Athletic Training Students’ Perceptions of Translating Knowledge From Classroom to Clinical Practice

• Athletic training students most frequently translate concepts within the (1) examination, assessment, and diagnosis and (2) therapeutic intervention domains of the Board of Certification practice analysis.

• The frequency of knowledge translation from the examination, assessment, and diagnosis, and therapeutic intervention domains may indicate that the patient care opportunities presented to students during their clinical experiences more frequently revolve around these domains of practice.

• Our findings suggest that the concepts students more readily translate into clinical practice may be dictated by the number of opportunities they receive for hands-on experience related to the concept(s) as well as the perceptions of others (ie, preceptors) about the relevancy of the information to contemporary athletic training clinical practice.

• The disconnect between knowledge gained in the classroom and the opportunities available during clinical experiences highlights a need to promote synergy between faculty and preceptors to ensure students are exposed to new knowledge and skills.

• Faculty and preceptors should ensure students are regularly provided opportunities for hands-on experience in all domains of practice to better facilitate the translation of knowledge and skill in clinical practice.

The concept of knowledge translation has been around for decades but was not operationally defined until 2006 by the Canadian Institutes of Health Research. They defined knowledge translation as

While this definition speaks to knowledge translation as the use of new evidence in clinical practice (eg, evidence-based practice), other authors, including Menear et al,²  have simplified its meaning to a broader context by describing knowledge translation as the act of shifting knowledge into action. When knowledge is not translated into action effectively, a theory-to-practice gap remains.

The theory-to-practice gap has been well established in pedagogical literature and is especially prevalent in health care education, where students are expected to take didactically taught content and apply it in clinical settings.^3,4  In nursing, the theory-to-practice gap has been defined as a dissonance between desired and demonstrated learning.⁴  While no such definition exists for athletic training, the theory-to-practice gap has been further emphasized in athletic training programs (ATPs) since the transition of entry-level education to the graduate level brought about new accreditation standards. These standards introduced significant changes in expected skill performance by graduates of such programs.⁵  Students within ATPs are likely to be taught skills within the classroom that their preceptors have not been formally educated on. Therefore, students’ opportunities to implement such skills during clinical experiences are inhibited. Even before introducing the new standards, the theory-to-practice gap had been identified in professional athletic training students (ATSs) and was classified by some students as a challenge they struggled with during their educational experiences.⁶ 

The theory-to-practice gap in health care education has motivated educators and clinicians to devise strategies to better bridge didactic learning with clinical practice application.^3,4,7  The concept of knowledge translation has been discussed relative to athletic training practice.^8,9  Welch Bacon et al⁸  proposed the need for athletic trainers to develop and implement knowledge translation strategies to provide high-quality patient care effectively. Theoretically, the place in which athletic trainers should begin learning how to translate knowledge to bridge the theory-to-practice gap is within their professional ATP. Ultimately, the theory-to-practice gap should motivate students to conscientiously contextualize the didactic content they received and critically consider its importance in clinical practice.^3,6  Students who can do this demonstrate true knowledge translation and can bridge the theory-to-practice gap by providing care based on condition and individual patient circumstances.⁶ 

While knowledge translation is critical to students’ growth and development and a key component of becoming a well-rounded clinician, little is known about how ATSs apply didactically gained knowledge into clinical practice or their perceptions of when and how knowledge translation occurs. Therefore, in this study, we aimed to explore ATSs’ perceptions with knowledge translation during their professional athletic training educational experience.

We used a cross-sectional, Web-based survey with open-ended questions to explore professional ATSs’ perceptions of and experiences with translating knowledge from the classroom into clinical practice. The A.T. Still University Institutional Review Board deemed this study as exempt research.

Athletic training students enrolled in a Commission on Accreditation of Athletic Training Education (CAATE)-accredited professional ATP were recruited at the time of this study. Since student information is not publicly available, participant recruitment occurred via e-mail to program directors (N = 385), who were asked to forward the recruitment e-mail to all enrolled students in their professional ATP. In total, 255 professional ATSs accessed our survey.

After an unsuccessful search of the available literature for an established instrument to address our study purpose, we developed a brief, Web-based survey hosted on the Qualtrics platform. The survey consisted of 7 demographic items and 6 open-ended questions (Figure 1). Once developed, the survey was reviewed for face and content validity by 3 athletic training educators with experience in qualitative and survey research using an established validation process.¹⁰  Based on the feedback provided, we adjusted the wording of 2 survey items to enhance clarity. Due to the open-ended nature of the survey items, a reliability analysis was not warranted. However, to confirm clarity and comprehension of the survey questions, the survey was sent to 18 postprofessional master’s ATSs for piloting purposes once the face and content validation was complete. Sixteen students completed the survey, and no additional modifications were made to the instrument based on the feedback provided.

We sent a recruitment e-mail containing an introduction to the research team, the purpose statement of the research study, the estimated time needed to complete the survey (ie, 10 to 15 minutes), and a URL link to the Web-based survey to all program directors of CAATE-accredited professional ATPs in February 2020 (Figure 2). We asked each program director to forward the recruitment e-mail to all current ATSs enrolled in their program. Four e-mails were returned upon distribution; 1 was undeliverable, and 3 indicated the program director was out of the office for the entirety of the data collection period. Four program directors responded that they did not currently have students enrolled in their program. Therefore, the recruitment e-mail was received by 377 eligible and available program directors of CAATE-accredited professional ATPs. Data collection occurred during a continuous 4-week period, and 2 reminder e-mails were sent to program directors to encourage participation from ATSs. Due to the exempt nature of this research study, participant consent was implied upon voluntary completion of the survey items.

Due to the structure of the survey, only the responses from participants who replied to all open-ended items were included in the data analysis. While participants were not required to respond to each survey item to ensure their voluntary rights within exempt research were upheld,^11,12  during data analysis, we determined that responses to all survey items were necessary to understand participants’ perspectives regarding knowledge translation. Descriptive statistics characterized participant demographics using SPSS (version 27; IBM Corporation). At the same time, all textual data collected from the open-ended response items were analyzed using the consensual qualitative research (CQR) approach.^13,14 

The CQR tradition uses an inductive approach to data analysis and requires a research team and a multiphase consensus process. For this study, we used a 4-person data analysis team (C.E.W.B., R.K., A.M.P.L., J.M.C.). Three members of the team were established qualitative researchers, while 1 member was a novice researcher and went through the appropriate CQR training process as discussed by Hill et al.¹³  One member of the team served as the external auditor (J.M.C.), while the other 3 members were involved in each phase of data analysis. Near the end of data analysis, the external auditor completed a comprehensive review of all phases to confirm the final themes and categories were representative of participants’ perceptions and experiences.^13,14 

During the first data analysis phase, 3 members individually coded the first 25 participant responses and independently developed a codebook. The research team then met to discuss and develop a consensus codebook representing emergent themes and categories. The consensus codebook was then used for the second phase by coding the next 25 responses. No changes were made to the codebook by the end of phase 2, thus establishing the final consensus codebook. During phase 3, the 3 team members coded all remaining responses and met to confirm the codes. Next, all coded participant responses were separated into the respective themes and categories, and the external auditor reviewed all emergent findings. The Consolidated Criteria for Reporting Qualitative Research was used to ensure the conclusions of this study were comprehensively reported.¹⁵ 

The survey asked students to provide examples of information they have translated from the classroom to clinical experiences. During data analysis, we chose a deductive approach to analyze the data collected from this specific survey item since participants’ responses closely aligned with the domains of athletic training practice established by the Board of Certification (BOC).¹⁶  While still following the consensus approach described, we coded participant responses to this survey item into preestablished categories: injury and illness prevention and wellness promotion; examination, assessment, and diagnosis; immediate and emergency care; therapeutic intervention; health care administration and professional responsibility.

Since all survey items were optional to maintain participants’ rights, we deemed a survey complete if the respondent answered all the open-ended survey items. Therefore, of the 255 students who accessed the survey, we received completed responses (65.9% completion rate) from 168 students (118 women, 48 men, 2 missing; age = 22 ± 2.3 years) enrolled in CAATE-accredited professional ATPs in 28 states. Additional respondent demographics are displayed in Table 1.

Figure 3 displays the breakdown of the topics translated into clinical practice. In addition to the topics translated into clinical practice, 3 themes emerged during data analysis: application of knowledge to clinical practice, challenges prohibiting successful knowledge translation, and strategies to promote knowledge translation.

Students identified several factors influencing their opportunity or willingness to apply knowledge gained from the classroom to clinical practice. During data analysis, 4 categories emerged: student self-efficacy, setting- or patient-driven application, preceptor-driven application, and classroom-driven application.

One of the factors that influenced students’ willingness to apply knowledge from the classroom during clinical experiences was their self-efficacy, that is, their belief that they can execute behaviors and tasks to produce specific performance results.¹⁷  One student remarked:

Another student commented that he or she usually applies knowledge from the classroom “only when I can successfully and correctly apply the information independently.”

Some students discussed how their motivation to include knowledge gained from the classroom is driven by which topics are most interesting to them. One student explained, “I feel that the topics and information that I find to be the most interesting in the classroom is the information that I’m more willing to apply during clinical experiences.” Others related translating information based on their comfort. One student commented, “I usually translate something if I feel comfortable doing it.” In contrast, another student noted that “it depends on how well I understand the topic and if I can see the practicality of doing it in clinical practice.” A third student explained:

Finally, 1 student described that translating knowledge from the classroom to clinical practice was about taking opportunities to do so when they become available. He or she commented:

In addition to student self-efficacy, participants also described how the clinical setting or the patient population influenced their application of knowledge gained from the classroom. One student remarked:

Another student commented on how exposure to particular patient cases affects what information gets translated into clinical practice. He or she commented:

Students also wrote about the connections between theory and practice and how that bridge relates to the patient populations they encounter during their clinical experiences. One student noted, “[T]he types of patients and injuries I see in clinical determined what information from the classroom is useful.” Another student stated:

A third student remarked how “philosophies taught in the classroom are sometimes not accepted or practiced at my clinical experiences,” while a fourth student summarized the bridge between theory and practice by noting:

Students also described the influence of preceptors on what knowledge a student decides to translate to clinical practice. One student noted that “much of the information I have translated to my clinical experience is led by the preceptor I have at the time. I ask for [his or her] advice and try to learn from their experiences.” Similarly, other students remarked, “I talk to my preceptors and get their opinion[s] on whether certain skills and knowledge taught [in the classroom] are useful,” and, “I use my preceptors as a basis as to what information is necessary to be used in clinical [practice].” One student shared:

Students also wrote about how their preceptors’ reactions to new knowledge were a deciding factor in whether they chose to translate it into practice. One student stated, “It depends on the clinical site I’m at and how willing the preceptors are to accept new ideas or ways of practice.” Another student described, “[I]f I ask my preceptor and they seem agreeable about [the knowledge], then I may incorporate it. However, if they shoot down the idea, I am far less likely to introduce it into my own care.”

While not as common as preceptor-driven application, students also described the classroom's role in knowledge translation. One student noted:

Similarly, another student remarked, “I feel as though anything we have learned in the classroom is fair game to be used in my clinical experiences.”

Other students remarked how they intentionally try to support what they learned from the classroom into practice. One student stated:

Other students commented, “I try to implement all information learned in the classroom into my clinical experiences and use my actual experience to grow and be more confident in my own knowledge,” and, “I try to incorporate everything I learn in the classroom, but if those strategies don’t work for me, I can feel free to try something new.” Finally, 1 student summarized classroom-driven application by noting:

Alongside exploring the factors that influence decisions to translate knowledge from the classroom to clinical practice, we also asked students to discuss the challenges they have encountered that prohibit successful knowledge translation. Five categories related to challenges emerged during data analysis, including relatability between key stakeholders, classroom relevance, knowledge prioritization, limited exposure to content taught in the classroom, and self-confidence.

One of the challenges students wrote about regarding knowledge translation was the relatability between key stakeholder groups. Some students commented that the unique ways educators teach the same content posed a challenge. For example, 1 student commented, “[I]f teachers have different ideas on how topics should be taught, it can be challenging and confusing to translate that information to the clinical setting due to differences between classes.” Another student mentioned, “It is also hard with conflicting information in different classes to decide what you think is correct or how to use your discretion.”

Other students discussed how differences between educators and preceptors created knowledge translation difficulties. One student noted, “[M]any different opinions and views can make it difficult to put into practice what I learn in the class.” Another student stated, “[O]ne main challenge I have encountered is that different professors and preceptors do and teach things very differently, so it is sometimes hard to find your way of doing things.” Similarly, a third student described that

Students also described the challenges of translating knowledge when preceptors disagree with what is taught in the classroom. One student commented, “[P]receptors don’t believe in some of the things we learn [in the classroom].” Similarly, another student noted that

Likewise, 1 student remarked that

In addition to the relatability between key stakeholders, students also struggled with translating knowledge from the classroom to clinical practice when they could not grasp the relevance of what was taught. One student explained:

Similarly, another student commented, “[W]e are taught a lot of tests or ideas in class that are not clinically significant, which makes it difficult to decide exactly which ideas we should focus on in clinical practice.” A third student stated, “[W]e learn by the book for everything, but not everything is done by the book in the clinical setting, which tends to get me confused.”

Several students also expressed frustration that what they are taught often feels dichotomous, indicating that knowledge is either taught “the [BOC] way versus how clinicians actually practice.” Another respondent said, “[I]n the classroom, we learn that things are done in a set pattern; however, in the clinical setting, that is almost never the case at all.” Students also commented that they believe “the information I’ve learned in the classroom is not representative of what is realistic within many athletic training settings” or that “the classroom tries to make everything black and white, but there are a lot of gray areas in the clinic.”

Knowledge prioritization was another challenge that emerged during data analysis. Students expressed difficulties identifying which knowledge and information were more critical or applicable in a given scenario. One student described:

Another student commented, “[T]he hardest thing about translating information from the classroom is figuring out what is most important in this scenario compared to what is not as necessary.” A third student remarked:

Finally, one student explained:

Students frequently described limited or lack of exposure as a challenge to translating knowledge from the classroom to clinical practice. One student remarked, “[A]s someone that learns by doing, if I learn something and am not able to implement it at that time, there’s a high likelihood I will forget about it.” Other students commented about the disconnect between when a concept is taught in the classroom and when or if they experience it during clinical experiences. One student explained:

Similarly, another student wrote, “[I]t is difficult to translate knowledge on a topic or skill that doesn’t get used often or during situations you are not placed in.” One student summarized that “in an actual emergency situation, no [amount of] classroom practice will actually prepare you for that actual, real-life moment.”

Students also described how particular topics or settings impeded their knowledge translation. One student noted the “university/college setting is very limited in the variety and number of patients and injuries I am exposed to,” while another student commented, “I have a hard time translating my shoulder evaluation skills in my clinical experiences because most of the rotations I have had are mainly lower extremity only.” Finally, several students wrote about the challenges of translating administration-related tasks. One student explained, “[T]ranslating topics we discuss from my athletic training administration class are very difficult because we don’t really get any opportunity to do those aspects during our clinical experience.”

In addition to external variables affecting knowledge translation, students also detailed how their self-confidence impeded their ability to translate knowledge from the classroom to clinical practice. One student explained:

Another student noted, “[I]f I’ve had trouble conceptualizing what was learned in the classroom, I’ll likely struggle with it in the clinic. It’s really about my confidence in that skill.” Several students also commented how they “lack the confidence to complete tasks, especially if someone is standing over me and critiquing what I am doing.” Other students discussed how their confidence waivered when they had to explain something to someone else. One student stated:

Finally, numerous students described their struggle with self-confidence because they “don’t want to mess up in front of a patient or preceptors.”

We asked participants to describe strategies they believe educators, preceptors, and students could employ to strengthen the translation of new knowledge from the classroom into clinical practice. Data from these responses were reduced into 5 distinct categories that focused on more application-based practice opportunities, involvement in clinical practice, identifying clinical relevance of content during instruction, enhancing stakeholder communication and involvement, and encouraging and maintaining a growth mindset. The number of participant responses coded into each category by stakeholder group is displayed in Figure 4, and supporting quotes are provided in Table 2.

Our participants agreed that all 3 stakeholder groups (ie, educators, preceptors, and students) should seek and provide more application-based practice opportunities to allow students to gain hands-on exposure to new content learned in the classroom and during clinical experiences. Students generally described that educators should shift away from lecture-based classroom teaching methods and focus on providing more active learning approaches. At the same time, preceptors should offer more opportunities for students to practice skills and simulated patient encounters during clinical experiences. Students also self-reflected that they should be more proactive in seeking practice-based opportunities, whether with fellow students, peers, or their preceptors during clinical experiences.

Although not as prevalent as the other categories within this theme, some students wrote about the need for educators and students to be more involved in clinical practice. For the educators, students described that having faculty that actively practice in the clinical setting would be beneficial because they can discuss current practice trends with recent patient case examples. Students, on the other hand, identified that they need to be more proactive about being actively involved in patient encounters that occur during clinical experiences rather than observing them.

Participants identified that educators, preceptors, and students must work toward identifying the clinical relevance of content taught during didactic instruction. Students shared that it would help make stronger connections between the classroom and clinical practice if educators could share more current examples of how the content being taught directly connects to contemporary athletic training practice. Likewise, students highlighted the value added if preceptors also discussed connections between didactic content and clinical practice more positively rather than dismissing newly learned content as irrelevant to clinical practice. Some students also wrote they could be more proactive about seeking the relevancy of the content they are being taught.

Students wrote about the gaps in communication they have noticed between educators and preceptors and how a lack of involvement from preceptors in the classroom and educators in the clinical practice environment affects the knowledge they translate. In general, students expressed a need for more collaboration between the 2 groups to help students feel more confident in the content being discussed in both realms. Additionally, students expressed a desire for more learning opportunities from preceptors and more in-depth discussions with preceptors to gain a better theoretical understanding of why a particular approach is most appropriate from the preceptors’ perspectives.

Finally, our participants described the importance of encouraging and maintaining a growth mindset. They addressed the desire for preceptors to push students to make clinical decisions and then explain their rationale out loud regarding those decisions. They also remarked how preceptors should be more open to learning as a 2-way process in which the student can contribute contemporary and up-to-date knowledge during discussion of particular content areas. Students also reflected on their growth mindset and how they could be more proactive in their learning experience by asking more questions, reflecting on the content taught in the classroom, and seeking out more opportunities to apply or practice what they have been taught rather than waiting for the opportunity to be presented to them.

Knowledge translation is a dynamic and iterative process employed to improve individual and population health, fortify health care systems, and provide more effective health care services to patient populations. Knowledge translation includes synthesizing, disseminating, exchanging, and applying knowledge in clinical practice to benefit the patient.¹⁸  Our participants identified topics translated into clinical practice and further expanded on the facilitators of knowledge translation by applying knowledge to clinical practice. Translating knowledge to clinical practice was possible due to student self-efficacy and with facilitation through patient-, preceptor-, and classroom-driven approaches. Participants in our study also noted challenges that included relatability between educators and preceptors, the relevance of knowledge taught in the classroom, the need to prioritize which knowledge should be translated, limited exposure in clinical practice to content taught within the classroom, and a lack of self-confidence in their knowledge. Lastly, our participants identified strategies to overcome these challenges, such as being provided more application-based practice opportunities, identification of the clinical relevance of didactic content during the initial instruction of the topic, increasing clinical practice experience among educators, enhancing communication between educators and preceptors, and finally, the development and maintenance of a growth mindset throughout knowledge acquisition and translation processes.

The participants in our study identified that self-efficacy, patient-driven opportunities, and preceptor-driven opportunities all contribute to their ability to translate knowledge. Participants also noted that, in some instances, content covered in didactic settings was not always readily translatable to the clinical setting.

The construct of self-efficacy has been widely studied within athletic training education and external to the profession. Self-efficacy is driven by 4 contributing factors: past accomplishments, vicarious experiences, verbal persuasion, and emotional arousal.^17,19  When applying this construct to clinical education, past accomplishments would constitute successful past performance of a skill (clinically or didactically), vicarious experiences would include observation of someone else successfully performing a skill, verbal persuasion would consist of being encouraged to perform the skill by an instructor or preceptor, and emotional arousal would include the emotional response when presented with an opportunity to perform a skill, such as excitement or nervousness. Self-efficacy is rooted in other psychological constructs, such as reward-based motivation, self-regulation, and anxiety.^17,20,21  Applying this context to our findings, we can reasonably determine that, when students are allowed to translate knowledge into clinical practice, the following factors will likely influence their ability and willingness to do so. Past accomplishments, such as having a previous clinical opportunity or high-fidelity simulation in which the student could apply knowledge successfully, would influence their willingness and ability to translate knowledge in similar opportunities in the future. The frequency of the opportunity to observe a classmate, preceptor, or another clinician translating the same knowledge to practice will make it more likely that a student will do the same. Encouragement from preceptors during patient encounters to inspire students to translate knowledge effectively would also support the knowledge translation process. Lastly, individuals are most likely to be motivated to translate knowledge when the knowledge itself is of high interest to them and their practice.⁸ 

The types of knowledge that our participants described translating most often were in the 2 domains of examination, assessment, and diagnosis and therapeutic interventions. In part, they indicated that these areas were most common because of the opportunities presented to them during their clinical experiences. Data on patient encounter opportunities indicate that ATSs participate in evaluation and examination, application of therapeutic modalities, and care, treatment, and rehabilitation for more than three-quarters of their patient interactions while in clinical experience.²²  Based on this information, we feel that the content areas of the self-reported knowledge translation of our participants are likely highly accurate. Additionally, the BOC conducts a practice analysis using responses from early professionals that have more recently transitioned to practice. This analysis serves as the blueprint for developing the credentialing examination for athletic trainers.¹⁶  In the 8th edition of this document, the domains of (1) assessment, evaluation, and diagnosis and (2) therapeutic interventions are the heaviest-weighted domains on the BOC exam.²³  Due to the emphasis on the exam in these content areas, education programs will likely emphasize this content more heavily. Thus, students will have greater self-efficacy around skills within these 2 domains. We would postulate that this contributes to students’ comfort and confidence in translating knowledge in these areas when presented with patient encounters that warrant evaluation and diagnosis or therapeutic intervention. Interestingly, this creates a cyclical process whereby specific skillsets are most heavily emphasized on the BOC exam and clinical practice, developing confidence and practice silos within these particular domains. Subsequently, the emphasis on specific domains may hinder educational and clinical practice evolution as the health care landscape continues to change (Figure 5).

Our participants also noted that it can be challenging to translate knowledge from didactically taught content to clinical practice. This challenge was previously identified in the literature by preceptors and program faculty.²⁴  Both faculty and preceptors have struggled to bridge the divide between didactic instruction and real-life clinical practice. As a result, additional efforts may need to be made to address these gaps. It has been previously suggested in medical and nursing education that the inclusion of activities which link clinical practice to the content taught in the classroom, such as simulations, patient cases, or grand rounds, can improve this barrier to knowledge translation.^8,24–26  However, it should be noted that the provision of simulation alone is unlikely to promote significant changes in knowledge translation, and neither will isolated didactic exposure to the content. Farkas et al²⁷  proposed that the 4E framework, which promotes a hierarchical pipeline from knowledge exposure to embedded use in clinical practice, will likely need to be implemented in education. After exposure to knowledge, experience to increase knowledge or attitudes is the second step of the 4E framework. This is the step that students desire to improve upon their knowledge translation from the classroom to clinical practice.^8,27  This will require both patient- and preceptor-driven strategies to allow for opportunities to implement skills and knowledge that are less frequently seen in traditional athletic training facilities. Preceptor-driven strategies will require preceptors to seek opportunities to expose students to less frequently seen conditions or scenarios. Through a combination of vicarious experience, verbal encouragement, and emotional arousal to promote self-efficacy, preceptors can then use these opportunities to improve students’ abilities to translate knowledge outside of the domains of assessment, evaluation, and diagnosis or therapeutic interventions.^17,20  Patient-driven strategies will require purposeful clinical education setting placement on the part of program administrators to ensure students are exposed to not only a wide variety of patients but opportunities to engage in the other domains of practice, such as risk reduction, wellness, and health literacy, critical incident management, and health administration and professional responsibility.²³  Ideally, if these types of strategies for knowledge translation are implemented, it could ultimately break the cycle of siloed emphasis of domains of practice in education and clinical practice.

Our participants highlighted that some of the challenges that ultimately inhibit knowledge translation had to do with the inconsistency and incongruency in how concepts were taught. Some identified that the same concepts are taught differently, even between didactic course instructors. Others noted that how specific skills are taught in the classroom is not the same as how their preceptor expected them to perform said skill in clinical practice.

Previous researchers in athletic training have highlighted the gap between what is being taught in the educational pathways of aspiring clinicians compared with established clinicians’ practice patterns.^7,9  This challenge has once again been brought to the forefront with the CAATE’s release of updated curricular content standards that went into effect for graduate professional programs in 2020.⁵  The CAATE included content that previously was not required to be taught in entry-level education, including dislocation reduction, administration of naloxone, performing diagnostic tests, and using biometric data to guide prevention, intervention, and performance enhancement plans.⁵  The quantified time lag between the introduction of new knowledge or skills and the widespread implementation of that information into practices has been estimated to be approximately 17 years.²⁸  The inclusion of new knowledge and skills in the entry-level preparation of clinicians requires upskilling of the professions’ educators and clinicians to ensure that students are appropriately taught and assessed in both the didactic and clinical learning environments. Suppose intentional upskilling does not occur and the profession relies on the typically slow adoption of new information. In that case, we could anticipate widespread inclusion of the curricular content standards’ newly introduced skills into the day-to-day practice of athletic training around 2037. The challenge our participants pointed out was that the skills are now required to be taught in professional preparation, but many preceptors have not been taught such skills and, resultingly, are unable to allow students to practice or perform said skills in clinical practice. Additionally, preceptors need to have access to continuing education in curricular content areas, and this effort must be intentional to encourage their inclusion in clinical practice in a timely fashion.

Interestingly, the availability of continuing education in the newly introduced curricular content areas seemingly could create a metachallenge, with preceptors needing to ensure that they not only attend the continuing education but translate the knowledge gained into their own clinical practice to model and facilitate student knowledge translation. Previous researchers have suggested that clinicians primarily select continuing education opportunities that reinforce previously learned content except when forced to select content from specific categories, such as evidence-based practice continuing education.^9,29  Following suit, if a need is present, as suggested by our participants, for the upskilling of preceptors to ensure newly taught content is fully translated to clinical practice, it is possible that continuing education in the new curricular content is needed and may even need to be required by the BOC. This targeted effort would result in an upskilled preceptor force that would be crucial to the knowledge translation efforts of ATSs and newly transitioned athletic trainers.

The existing evidence on role fulfillment among educators and preceptors suggests that increased communication between stakeholder groups can reduce or eliminate some of the challenges that both groups identify relative to translating didactically taught content to clinical experience opportunities. When communication between program faculty and preceptors is effective, frequent, and focuses on students’ needs and progression, both faculty and preceptors were able to identify an improved benefit on student development.⁷  Thus, we suggest that those responsible for delivering repeated didactic content (across multiple courses within a program) work to increase communication and understanding between parties regarding how content is taught. Additionally, communication between preceptors and program faculty should similarly be improved to facilitate knowledge translation from the classroom to the clinic. One way this could be achieved would be to invite preceptors to participate in courses in which new content is being taught. Students who learn alongside their preceptors may feel more comfortable practicing didactic content in the clinical setting if they know their preceptor was taught the same way to perform a given skill.

Our participants also identified that one of the challenges they faced in translating knowledge was feelings of discomfort when put in positions in which the knowledge or skills they were taught didactically conflicted with what a preceptor employs clinically. Evidence from the field of nursing has demonstrated that novice clinicians, especially under the supervision of a newly assigned preceptor, struggled with critical thinking because the power dynamic with the supervising preceptor, and the emphasis on task completion, created anxiety. The resulting anxiety was linked to decreased dialog and practice reflection.³⁰  Similarly, in nursing, research efforts to promote critical thinking among students in clinical rotations identified the need for preceptors to create a space for dialog that encouraged questions, reflection, and critical thinking.³¹  Athletic training preceptors should consider how they create space for questions within clinical practice and encourage student dialog, questioning, and critical thinking early on in the clinical rotation. Additionally, the program faculty who provide preceptor training and development should emphasize the need for this space before students are assigned to their sites.

Participants in this study emphasized the duality of confidence and growth mindset and the combined effect of the 2 concepts on their ability to translate knowledge from the classroom to clinical practice. Lacking confidence inhibited their abilities to translate knowledge effectively while possessing confidence promoted knowledge translation. Furthermore, having a growth mindset facilitated students’ development of confidence. In research on growth mindset, Duckworth et al^32–34  highlighted that intelligence, while often thought of as the most crucial component to student success, is not the most significant predictor of student success, but rather grit is. Grit is a combination of passion and perseverance. Some data from athletic training education literature suggest that students are not given frequent opportunities to perform complex patient encounters while in clinical experiences.²²  It is important to note that this likely suppresses student confidence and growth mindset development, as it limits their exposure to challenging cases and decreases the need to apply critical thinking and decision making during clinical education.

Duckworth et al^32–34  and Dweck³⁵  have, in their respective work, demonstrated that a students’ beliefs about their intellectual abilities are likely to influence their success; if they believe their intelligence is fixed, then when they encounter challenges and setbacks, it is viewed as inevitable and insurmountable. Alternatively, if students believe they can change their abilities and improve upon them, they are more likely to pursue opportunities for growth and make efforts toward change. Duckworth et al^32–34  and Dweck³⁵  impressed upon their readers that having a growth mindset does require both grit and perseverance but that those monikers are not synonymous with time spent in pursuit of growth. Relating this concept to athletic training education would indicate that students can be coaxed into a growth mindset academically by understanding that they can learn and that a willingness to learn is a far more significant predictor of their success than the summation of knowledge previously learned. This is especially pertinent to knowledge translation in the clinical setting when preceptors create the aforementioned space for questions and critical thinking, thus encouraging a growth mindset and potential confidence within the students they are precepting. To best promote knowledge translation among ATSs, preceptors must create a space that encourages student questioning. Both educators and preceptors need to reinforce to students their unlimited learning capacity rather than emphasizing previously demonstrated intellectual abilities. Establishing a growth mindset among students will strengthen confidence in their abilities and likely increase knowledge translation of didactically taught content to clinical practice.

The voluntary nature of survey research presents an inherent limitation related to self-selection. Since participants were not required to respond to every survey item, it is possible they only responded to items they felt comfortable with or were knowledgeable about. To minimize this potential limitation, we only included responses from participants that answered all open-ended questions to ensure we gained a complete perspective of each participant’s view regarding the topic. Additionally, researcher bias was another potential limitation due to the textual nature of the data. To minimize this limitation, we used a rigorous, multiphase data analysis approach that required consensus to be met at each phase by a multiperson research team.^13,14  We also included an auditor to review the data and ensure that the participant voice was well represented. In our research, we aimed to understand ATSs’ perceptions of knowledge translation. To ensure participants responded organically to each survey item, we did not provide them with an operational definition of knowledge translation. Still, when warranted, we did encourage the inclusion of examples to support their responses to each item.

Additionally, while it was essential to understand all ATSs’ perceptions of knowledge translation, we recognize some inherent limitations to our sampling pool. First, we did not delimit our sample to only ATSs from professional graduate programs. Since knowledge translation is an iterative process, we did not believe the type of program would influence students’ perceptions of the concepts. Additionally, both program types were viable options for degree completion at the time of this study. Now that professional education has transitioned to the graduate level, further investigation regarding ATSs’ perceptions of knowledge translation may be warranted. Secondly, we recruited all professional ATSs to participate in this study, regardless of how many semesters they had completed at the time of data collection. It is possible that participants’ perceptions of knowledge translation were influenced by the opportunities or lack of opportunities they had during clinical experiences depending on their progression within the program at the time of data collection. Students further along in the professional ATP may have inherently had more opportunities or hands-on exposures to help facilitate knowledge translation, while students in the beginning phases of the program may not. This scenario could have influenced how students responded to the survey items. Therefore, further research is necessary to explore the knowledge translation experiences of final-term ATSs to better conceptualize which influencing factors positively or negatively affect their opportunity to translate knowledge gained from the classroom into clinical practice.

Findings from our study suggest that, based on students’ perceptions, the knowledge they translate from the classroom to clinical practice may be based more on circumstance and the influences of others (ie, preceptors, patients) than an intentional action. Students highlighted a disconnect between what was taught in the classroom and what was experienced during clinical education opportunities, which left students with uncertainty about which information was important and meaningful for clinical practice. They also expressed concern that the information taught in the classroom was often not modeled by preceptors during clinical experiences or not accepted by their preceptors as relevant to contemporary athletic training practice, further exacerbating their uncertainty. Positive attitudes about the information gained are central to successful knowledge translation.^8,27  Therefore, if the information students are taught in the classroom is not being modeled by preceptors or is not viewed favorably by preceptors as a realistic component of clinical practice, it is unsurprising that students may be less likely to translate that knowledge or skill into their practice.

While these findings only consider students’ perceptions of their experiences and do not account for what may be occurring, more intentional focus to promote synergy between faculty and preceptors may be warranted to ensure the information taught didactically is well aligned with what students are encountering during clinical experiences. Furthermore, implementing established knowledge translation models, such as the 4E Framework,²⁷  may be beneficial to ensure students are not only exposed to new knowledge and skills but are regularly encountering intentional experiences to increase their competence and self-efficacy of the content over time.