Context

Transition to practice (TTP) is a period of growth in which new athletic trainers (ATs) respond to stressful changes and develop confidence and self-efficacy. Employers have an important role in TTP.

Objective

To explore multiple stakeholders’ perceptions of ways for organizations to support new ATs during TTP.

Design

Qualitative study.

Patients or Other Participants

Athletic trainers from 3 stakeholder groups participated, guided by data saturation: 10 faculty members and 8 preceptors (age = 43 ± 10 years, experience = 11 ± 12 years), 16 supervisors of newly credentialed ATs (age = 52 ± 11 years), and 17 early professional ATs (age = 26 ± 5 years, experience = 9.5 ± 5 months).

Data Collection and Analysis

Participants were recruited via purposive sampling through an e-mail blast from the National Athletic Trainers’ Association. Participants were interviewed via phone or Web-based platform using a semistructured interview guide. Data were analyzed through consensual qualitative review. Trustworthiness was established via peer review and multianalyst triangulation.

Results

Four themes emerged. Employers felt they had a responsibility in mentoring new ATs and assisting with professional socialization. Onboarding described the organizational processes used to orient new ATs to their roles, including formal orientation, mentoring, evaluation, and feedback. Additionally, support was provided to new ATs through informal mentoring, relationships with coworkers, and professional development. Support often extended beyond professional needs to address personal challenges. Conflicting priorities occurred when employers wanted to provide more mentoring but were limited from other responsibilities and differences between employees’ and employers’ expectations of work-life balance.

Conclusions

To build on professional education, employers should provide comprehensive onboarding, formal mentoring, and informal personal and professional support. However, challenges may arise when their own clinical requirements limit the time they can spend mentoring new ATs. Organizations should ensure supervisors have adequate support to assist in the TTP for new ATs. Educators can prepare students to engage in dialog on work-life balance, expectations, and compensation to assist with TTP.

  • Education and socialization extend beyond professional preparation, and employers feel they have a responsibility to educate new athletic trainers into their roles.

  • Onboarding exists as a form of new employee education, and employers play a critical role in educating new athletic trainers through formal and informal onboarding processes to ensure role integration.

  • Onboarding programs should be implemented to educate and assist new athletic trainers through the transition to practice.

The transition to practice (TTP) for newly credentialed athletic trainers (ATs) has been described as a clash of cultures and presents many challenges, such as making decisions, role ambiguity, and mentor inaccessibility.1–3  As new ATs transition into their roles, they are not only adjusting to being independent clinicians but adapting to a new organization with new roles and organizational cultures. Similarly, new nursing and physician assistant clinicians also face stress, feelings of isolation, doubt, and frustration during the transition.4,5  Organizational factors such as onboarding decrease stress, improve outcomes, and reduce attrition.5–7 

Organizational socialization is the process by which an individual learns roles and responsibilities of the position while integrating into the professional culture.8,9  Organizational socialization begins when an individual enters their role and faces a period of adjustment and uncertainty, but individuals learn through formal and informal processes to become familiar with their role.9  Socialization tactics include mentoring, role orientation, continued development or onboarding, and support. Successful socialization culminates in an individual gaining stability in their role, which can be impacted by individual factors (eg, adaptability), organizational factors (eg, orientation, mentoring, support), and an individual’s fit for the role. Hindrances to successful socialization include poor organizational fit, burnout and quality of life issues, lack of support, role uncertainty, and challenges managing time.1–3,9,10 

Previously, the graduate assistantship model served as a socializing agent for new ATs. One of the many benefits of the graduate assistant model was the prevalence of mentoring and professional development inherent in the role.11  Many supervisors viewed mentoring, providing feedback, and facilitating professional development opportunities as important aspects of supervising ATs.8  However, with the professional degree transition to the postbaccalaureate level and the inability to rely on the graduate assistantship model as a socializing agent, it is vital for employers to purposefully assist in organizational socialization of new ATs.12  Further, new health care clinicians specifically seek employment in settings that provide mentoring and support during the transition.6,13  Research exploring TTP from many perspectives has increased, including employers’ perspectives of the preparation of new ATs, onboarding provided to new ATs, mentoring during TTP, and new ATs’ perceptions of the TTP; however, the organizational socialization aspects associated with TTP from multiple perspectives simultaneously have not been explored.1–3,10,14–17  Understanding the organizational aspects from various perspectives can provide insight into the socialization process, needs, and challenges during the TTP. The purpose of this study was to explore the transition to autonomous clinical practice from the perspectives of various stakeholders involved in the process. The current manuscript is a part of a larger study which also explored anticipatory socialization and the integration process, while this portion focuses on the organizational aspects and socialization for new ATs.10,15 

Three researchers currently serving as faculty members in athletic training programs made up the core research group, all of which have experience and multiple publications with qualitative research techniques. One additional member of the research team is a full-time athletic training clinician. The research team did not have any preestablished relationships with the study participants.

Our study was grounded in the theoretical framework of symbolic interactionism, which emphasizes how the interaction, culture, and environment shapes how an individual constructs meaning of their experience.8  This study employed a consensual qualitative research (CQR) approach which used the research team (3 investigators) to reach a consensus interpretation of the data.18  The CQR approach was used because the multianalyst triangulation approach limits individual biases. Institutional review board approval was obtained before initiating the study, and all participants provided informed consent.

Participants

The study included 3 groups of participants: early professionals (EPs), supervisors and mentors of EPs, and educators (athletic training program faculty and preceptors). Inclusion criteria for EPs was those who had graduated from a professional program within the last 2 years and were employed full time as ATs. Inclusion criteria for supervisors and mentors included (1) ATs in a supervisory role for new ATs (eg, head ATs, sports medicine directors) or (2) involved in the hiring or mentoring process of new ATs. Mentors were either assigned formally or self-proclaimed informal mentors. The inclusion criteria for the educator group were (1) serving as a faculty member or preceptor in an athletic training program and (2) serving in that role within the past year. Educators were primarily in master’s programs, but some were involved in the overlap period as their programs were transitioning to the master’s level. Exclusion criteria consisted of individuals who did not meet the inclusion criteria at the time of the study or supervisors who had not supervised an EP AT in the previous year.

Between the 3 groups, 51 ATs participated in this study: 10 faculty members and 8 preceptors (age = 43 ± 10 years, experience = 11 ± 12 years), 16 supervisors and mentors of EPs (age = 52 ± 11 years), and 17 EPs (age = 26 ± 5 years, experience = 9.5 ± 5 months). Demographic information can be found in Table 1.

Table 1.

Participant Demographic Information

Participant Demographic Information
Participant Demographic Information

Procedures

We recruited participants through purposive sampling, with an e-mail sent through the National Athletic Trainers’ Association (NATA) to 500 randomly selected members who were categorized as EP, 852 members who identified themselves as faculty, and an additional 2000 randomly selected members across all settings. The recruitment e-mail included a link to a survey in which potential participants provided consent, demographic information, and contact information. Participants who met the inclusion criteria were interviewed individually via phone or Zoom using a semistructured interview guide. Interviews were conducted by a member of the research team (supervisor or mentor: A.B.T., faculty or preceptor: T.M.K., EPs: T.G.B.). Interviews lasted approximately 45 to 60 minutes and were recorded and transcribed verbatim. Interviews were conducted until data saturation was met for each group. Data saturation occurred between interviews 12 to 14 in each group, and then we confirmed saturation by completing the additional interviews that were already scheduled.

Instrumentation

Three semistructured interview guides were developed for this study: EP, supervisors and mentors, and educators. Each interview guide consisted of approximately 14 to 20 questions developed based on the specific aims, research questions, and current onboarding and TTP literature.1–3,17,19–21  Interview guides are in the Appendix. Content validity of the instruments was established via peer review. Four experts in athletic training research and qualitative research methods reviewed the instruments for clarity, content, and validity. Peer reviewers were given the purpose of the study, research questions, and interview guides and were asked to rate each question on relevance and clarity and provide qualitative feedback. Peer reviewers were external to the study. After editing the interview guides based on expert feedback, we pilot tested the instruments for question clarity and flow with 6 individuals (2 from each group) who met the inclusion criteria. Minor modifications were made for clarity and content. Data from pilot tests were not included in the final analysis.

Data Analysis and Trustworthiness

Data were analyzed via CQR, with data coded for common themes and subthemes. The CQR team consisted of the first 3 authors, with the fourth author serving as an internal auditor. An external auditor with experience with CQR was also used to confirm codes. To analyze the data, each member of the research team independently coded 3 transcripts from the first stakeholder group (supervisor or mentor). The research team then discussed codes until a consensus was reached. Then the team coded another supervisor or mentor transcript to confirm the codes and ensure codebook accuracy. One member of the research team (A.B.T.) coded the remaining supervisor or mentor transcripts using the codebook that was created. Once coded, the transcripts were split between the other 2 members (T.M.K., T.G.B.) to confirm the codes. We repeated the CQR process for the preceptor or faculty transcripts and then the EP transcripts. The codebook was updated throughout. Once the transcripts were all coded, an external auditor reviewed each transcript and the codebook to confirm codes. See the Figure for CQR process and Table 2 for the thematic analysis codebook iterative process.

Figure.

Consensual qualitative review process.

Figure.

Consensual qualitative review process.

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Table 2.

Thematic Analysis Iteration for Organization Aspects of TTP

Thematic Analysis Iteration for Organization Aspects of TTP
Thematic Analysis Iteration for Organization Aspects of TTP

We established trustworthiness via multianalyst triangulation, narrative accuracy member checks, and the use of internal and external auditors. Participants were sent a copy of their transcript for review after the interviews were transcribed. Participants were asked to respond with any changes. No changes to the content were needed after member checks, only small grammatical changes. By using a research team with continued code confirmations, we reduced potential for bias associated with analysis with 1 researcher. Additionally, the multistakeholder perspective provided data triangulation. The research team used the Standards for Reporting Qualitative Research to ensure necessary reporting criteria.22 

Four themes emerged: employer’s responsibility, onboarding, support, and conflicting priorities. Each theme was further broken down into subthemes that describe the organizational aspects of TTP. Additional supporting quotes are in Table 3, and a coding frequency chart is in Table 4.

Table 3.

Emergent Themes With Supporting Quotes

Emergent Themes With Supporting Quotes
Emergent Themes With Supporting Quotes
Table 4.

Frequencies for Themes and Subthemes

Frequencies for Themes and Subthemes
Frequencies for Themes and Subthemes

Employer’s Responsibility

Participants who employed newly credentialed ATs felt they had a responsibility for educating and mentoring new ATs and sharing their knowledge and experience to ensure new ATs are successful in their role. Additionally, all the educators felt they had a responsibility for mentoring new ATs. The theme discusses the reasons employers felt they had a responsibility to new ATs, such as providing opportunities, investing in the future, professional responsibility and reputation, and cost containment and risk management.

Provide Opportunities for EPs.

Employer participants felt they could provide developmental opportunities to new ATs to allow them to grow as clinicians while also benefitting the employer. Twyla discussed conversations with her secondary school administrators, who wanted to hire an additional AT. She stated:

I felt very strongly that, if all these jobs are advertising 3 to 5 years of experience, where are they going to get that experience? They [administration] want someone with more experience. I explained this is an opportunity for both of us. I pulled up the jobs on NATA, and said, “Look, show me where there’s a job for a new grad. How are they supposed to learn?” Then I was like, “How are young coaches going to learn?” You need to bring in young coaches under an experienced coach and give them the opportunity to learn. How do you do it with your teachers? You bring in young teachers that you work with, and you help them become better teachers. That’s what we have to do.

Similarly, some employers knew the new ATs were there to learn and then go on to other positions. Jake commented:

My role is to make sure they’re prepared to go from working with us and move into a full-time position, knowing and confident that they’re going to be able to understand and be able to function.

He continued:

Because of my commitment to bringing them in, I know this is not something that is a requirement for me, but now I have taken on that role and responsibility and that I’m obligated to them.

Employer participants, especially those who supervise and mentor temporary ATs, felt they have a duty to help new ATs transition into their roles and prepare them for the next step.

Investing in the Future.

Employer participants also felt it was the organizations’ and their personal responsibility to socialize new ATs into their role to invest in future ATs and strengthen the profession. The sentiment existed even if it was not directly part of their job responsibilities. Johnny commented:

I think, as any employer should make an investment in a person to hire them, I would hope that to be the case, although I know it’s not. They should set up an opportunity for there to be a preceptor of some sort. It could be a peer or superior but to give them the opportunity to either voice concern, confusion, or questions, to receive feedback. I think, clinically, they have an opportunity to advance their skills by virtue of having interactions with other people, but I think that responsibility absolutely does lie with the professional organizations that hire them.

While participants recognized that not all employers provide the necessary socialization, most of our supervisor and mentor participants saw this as part of their role. Patrick commented:

My role mainly is support and to get them the information that they need to gently guide them without being overbearing, to allow them to learn and to support them and guide them as they grow into this profession.

Overall, supervisor and mentor participants felt that employers had an obligation to assist with the TTP; however, it does not occur with all positions. Gwen commented that employers often complain about new ATs adapting during TTP but do not always recognize their role in helping new ATs adapt. She stated:

I’ve heard it in 4 different states of supervisors of outreach ATs, but not a single one of them has developed anything in their onboarding program to address it. That’s concerning because it’s just perpetuating the problem.

Reflection on Supervisor.

Another reason supervisors felt a responsibility toward new ATs was because of their own reputation. New ATs reflect the supervisor, employer, and profession, and supervisors wanted to ensure the new ATs were a positive reflection. Jake commented about recommending one of his temporary ATs to colleagues:

I’ll know they’re getting somebody who is going to do an above standard job, and I’m not going to get a phone call later on. There’s no way I’m going to do that [recommend them if they are not ready]. It’s my sole responsibility. I’m obligated to employers to make sure, when I am used as a reference, I feel confident they’re ready to take the position on.

Stevie shared similar views:

As an employee and administrator at my institution, my responsibilities are to guide them and strengthen our program. I feel almost selfish saying that. We want to have the strongest program. We want employees who are very strong in their skills. Should they decide to seek another opportunity, they see our name on the resume and, “Oh, you came from there? Okay. We know about these people. We know they do ABC.” It’s guidance, but also different motives.

Supervisors felt they are ultimately responsible for the new AT and their skills, and those were a reflection on the supervisor and ultimately the employer.

Cost Containment and Risk Management.

While employers felt they were responsible for socializing new ATs, part of the motivation was also for retention and cost containment, which ultimately benefits the organization. Johnny commented:

It’s about retention. You have [ATs] who stay. Every time you onboard an FTE [full-time equivalent], it’s expensive, but if you keep them in the profession, you’ll continue to see growth and longevity. You will see a lower turnover rate.

Bob shared similar concerns about the time and expense required to hire new ATs:

It boils down to not just making them successful as an AT because, if they’re not successful, that’s more work I have to do. I have to find somebody else to take this position. It’s about training them so they can be successful.

Eric stated the employers need to

[s]et them up to be successful, whether it is through praise or corrections. You set them up to be successful because when they’re successful, our company’s successful. When our company is successful, our clients are happy. When our clients are happy, we get to keep our job.

In addition to the added costs associated with recruiting and hiring new ATs, employer participants recognized the need for onboarding from a risk mitigation lens. Gwen commented:

Even if we don’t see it as a duty to [new ATs], then it’s the duty to your organization to protect and mitigate risk. Even if you don’t value your associates and you don’t want to see them better, well, how naive is it that you don’t want to produce a better brand, and two, how do you not want to protect yourself in your organization from liability by improving the skillset of your associates?

Many of the employer participants recognized that helping new ATs adjust to their job will cost money, but organizations should view it as an investment. If new ATs can thrive in their roles, they are more likely to stay in the position, which ultimately saves money.

Onboarding

Onboarding describes the organizational processes used to orient new ATs to their roles. Participants felt onboarding was vitally important to the TTP for new ATs. Gwen, a supervisor, commented, “Onboarding to me is something that I think is critically important.” The theme describes how organizations onboarded new ATs through formal orientation, expectations, mentoring, and evaluation and feedback.

Orientation.

Some supervisors and EPs described onboarding processes that lasted between 3 months to the first year of practice, while others described their onboarding as good luck (ie, no onboarding or orientation). Orientation also varied widely for participants. Employer participants described processes that began after the interview, in which the new employee learned policies and procedures, organizational values, and daily processes (eg, how to use information technology systems, facility tours, where to get their badge). Jocelyn, an employer, commented, “We look to have an open line of communication from the beginning so there’s no sink or swim. I think that positively impacted the transition to the roles that I’ve hired the [ATs] to serve in.” Often, the employers who hired ATs through a hospital system described a 2-part orientation, which included hospital-specific information but then continued for athletic-training–specific information. Emily, an EP, stated: “He [supervisor] had a great onboarding process. He made sure I was trained in SportsWare. He made sure I had a whole notebook on how to do their policies and procedures.” Eric, a supervisor, described:

There’s an onboarding process that is 3 weeks to 12 weeks, depending on the environment. It looks like familiarization with rules, specific documentation software, familiarization with specific lingo, familiarization with those requirements, familiarization with our clients and leadership management.

Having a gradual orientation process is beneficial for new ATs to better understand their roles. Jason, an EP, commented:

I think my transition was good because of my mentor. For the first few weeks, she would be at practice with me, explain everything to me, everything I need to know. She introduced me to the coaches. It was a good transition. She was supervising all the rehabs, but slowly letting me take over and handle things. She slowly handed that off to me, which was good for me, definitely [a good transition] because I wasn’t thrown in where I was just like, “All right, here are your athletes.”

Unfortunately, some of the EPs reported instances in which they were thrown in without an orientation into their roles. Those who did not have an orientation shared some tactics that would have been helpful during the transition. Stephanie, an EP, commented, “I think maybe having like a set of policies and procedures or an orientation would have made it go a little bit smoother.” All stakeholder groups felt orientation was beneficial to help new ATs transition into their roles more effectively; however, not all EPs were provided with an orientation session that met their needs.

Expectations.

Part of the onboarding process is to relay expectations, as it is important for new ATs to understand their roles and meet employer expectations, and supervisors described relaying expectations as a part of initial orientation. As part of the expectations, employers presume that new ATs will be able to practice autonomously at the entry level. Jocelyn simply stated she expects that “[t]hey can operate independently.” Patrick concurred, stating:

Even though they’re entry level, I expect them to handle any situation, and if they are not comfortable, they need to know where to get help. They are credentialed. They should be able to perform all skills.

Additionally, supervisors expected new ATs to be open and willing to learn. Eric stated, “In general, I expect them to be receptive. Once they get comfortable and learning about the setting, I expect them to be participatory. I expect them to want to learn about the setting.” Johnny agreed, stating:

Utilize their education but be openminded to what they’re experiencing, their mentoring. No matter where you go, you’re going to develop new ways of doing things by virtue of who you’re working for. I want them to ask questions.

Most employer participants recognized that new ATs were entry level and expected them to have entry-level athletic training skills; however, they also expected their employees to maintain professionalism, continue learning, and ask for help when they were unsure of how to handle a situation.

While employers expected new ATs to be able to function, some employers did not relay expectations during orientation and onboarding. Early professional participants who did not have role specific orientations felt they did not understand each aspect of role expectations. Stephanie, an EP, commented:

There wasn’t like a set of rules or guidelines, not for athletic training. Maybe having what you mentioned earlier, like a set of policies and procedures or an orientation, would have made it go a little bit smoother.

Additionally, sometimes EPs felt the expectations felt went beyond what employers reported of being an AT. Julia, an EP, commented:

I came into this, and they just expected me to know how to do all of these things. I know how to be an [AT]. I don’t know how to be a teacher or organize a class. I don’t know how to make a schedule or reserve a gym.

Regardless of expectations, EPs should learn about specific employer expectations through orientation.

Evaluation and Feedback.

Evaluation and feedback are important aspects of onboarding, which can be formal (evaluation) or informal (ongoing feedback) processes. Many supervisors reported a formal evaluation process scheduled throughout the year, which included self-evaluations, site visits, stakeholder surveys (eg, coaches, patients, parents, administrators), and supervisor evaluations. Jocelyn, a supervisor, described their process:

We’re required to do yearly evaluations on criteria and a set scale. The [ATs] rate themselves first, and then we have a conversation together on my ratings. These are things like dependability, timeliness, honesty, accountability. We use specific examples using the scale and the criteria for evaluation. We’re talking about very concrete, tangible things, and you look at and improving in the future. It’s not undefined.

Employers provide information on what could be improved upon, but they also recognize areas of strength. Jake said:

It’s not only identifying areas of improvement, but I also want to emphasize the areas of strength, things I want them to continue doing, things they’re proficient in. I want to get their take to identify improvement areas or even strength and then solutions. We’re identifying, discussing, and then coming up with solutions.

After reviewing the evaluation, Patrick describes the next steps:

We sit down and go over it. We set goals. We follow up on past goals to make sure that those have been met or exceeded and think of where this employee wants to go to advance their career.

The evaluation process is used to communicate about job performance, sometimes determine raises or bonuses, and ensures ATs have the necessary resources or support to meet their goals.

In addition to formal evaluations, supervisors also provide informal feedback. Moira stated:

Feedback is given all the time, but the official formal feedback in writing and with resources and the recheck is done at 3, 6, 9, and 11 months, but they’ll be getting informal feedback on a regular basis.

Employers recognize that EPs crave regular and immediate feedback, and the formal evaluation process does not always provide that. Stephanie, an EP commented, “I’d appreciate [feedback]. I wouldn’t say enjoy it, but I would like that feedback so I could adapt and change what I need to so I can better serve the community.” Employers and EPs recognize that, without feedback, they cannot fix errors and improve. Julia, an EP, stated:

Especially as a young professional, I want someone to say, “You did this wrong. Fix it,” so I know what I’m doing. I could be doing stuff completely off the book, and no one would tell me any different.

Eric, a supervisor, commented:

If I hire someone in January and they make a mistake in March, I’m not going to wait until next January to tell them about it. Conversely, if they do something fabulous in February, I’m not going to wait until the next January to tell them about it. Every day is a review. If you do good stuff along the way, you got to tell people you did a good job. You don’t wait 6 months to tell them.

Formal Mentoring.

Some employers assigned mentors to assist the new ATs in their understanding of expectations and organizational procedures, collaborate on patient cases, and provide support for the new ATs. Often the mentor was an experienced individual within the organization but could also be the supervisor or peer. Eric commented, “In addition to the onboarding process, we have a mentorship program where more experienced individuals are assigned as a mentor.” Most supervisors who provided formal mentoring recognized the positive impact that it had on TTP, but not all employers provided specific mentoring for their new employees. Participants saw the benefits and felt employers should provide mentoring. Samantha, an EP, valued the relationship with her mentor to help her transition. She commented:

She’s been the most helpful, just because she’s an immediate resource because I work with her every day. We made the rounds with coaches and admins, and she introduced me. We went through our emergency action plan and how we refer. She taught me how to use our concussion system.

While all stakeholders valued mentoring, some participants noted that some new ATs may feel uneasy sharing their challenges with their direct supervisor. Lena, a faculty member, commented:

Mentors are extremely important individuals during [TTP]. You take in the worst-case scenario; the mentor is the supervisor by default, which is not the same thing. The supervisor is something completely different than a mentor.

Mentoring is an important aspect of TTP, but identifying a mentor who does not directly evaluate the new AT may be most beneficial.

Support

In addition to formalized processes, support was also provided to new ATs through informal mentoring and development. Support often extended beyond professional needs and met personal challenges.

Informal Mentoring.

Participants described the value of informal mentoring that evolved organically because of the organizational culture of mentoring or due to proximity. Informal mentoring allowed new ATs to consult and seek advice from individuals who were not their direct supervisors or in charge of their performance evaluations. Eli, a faculty member, commented that new ATs need a nonsupervisor mentor and someone who understands what they are going through. Eli stated:

The biggest thing is I don’t want to necessarily say a mentor but someone who is there to help them who isn’t their direct supervisor. The chain of command or authoritarian figurehead is not the person that they need.

Erin, a new AT, benefitted from the informal relationship with her coworker, commenting:

We do it informally. I’m grateful to have a coworker that appreciates communication. We communicate easily back and forth, and it’s [an] interesting dichotomy situation we’re in. He’s an older gentleman. He’s been in the profession for 30 years. I’m young and green, and I have all these fresh new ideas. So there’s a little bit of him giving me this confidence boost I need.

Alexis, a mentor, tries to get to know the person through the interview process and then tailors the mentoring she provides to their personality and needs. She commented:

It’s important to really get to know the person, who they are, before the [AT]. What do they like to do? Who are they? So I can better understand them before jumping into assisting them and mentoring them. What are their strengths? What are their weaknesses? How can I develop them from there? I feel like that helps them get comfortable. Then we can learn more about what areas improvement are needed.

Informal mentoring relationships help support new ATs and provide a sense of belonging beyond formalized methods of onboarding and mentoring from their supervisors.

Development.

As a part of support, new ATs also experienced professional development and growth as they worked with their support systems. Participants described collaborative learning with their colleagues to enhance their socialization. Alexis described reviewing cases with new ATs at her institution to help develop their skills:

I have cases, and I try to debrief with them. We had an acute injury on the field. This is how I got them off the field. This was my line of communication. This is what I did. I can provide examples of how to handle situations and lead by action.

Supervisors felt it was important to be professional role models and share their experiences. Roland, a supervisor, stated, “Taking the experience of what I might have had over the years and trying to expose them to those sorts of things.” Stevie, a supervisor, concurred stating, “We’re a great advantage in hiring younger ATs, and we can help to support any areas they feel that they may need assistance or improvement or weakness.” Samantha, an EP, has benefitted from working with her coworkers. She shared:

Learning organization and administration stuff from my coworkers is really helpful. We’re not doing everything at once, but I did inventory this time. She’ll show me how to do reports, stuff not continuing education unit based, but something to keep learning.

Beyond specific athletic training skills, supervisors and mentors aim to develop the whole person. Herb stated:

I’m going to be here to walk beside you and mentor you along the way, how we interact with coaches and how you deal with administrators. Go with me to this meeting. Go with me here and there.

In addition to the examples provided in the quotes, participants also provided formal development through journal clubs, skill development, round table discussions, and assistance with professional skills such as resume writing and interviewing.

Conflicting Priorities

The last theme, conflicting priorities, occurred when tension between different aspects of the role existed, whether due to time constraints or different expectations and perceptions. This theme describes common clashes in athletic training: patient care versus mentoring, work-life balance, and employee versus employer expectations.

Patient Care Versus Mentoring.

From an employer and preceptor perspective, a time conflict exists in which employers want to provide more mentoring to new ATs, but their main priority is patient care. Any time spent mentoring is time away from their job duties. While mentoring is necessary, the ability to mentor often depends on staffing and job responsibilities. Alexis, a mentor, commented:

At [University name], other [ATs] are [mentoring]. I know, at other settings and places, it really depends. If they’re short staffed and how much they’re working and overflow they have, I don’t think [mentoring] is the top priority.

Early professionals also recognized the challenging position, and some of their preparation was impacted, as they were not able to have as many opportunities because the preceptors needed to focus on patient care. Bryce, an EP, stated:

I didn’t really understand until I started working. I didn’t get a ton of hands-on exposure. Not saying the preceptors were bad. They were trying to do their job, and we were trying to do our job.

While Bryce was reflecting on his professional preparation, he did not fully understand the conflict that arises between job expectations and some of the extras (eg, precepting, mentoring) until he started working full time. While many supervisors, colleagues, and preceptors provide mentoring to students and new ATs, they recognized the challenge of balancing full patient loads with aspects of their role that are not necessarily requirements.

Work-Life Balance.

The next conflicting priority emerged between balancing work and personal time. Both employees and employers recognized that role responsibilities need to be fulfilled but differed in their perceptions of work-life balance. Some employers recognized that new ATs advocated for themselves, which benefits the profession. Eric, an employer, commented, “They come out of school expecting work-life balance. That’s a positive thing older people like myself could benefit from.” Eli, a faculty member, commented:

We have empowered young professionals to be advocates for themselves and advocates for the profession and encouraging them to not take low paying jobs to improve the work-life integration for themselves. By doing so, that’s also created a conflict for them when they’re offered a job and they’re recently hired. They say, “You told me to advocate for myself and not work more than 40 hours a week, and now I’m working 70, and I made a comment to my boss, and now they think I’m lazy.” I think that’s where I’m seeing the biggest conflict in young professionals. We create this advocate for good stewardships of our employment process in athletic training but not how to handle those things when it doesn’t go the way we want it to or the way we had encouraged them to seek it out.

Kalinda, a faculty member, hopes employers and colleagues recognize that wanting some off time does not make them lazy. She stated:

We actually like athletic training. There’s this stigma that young professionals, because they are advocating for less time in the clinic, means that they don’t want to do AT or that they want to do it on their terms. No, they just want work-life balance that hasn’t always been there.

Johnny, an employer, acknowledged the work-life balance challenges that new ATs face but also noted that they are hired to do the job and complete their responsibilities. He stated:

They must realize there’s a job to do, and so that balancing act of getting the job done efficiently, effectively, that’s one thing young professionals are faced with. How do you manage personal and professional work in life? You’re hired to do this job. It’s your responsibility.

Participants felt work-life balance was a consistent conflict, and some negotiation between EPs and employers was required.

Employer Versus Employee Expectations.

Like work-life balance, conflicts arose between employer and employee expectations. While conflict directly impacts work-life balance, the current subtheme focuses on the expectations of employers and employees’ perceptions and desires for compensation if they are expected to work more than contracted. Employer participants felt that new ATs were less willing to go above and beyond at work or volunteer to help others, while new ATs advocate for more balance between expectations and compensation. Some supervisor participants also felt new ATs were not as flexible, which is a necessary aspect of athletic training. Jake, a supervisor, commented:

One of the biggest challenges we’ll see is commitment. Sometimes I’m asking somebody, “Hey, I realize this is above and beyond. Can you cover this? Can you do that for us?” It’s sometimes for some of these younger people. I find… they’re more after… It doesn’t work for them as much. They need to have more time in advance. They’re not willing to step up quickly or spontaneously with coverage.

Conversely, some new ATs feel taken advantage of while others feel burned out when they consistently go above and beyond. Michelle, a new AT, commented:

I’ve only been here for a year, but I 100% feel like they take advantage of people they just hire and throw everything at them. Well, I just got hired. I’m not going to complain. I’m just going to do it.

New AT participants understood that schedules change, or they may need to work additional hours outside of the regular schedule to ensure they are fulfilling all their responsibilities; however, they feel the compensation should match the expectation. Emily, a new AT, stated:

We don’t want to have our lives taken from us by working 70 hours a week year round in a job that affords us no life at all. It would be different if I got paid more. It would be totally different. If I got compensated for all that time, I’d be like, “Oh yeah, I make $100,000 a year. I don’t care if I have a life. I have a bunch of money.” Well, I don’t. I’m poor. I’m poor, and I have no life, so what am I doing?

She continued:

I think the biggest thing with [TTP] and young professionals is making expectations versus compensation versus work-life balance more congruent. I think that’s forever going to be the biggest issue. It’s going to be something that we see until we find a way to make those a little bit more congruent.

Julia agreed, stating, “If I’m not required to be there, I’m not going to kill myself over you wanting me to work more than I’m getting paid to work. That’s crazy.”

The purpose of this study was to explore the organizational aspects during TTP from perspectives of various stakeholders. Our results build on the current TTP literature by simultaneously exploring multiple perspectives of organizational considerations, such as employers’ roles, cost containment, and how to balance conflicting priorities.

Employers’ Responsibility

Transition to practice is marked with stress, uncertainty, and role ambiguity, which ultimately impacts patient care.2  Many supervisor participants felt they had a responsibility to pay it forward to assist and educate new ATs since their own mentors provided socialization. New ATs already seek guidance from experienced ATs, and this support will likely become more crucial as the profession fully shifts away from the graduate assistantship model.20  Many employers are stepping into the role to provide opportunities for development, both formally and informally.16  Consistent with the literature, participants recognized that supervisors of new ATs were ultimately responsible for them and the patient care provided.8,11 

One aspect that employer participants consistently discussed was cost containment and risk management. Supervisors recognized that they had a fiduciary duty to the organization to keep costs low, which includes decreasing clinician errors and retaining ATs. Promoting a culture of safety and providing quality patient care should be a priority, but this may be challenging if new ATs are providing care in isolation or without formal orientations into their roles.23  New clinicians’ stress and anxiety may negatively impact their clinical performance and result in errors, such as referring patients to the wrong physician.2  Employers have a responsibility to ensure their new ATs are providing quality care. Furthermore, participants in our study believed new ATs reflect the supervisor and organization, so supporting new ATs also aids in image management and can improve retention.

Across many industries employers are reporting a worker shortage.5,24–26  Attrition increases costs and negatively impacts organizational effectiveness.27  Nursing researchers have found between 35% to 60% turnover rate in the first year of clinical practice and many cite poor training, inadequate orientation, lack of support, misunderstanding procedures, high stress levels, and anxiety as major contributing factors in the decision to leave during their first year.7,28  Similarly, new ATs who had lower comfort levels, lower feelings of mentorship and support, and lower feelings of organizational integration were more likely to consider leaving the athletic training profession.18  Employers can ensure safe patient care, assist with retention, and invest in the future of the profession by providing education, professional development, and formal onboarding.5,7 

Onboarding Processes

Onboarding is a formalized process that integrates new employees into their new organization and explains organizational processes and the beliefs and values of the organization.18  Participants across stakeholder groups felt employers had a responsibility to provide onboarding but had vastly different experiences. This is consistent with previous research in which orientations for new ATs (eg, formal meetings, providing policies and procedures, tours of facilities, introductions) varied.18  Like in previous reports, EP participants who experienced a formal orientation process felt their transition went smoothly, while those who did not have formal orientations were unsure of some of their role expectations.29  Although employers may recognize they are hiring entry level ATs, relaying specific expectations during orientation can help EPs work more effectively to meet those expectations.2,8,16 

Other important components of new ATs’ TTP were providing feedback and mentorship. Formal evaluations were used to provide feedback to new ATs at regularly scheduled intervals, and some supervisors also used informal conversations to provide more regular feedback. Early professional participants commonly wanted regular feedback on performance, which assists with role validation and increased confidence.2,16  Honest, regular feedback is needed for new ATs to adjust and develop their skills.17  If supervisors are unable to provide regular feedback, they should consider more frequent evaluation periods (eg, monthly) or help them find meaningful mentors. Although previous researchers have noted the benefit of informal mentoring relationships, our results show that formal mentors, if they are well selected and invested, can positively impact the TTP.29  Supervisor participants recognized mentoring relationships were vital and were willing to invest time to make the relationship worthwhile. Mentors within the organization can provide timely support and guidance on organizational policies, expectations, and collaboration. Additionally, if new ATs are assigned mentors, it can alleviate stress since they do not have to find someone who is willing to step into that role. When hiring new ATs, supervisors should develop a mentoring program to ensure success during the TTP. If the new ATs are employed in settings without other ATs to serve as mentors (eg, secondary school setting directly hiring the AT), new ATs should seek ways to develop mentoring relationships with other ATs within their conference or district.

Support

Support provided during the TTP is paramount to new ATs’ success.18  Graduate assistant ATs in the collegiate setting who received support felt they transitioned to independent practice more effectively.11  From a supervisor perspective, support and mentoring resulted in fewer instances of new ATs needing to be remediated or removed from their position due to inadequate performance.8  Providing initial support and supervision affords an opportunity for new ATs to receive feedback and for supervisors to intervene on behalf of patients as needed.

Our participants also discussed how informal mentoring relationships evolved though collaboration and welcoming environments and offered much needed support. Reviewing patient cases, sharing experiences, and working with supervisors to set goals and tailor strategies to meet goals were helpful. Professionally, relationships with colleagues provided advice, helped clarify role expectations and institutional policy, and provided collaboration with difficult patient cases. Personally, relationships with colleagues and informal mentoring helped EPs feel more comfortable in their roles and asking questions. However, the relationships and professional development opportunities were more prevalent for participants in the collegiate setting, or those who were employed by organizations with multiple ATs. Athletic trainers in the secondary school setting are often the only health care provider on site especially after normal school hours, so developing supportive relationships and having informal mentors is challenging. While former preceptors may serve as mentors, they may not be able to provide assistance specific to the role. New ATs can form relationships with administrators, coaches, athletic directors, and team physicians, which leads to role legitimization, retention, and allows ATs to focus on their role as health care providers.27  New ATs are encouraged to develop professional collegial relationships with other ATs or staff members to assist with TTP.

Conflicting Priorities

Conflicting priorities were apparent with all stakeholder groups but presented differently. For employers and mentors, conflict often arose when they wanted to provide more mentorship and support but could not prioritize mentoring over patient loads. This time constraint is not new, so if mentoring is important to the employer and institution, supervisors should include mentoring in the job description to allow employees to prioritize development of new ATs.8 

For EPs, work-life balance emerged as a conflict as they attempted to set professional boundaries and find balance to avoid burnout, while still fulfilling duties.10  Supervisors noted EPs viewed work differently, and advocating for themselves was overall positive and benefited the profession; however, the job still needs to be done. The quest for work-life balance may lead to conflict and incongruence between employee expectations for balance and employer expectations of the role. Researchers in nursing have found new nurses tend to leave jobs and potentially the profession when their expectations and the workplace reality do not align.30  Like our results, supervisors felt new ATs do not fully understand what is expected in the role, such as working second shift or nights and weekends.14  These are factors that lead to burnout and attrition. Immersive clinical education experiences have been purported to help athletic training students experience the totality of an ATs’ responsibilities, which may help new ATs better understand job expectations.31  Future researchers should explore the incongruence between employer and employee expectations and its impact on burnout and attrition.

Many of our participants recognized a culture shift is occurring that entails employees advocating for themselves to not take on the extra responsibilities or working whenever athletes need them (eg, communication with an athlete at midnight). While being fully accessible has historically been the expectation, it is not feasible, realistic, or sustainable for an individual to be on call 24 hours a day, 7 days a week; however, supervisors with these expectations still exist.8,14  Faculty and preceptors have empowered students and EPs to advocate for themselves, but they are not always prepared to navigate these conflicting priorities. Educators should consider adding conflict resolution and navigating difficult conversations as a part of the curriculum to allow EPs to professionally handle conflicting priorities.

As Generation Z and millennials make up a larger portion of the workforce, the outlook on work will continue to evolve. Thus, changes must be made for the vitality of the profession, and tactics can be used to attract and retain quality ATs. Millennials and Generation Z have different work values and beliefs than previous generations and want meaningful work that is interesting, which includes development opportunities and an organization that cares about employee well-being.32  Whereas athletic training is meaningful work, employment trends demonstrate the profession must evolve. Employers are currently reporting challenges employing ATs, especially in the traditional settings.24–26,33  Anecdotally, employers are discussing how ATs are leaving for more lucrative or flexible jobs in other industries and employers are looking for creative ways to entice ATs to work in traditional settings (eg, offering tuition reimbursement, continuing education opportunities, mentoring, financial counseling).33  Employers should continue exploring ways to promote a workplace culture focusing on well-being and mental health of employees. Supervisors and employers have a duty to manage their expectations when it comes to the role of entry-level ATs, while new ATs also must understand role expectations.

Limitations and Future Directions

Our study is unique in that we sought perspectives from 3 different stakeholder groups; however, a limitation is that the 3 participant groups were not linked, and all participants were recruited individually. Future researchers could explore perceptions from multiple stakeholders that are linked (ie, EPs, one of their former preceptors or faculty, and their current employer or mentor). In addition, all the supervisor or mentor participants were ATs. Due to the recruitment process, we were only able to recruit participants who are members of the NATA. Supervisors and mentors self-selected to participate in this study, so there is a potential those who support TTP already see the value of orientation and onboarding. Others who do not see the value may have self-selected out of the study.

Additionally, most participants in the EP and supervisor groups were in the traditional settings. Transition to practice may look different between practice settings, and we elected to gain a more holistic view from multiple settings. Therefore, future researchers should explore perceptions of organizational aspects in specific settings. We also only interviewed participants at 1 time point. Longitudinal studies from employer, faculty, or preceptor perspectives throughout EP ATs’ transition could yield unique perspectives, especially as we fully transition professional education to the postbaccalaureate level.

Many organizational aspects are critical to the TTP and postcertification education of new ATs, such as onboarding, mentoring and support, and professional development. To assist with TTP, employers should provide comprehensive onboarding, formal mentoring, and informal personal and professional support. Employers have a responsibility to assist in the TTP for their new employees; however, challenges arise when job requirements limit mentoring opportunities. Organizations should ensure supervisors have adequate support to assist in the TTP for new ATs. Additional dialog on work-life balance, expectations, and compensation would benefit all ATs and assist in new ATs’ TTP.

This is a unique time for athletic training because new ATs can be selective and seek employment settings that provide balance and support their TTP. Employers should recognize their role in supporting new ATs and follow recommendations of the NATA Reshaping Education Document by providing onboarding and orientation, continuing education and professional development, and TTP programs.12  Support and onboarding through the TTP increases confidence, alleviates stress, and enhances role integration, which ultimately impacts patient care.

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Appendix. Interview Guides

Supervisor or Mentor of Early Professional ATs

  1. How many years of experience do you have in your current role?

  2. Please describe your typical responsibilities in your current role.

    • Are you responsible for performance evaluations of (the) AT(s)?

    • How did you learn how to evaluate the performance of AT(s)?

    • How comfortable are you with this responsibility?

  3. How many ATs have you hired within the past 5 years?

    • How many of those were starting their first job with autonomy over clinical AT decisions?

    • How many of those had less than 5 years of clinical AT experience?

    • What support structures, if any, are in place to assist new hires?

  4. What do you see as the major advantages associated with hiring young professionals?

    • Are there certain skills and/or traits that they excel with?

    • How/why do you think they excel at these?

  5. What do you see as the major challenges associated with hiring young professionals?

    • Are there certain skills that they struggle with?

    • How do you think these skills could be improved during professional preparation, if at all?

  6. Please describe your expectations for new ATs.

    • In what areas do most new ATs meet these expectations?

    • In what areas do most new ATs fail to meet these expectations?

  7. Could you please describe the evaluation process for the ATs you supervise?

    • How frequently does this occur?

    • How are areas for improvement addressed?

      • Are there any skill improvement programs offered?

  8. What do you feel is your role (or responsibility) with young professionals as they transition to practice?

  9. How long does it typically take for young professionals to be successfully integrated into their role?

    • How does this compare to experienced ATs?

  10. Is there anything you would like to add? Anything we did not cover?

Athletic Training Educators (Faculty or Preceptor)

  1. How many years of experience do you have in your current role?

  2. Please describe your typical responsibilities in your current role.

  3. How many ATs have you mentored within the past 5 years?

    • How many of those accepted jobs working clinically as ATs?

  4. What do you see as the major advantages associated with hiring young professionals?

    • Are there certain skills that they excel with?

    • How/why do you think they excel at these?

  5. What do you see as the major challenges associated with hiring young professionals?

    • Are there certain skills that they struggle with?

    • How do you think these skills could be improved during professional preparation, if at all?

  6. Do former students contact you for advice?

    • Please describe a typical scenario underpinning these situations.

    • Is there a common theme?

    • How do you react to these situations?

  7. What advice would you provide to those getting ready to transition to autonomous clinical practice?

    • Are there specific resources you recommend to facilitate transition?

  8. What do you feel is your role (or responsibility) with young professionals as they transition to practice?

  9. What do you perceive young professionals need during their transition to practice (e.g., support, mentoring)?

  10. What feedback have you received from employers or alumni related to the transition to practice for new ATs?

  11. Is there anything you would like to add? Anything we did not cover?

Early Professional ATs

  1. How many years of experience do you have in your current role?

  2. Please describe your typical responsibilities in your current role.

  3. How prepared did you feel upon taking your first job working as an AT?

    • What made you feel prepared?

    • Are there any areas in which you felt you needed more preparation?

    • What skills, if any, do you wish you had more preparation in during your professional education?

    • Is there anything that could have been done during your professional education to help you feel more prepared?

  4. What do you see as the major advantages associated with hiring young professionals?

    • Are there certain skills that they excel with?

    • How/why do you think they excel at these?

  5. What do you see as the major challenges associated with hiring young professionals?

    • Are there certain skills that they struggle with?

    • How do you think these skills could be improved during professional preparation, if at all?

  6. What do you do if you are faced with a situation where you aren’t sure what to do?

    • Who do you turn to for help making tough clinical decisions?

    • Who do you turn to for help dealing with a difficult coach or coworker?

  7. What do you see as your educational needs now that you have graduated and are working as an AT?

    • Are there specific continuing education needs that you hope to fill?

    • How do you plan to obtain your CEUs?

  8. What would you tell yourself before starting your first job that you wish you would have known?

    • Is there anything that would have made your transition to practice smoother?

  9. Is there anything you would like to add? Anything we did not cover?

Abbreviations: AT, athletic trainer; CEU, continuing education unit.