth to facilitate transition to practice. Therefore, it is recommended that professional program faculty ensure that students complete diverse clinical educational experiences and practice professional behaviors during their education. Preceptors can also engage students in all facets of ATs' job responsibilities, including difficult conversations and working with complex cases. Collaboration among stakeholders is necessary to develop these skills to better prepare students to confidently make autonomous clinical decisions and navigate the workplace as they transition to practice.

We thank California State University Fullerton's College of Health and Human Development (Research Support Program) for partial funding to support this project. We also thank Margaret L. Ha, MS, ATC (Sports Conditioning and Rehabilitation in Orange, CA), for serving as the external auditor.