Factors of Persistence Among Graduates of Athletic Training Education Programs Open Access

Retention is a term used by an institution, department, or program to describe maintained enrollment1 and can be expressed as the percentage of students who graduate from a program into which they matriculate.2,3 Little research about retention in undergraduate athletic training education programs (ATEPs) is available.1 However, recruiting and retaining students is becoming increasingly important to faculty because the number of programs has increased dramatically in recent years, giving students more options from which to choose.4 Maintaining high retention rates is important to preserving the reputation and quality of ATEPs and institutions.5 In particular, high attrition rates can threaten the financial stability and vitality of the program.5,6 Attrition of lower-achieving students has been viewed as a “weeding-out” process, yet improving persistence to graduation of academically sound students will assist the athletic training (AT) profession by providing strong clinicians.5 

To determine factors that lead to persistence, investigators have compared senior AT students with students who switched from AT to a different academic program.6 They determined that student motivation to finish the program was the most important factor in student persistence. Unmotivated students who did not put forth strong efforts usually did not finish their ATEPs. Getting students involved early and keeping them interested in AT through strong clinical learning experiences were also very important to enrollment. Finally, peer support groups also appeared to play a role in the decision to persist in an ATEP.

Other researchers4 have investigated attractors, facilitators, and barriers to careers in AT of current students. They found that current students were attracted to AT because of the association with sports and athletes and because they like to help people and enjoy being part of a team. Facilitators to choosing AT were a positive relationship with the student's high school athletic trainer, a history of injury while participating in athletics, and taking an AT class in high school. Time constraints and an interest in a different career were found to be barriers to choosing AT.4 

Although light has been shed on the factors persuading potential recruits to enter the profession of AT4 and persist to the senior year,6 the reasons some students graduate from ATEPs and others leave them before completion remain unclear. No researchers have sought data from recent graduates to determine reasons for their successful persistence. Therefore, the purpose of our study was to describe the reasons recent graduates who were enrolled in a postprofessional program accredited by the National Athletic Trainers' Association (NATA) persisted to graduation in their accredited undergraduate ATEPs. We hoped to extend the current literature by studying a select group of students who persisted to graduation from a diverse subset of ATEPs.

We chose to use strictly qualitative methods to gather a more holistic and greater understanding of persistence in ATEPs while keeping the data collection flexible and dynamic.7 Volunteers took part in in-depth, semistructured interviews lasting approximately 30 minutes in which they were asked questions about their experiences in their undergraduate degree programs. The semistructured format of the interviews allowed the researcher to ask the participants to expand on answers or to ask follow-up questions for further detail. The questions were devised based on the work of researchers examining initial socialization4 of current students and persistence6 of senior AT students. Examples of interview questions are provided in the Table. The interview questions were examined by an experienced qualitative researcher for content and pilot tested with a recently certified athletic trainer for clarity; the researcher and athletic trainer were not authors.

Fourteen students (12 women, 2 men; age = 22.21 ± 1.05 years, certified = 11) enrolled in an NATA-accredited post-professional education program volunteered to participate in this study. Although we chose these participants based on convenience, they also met our inclusion criterium of graduating from an accredited undergraduate ATEP, qualifying them as persisters. The participants started their graduate studies approximately 1 month before data collection. They represented 14 undergraduate ATEPs accredited by the Commission on Accreditation of Athletic Training Education (CAATE), including 6 research institutions, 6 master's institutions, and 2 baccalaureate colleges based on the Carnegie Foundation Classifications.8 The participants also attended institutions in 11 different states and 6 of the 10 districts within the NATA, providing geographic diversity. We thought this population would have perspectives that were different from those of a population from only 1 undergraduate institution, leading to better generalizability. Before coding interviews, we assigned pseudonyms to all participants to protect their anonymity. Participants gave informed consent by providing their names and e-mail addresses on an interview schedule sign-up sheet. The institutional review board of the host institution approved this research.

We obtained permission from the program director to talk to the graduate students at the end of a class. After explaining the purpose, risks, and benefits of the research project, the lead investigator (T.G.B.) asked for volunteers to participate in the research project. He also informed the recruits that they could withdraw from the study at any time during data collection or skip without penalty any questions they did not feel comfortable answering. Finally, the lead investigator gave the recruits examples of interview questions so they would know what to expect during the data collection session. All 15 members of the graduate class were present, and 14 agreed to participate. Participants received an e-mail reminder of their interview date and time. The primary investigator completed all one-on-one interviews with each participant. During data collection, we tape recorded the interviews for ease of analysis and monitored the data for saturation. We later transcribed the interviews verbatim and assigned a pseudonym to each participant.

We analyzed data through a grounded theory approach using open, axial, and selective coding procedures. During open coding, we broke down the data into discrete parts and noted similarities between those parts. Axial coding followed, and we focused on connecting data to form major categories and sub-categories. Central categories were identified through selective coding, which is a process that involves relating categories to one another and validating the relationships among those categories.9 We have been trained in qualitative methods through graduate coursework and are both AT educators. We chose to use grounded theory because it helps explain patterns of behavior for selected groups.10 Our purpose was to generate a theory to explain decisions of recent graduates of CAATE-accredited ATEPs to persist to graduation in their undergraduate programs, making grounded theory appropriate.

In qualitative research, the term trustworthiness refers to the authenticity of the data and conclusions.7 Multiple measures were taken to ensure trustworthiness of the data. As noted, the interviews were transcribed verbatim before coding and subsequent data analysis. Initially, we independently coded and analyzed the interview data. Then, we negotiated over the coding categories until we reached 100% agreement. We also performed member checks with all participants to verify the accuracy of our transcriptions and interpretations. A third researcher who had experience in qualitative research and was not an author examined the coding scheme and verified the final categories.

We asked the participants questions to try to elucidate what aspects of ATEPs facilitate a student's persistence to graduation. Four main themes emerged from the participants' interview data (Figure):

• Interactions with faculty, Approved Clinical Instructors (ACIs), and classmates play a major role in students' decisions to persist to graduation.

• The environments of ATEPs (ie, cohesiveness, small size of the program) influence decisions to persist to graduation.

• The educational experiences of students can solidify their decisions to persist to graduation.

• Career considerations influence students' choices to graduate from ATEPs.

The first category emerged from answers to questions about why the participants stayed in their ATEPs and what they liked best about their ATEPs. The faculty of the programs from which the participants graduated played a large role in their persistence. Most participants (10 of 14) mentioned that their interactions with faculty were a reason they stayed in the programs. Shelly stated,

When asked what she liked best about her program, Kelly responded,

Faculty appear to have a positive effect on students in ATEPs, and their availability and willingness to help guide students might affect students' decisions to persist in the programs.

As part of their undergraduate education, AT students must be engaged in clinical experiences in which they are supervised by an athletic trainer who is an ACI.11 Participants indicated that they enjoyed their interactions with their ACIs. For example, Heather stated, “I liked all my clinical instructors. . . . My first rotation I had women's volleyball, and I had a great clinical instructor. He was also really fun; . . . he also taught at the same time.” Most participants (10 of 14) also stated they thought their ACIs were supportive and helpful. Laura said,

Jordan agreed, stating that the best part of his program was “working with just some of the specific ACIs there, they were just great mentors.” Overall, the personality of ACIs and student–ACI relationships appear to positively influence students' decisions to persist to graduation.

Finally, participants described interactions with their classmates that influenced their persistence in ATEPs. Many participants (6 of 14) thought their classmates pushed them to succeed. For example, Shelly stated,

Amy reiterated Shelly's statement:

In these comments, Shelly and Amy alluded to their fellow AT students helping them through tough times by being available for conversation and advice.

The second category of themes revolved around the participants' perceptions of their ATEPs' environments. Most participants (8 of 14) stayed in their programs because they enjoyed their experiences. Amy stated,

Jordan agreed:

More than half of the participants (8 of 14), especially those from larger institutions, stated they enjoyed the small size of their programs. Susan, who attended a very large state flagship research institution, stated, “The small classes at a big university is kind of nice. I went from a 500-student class to a 7-student class.” When asked what she liked best about her didactic education, Lauren, who also attended a state flagship institution, replied, “Really small class sizes; there was a lot of individual attention.” Some participants (4 of 14) also enjoyed the family-like atmosphere of ATEPs. Tracey stated, “We would all get together, the clinical staff and the students, and they would give out awards to students and play little games, they were fun.” For these participants, the small class sizes and the sense of the program being close knit deterred them from considering other academic programs.

Both the didactic and clinical education experiences of the participants also played a major role in their decisions to persist in their ATEPs. “I loved my classes. I thought that they taught us a huge amount, and if I didn't like them I probably would have left or transferred somewhere else,” stated Heather. Jordan also described his coursework as “definitely interesting to me. I think the information kept me into it [the program].” Ten other participants agreed that their didactic classes played a role in their decisions to persist in the ATEPs.

The clinical experiences of 13 of 14 participants were also facilitators to persistence in ATEPs. Rachael stated, “I ended up taking a lot out of every rotation. . . . That really influenced me to stick around [in the program].” Especially helpful to the participants was the autonomy they enjoyed as upperclass students. Lisa commented on her clinical experiences:

Other participants also thought their clinical experiences reinforced the concepts they learned in class and allowed them to apply the knowledge they were learning in the classroom. For example, Susan stated,

Almost all participants (11 of 14) thought that they had experiences that reaffirmed their decisions to become athletic trainers. Several participants, such as Colleen and Shelly, thought they addressed situations appropriately and gained confidence in their skills. Colleen said,

Shelly agreed:

For both students, clinical education solidified their decisions to persist through their ATEPs. Shelly's perceived autonomy was a positive experience for her, reaffirming her skills. Of interest, the athletes she encountered during her clinical experiences helped her decide to persist.

The final category of themes that emerged revolved around career considerations. Most participants completed their ATEPs because they enjoyed what they were doing. Amy stated, “I loved it [AT]. . . . I would just enjoy the atmosphere, working with the athletes, getting them better.” Many of the participants (11 of 14) decided to practice AT because they wanted to help others or they wanted to be around sports and work with athletes. Tracey stated,

Alison agreed: “I think my interest in sports and my interest in helping people. . . . I think that's [why AT's] the best fit for me.” When asked why they were attracted to a career in AT, a typical response was, “Sports are such a huge thing in our country, it's like some people's number 1 priority. . . . It's always going to be around, and I'm always going to be interested in it.” Several others liked the high-intensity and fast-paced environment, liked that each day brings a different challenge, and did not want a desk job. Colleen was attracted to a job in AT because

Clinical education reaffirmed students' commitment not only to their ATEPs but also to the profession of AT by ensuring that they would enjoy working in the future.

Our results add greater understanding to what is already known about persistence in ATEPs. We studied recent AT graduates and used in-depth interviews to gain a more comprehensive appreciation of the factors that matter most in AT students' decisions to persist to graduation. In previous research on student persistence, investigators focused on AT students in their senior years, whereas we focused on students who had completed their ATEPs. Our participants chose to pursue NATA-accredited postprofessional ATEPs, which indicates a desire not only to persist but also to receive advanced training in the field. Our results suggested that interactions with others, the environment of the ATEP, the educational experiences in which the students engage, and career considerations have strong links to the decision to persist to graduation.

Similar to our findings, student interaction with faculty that is more informal and friendly has been found to aid in student retention12–15 by improving the willingness and enthusiasm of students to learn on their own.16 These student–faculty interactions are particularly important because they facilitate the reciprocation of learning. Students are counseled in ways that assist with the transition to college life, which is referred to as the separation process,17 and faculty gain experience promoting academic and lifelong learning through one-on-one sessions.18 Based on our results, we also believe positive interactions with ACIs have encouraging effects on persistence to graduation, especially because AT students identify ACIs as mentors.19 As researchers have found in nursing,16,20 we believe the mentoring that occurs between AT students and ACIs is an important part of the professional socialization process and appears to increase persistence during enrollment in the undergraduate ATEP.

Our participants' interactions with their peers were mostly encouraging and therefore positively influenced decisions to persist in ATEPs. This is consistent with findings6 that showed the benefit of peer support groups in ATEPs: More than half of the 125 participants stated that their decisions to persist in their ATEPs were influenced by their relationships with peers. We believe peer support groups facilitate student retention by stimulating interaction among classmates in the classroom and in the clinical setting. These relationships help improve student integration into the institution both socially and intellectually, leading to student persistence.17,21,22 

The positive environment and experiences from which our participants benefited also played a large role in their decisions to persist to graduation. The Student Integration Model17,21 states that when students become integrated into the institution, retention is more likely to occur. Integration is defined as the student becoming involved in the campus community and the feeling that he or she belongs in that community.17,21 It also has been defined as the amount of energy a student dedicates to his or her academic experiences both physically and mentally.23 The student must have abilities, goals, and values similar to those of the campus community to become integrated.16 On a smaller scale, students who more easily accept the discourses of the academic program also tend to achieve greater integration.24 Students who devote large amounts of time and effort to their ATEPs as required by clinical education might feel more attached and dedicated to the programs, especially if they are given appropriate autonomy. Therefore, if students become integrated into the programs with positive experiences and enjoy the large amount of time they spend in AT, they might be more likely to persist to graduation.1 Our participants enjoyed their classes and the small, family-like atmosphere that characterized their programs. We believe this perceived atmosphere facilitated the integration and eventual persistence of our participants. Students experienced this family-like atmosphere regardless of the institutional size, further supporting the theory that successful ATEPs are close-knit communities. As ATEPs strive to retain high-quality students to justify their continued existence, they need to maintain this family-like atmosphere even in the presence of large numbers of students.

For our participants, the fun and exciting environment they perceived appeared to facilitate persistence by outweighing the time commitment and their frustrations. In the nursing literature, stressful clinical experiences due to high demands have been linked to student attrition.25 We believe the rigorous coursework and time-consuming clinical education experiences that exist within ATEPs26 must be countered by AT faculty and staff becoming flexible with students' time to ensure that they will not abandon the major before they become interested in the core coursework and clinical education experiences.1 Students need to become integrated into the curriculum and their clinical education while finding time to engage socially with other students, faculty, and staff. Keeping clinical education expectations appropriate and manageable also will allow students to process and reflect on what they are learning.27 Therefore, educators should strive to create learning environments that are characterized by positive interactions and reasonable demands.

Students also need to feel that the experiences they are having are worthwhile and meaningful while occurring in a changing and exciting environment. Providing students with high-quality clinical experiences appears to be a very important aspect of increasing student retention to graduation. Consistent with previous work,6 we found that efforts to engage the participants in the daily operations of an AT room early in their clinical experiences appear to have given them a sense of belonging and to have improved their chances of persistence within their ATEPs. If students believe they are learning important concepts and enjoying themselves, the difficult coursework and time commitments do not seem to be overwhelming.

We found students who persisted to graduation enjoyed what they were doing, further stressing the importance of providing an exciting atmosphere. Similar to the work of previous authors,4 we found participants enjoyed sports and wanted to help others. Several participants (4 of 14) also stated they did not want a desk job at which they would be doing similar things every day. The participants appeared to enjoy the variety of responsibilities they might encounter, making each day different. However, students typically became interested in ATEPs based on their perceptions of the roles, skills, and job requirements graduates possess, so properly educating potential recruits about the profession is important.4 How the positive aspects of the profession can be marketed to underclass AT students remains unclear.

Several strategies have been postulated to help ATEPs increase their retention rates.1 Five main categories of activities have been presented with examples of activities to help students persist to graduation.1 Program administrators should appreciate cultural diversity, develop the career goals of the students, promote healthy relationships, create an interactive classroom, and encourage campus involvement of the students. Examples of activities that can help ATEPs reach these goals are developing clinical experiences with diverse populations, integrating professional goals early in the educational experiences of the students, developing peer mentoring programs, implementing class discussions involving critical thinking and student cooperation, and emphasizing the quality of clinical experiences instead of maintaining hourly requirements.1 In addition, providing underclass students with upperclass mentors might improve student integration,28,29 leading to persistence.

Some limitations of our study are important to note. The participants attended different ATEPs with different requirements to enter and remain in the program. The differences in programs make the experiences of our participants diverse and difficult to compare, but several themes did emerge. In addition, a common limitation of qualitative work is the difficulty of generalizing the results because our participants were a small snapshot of the entire AT graduate population. Although our participants came from different undergraduate programs covering many NATA districts, generalizing our results to the wide variety of CAATE-accredited undergraduate ATEPs is difficult. We also had poor sex balance (12 women, 2 men), and our participants were enrolled in a postprofessional ATEP, which might have biased the results.

In the future, researchers should continue to shed light on potential reasons for student persistence and attrition in undergraduate ATEPs. Investigating faculty perceptions of student retention in ATEPs would be interesting. Another potential area for future work might be analyzing why students leave the AT profession to pursue other opportunities after graduating from ATEPs. Finally, new persistence programs should be implemented and evaluated to determine their value to ATEPs.

The purpose of our study was to determine the factors that led students enrolled in an NATA-accredited postprofessional ATEP to persist to graduation from accredited undergraduate ATEPs. We were interested in who plays a role in students' decisions to remain in ATEPs, how the programs and the education experiences of the students influence decisions to persist to graduation, and why students were planning to enter the profession and have careers in AT. Faculty and ACIs might be very important factors in the persistence of AT students by being positive mentors. Classmates of AT students also factor into the decision to graduate from accredited ATEPs. The participants enjoyed the small size and family-like atmosphere of their programs and thought their classes were interesting. Positive clinical experiences appeared to play a major role in reaffirming the education and career choices of the students. The participants chose to persist in AT mainly because they were excited about the opportunity to help others and wanted to be around athletes. Completing ATEPs and entering the field of AT will allow them to achieve these career goals.

This research was presented in a poster at the 2011 Athletic Training Educators' Conference.

We thank Amy Orange for examining the interview questions; Jay Sedory, MEd, ATC, EMT-T, for pilot testing the interview questions; and Susan Guyer, DPE, ATC, CSCS, for examining the coding scheme and verifying the final categories.