Multistakeholder Perceptions of Young Professionals’ Integration During Role Transition

We used the consensual qualitative research approach to explore the transition for EP ATs and to limit researchers’ biases throughout the analysis process.^14,15  We recruited participants from 3 stakeholder groups to determine a holistic perspective of the experiences of ATs during the transition from student to autonomous practitioner while improving generalizability. Including multiple stakeholder groups allowed the data to create a triangulation effect, so the results could speak to the thoughts, opinions, and perceptions of all stakeholder groups.¹⁶ 

We recruited 17 EPs in the first 2 years of their first job postcertification (9 women, 8 men, age = 26 ± 5 years, experience = 9.5 ± 5 months), 16 supervisors of EPs (6 women, 10 men, age = 52 ± 11 years), and 10 faculty members and 8 preceptors (11 women, 7 men, age = 43 ± 10 years) via emails from the National Athletic Trainers’ Association (NATA). The use of the NATA as a gateway to prospective participants has been an effective and widely used research practice. Participant descriptive data can be found in Table 1. Data saturation, the point at which theoretical redundancy was achieved, drove recruitment and was met.

We created interview guides for each stakeholder group (EPs, supervisors and mentors of EPs, faculty, and preceptors) based on the current literature^1–5,7–13  regarding the transition to practice for EP ATs. The validation process for the interview guides consisted of expert review (n = 2) and pilot testing (n = 6) after initial creation by the research team. First, all authors met to discuss the interview guides, and we collaborated on drafts. We circulated the draft interview guides until no author had any further suggested additions or edits. Next, we shared the interview guides with 2 experts and asked them to review for clarity, relevance, and importance as related to the purpose of the study. We defined experts as scholars who had published peer-reviewed manuscripts related to the socialization of ATs or transition to practice for ATs. After editing based on the feedback provided, we provided the experts with revised interview guides. The experts suggested no additional changes. Finally, we pilot tested the interview guides with 2 stakeholders from each group (EPs, supervisors of EPs, faculty, and preceptors). They had no changes, allowing us to finalize the interview guides before recruitment. Data from the pilot interviews were not included in the final analysis.

After obtaining approval from the Institutional Review Board at the University of Lynchburg, we used the NATA mailing lists to recruit participants. We asked NATA administrative staff to send a recruitment email to 500 randomly selected individuals who recently (within the previous 9 months) passed the Board of Certification examination, 852 members who designated themselves as faculty, and an additional 2000 members across all settings. We also sent the recruitment email to program directors at every Commission on Accreditation of Athletic Training Education–accredited professional master’s program in the United States and asked them to forward the email to those who met our inclusion criteria. Finally, we posted our recruitment text to several social media platforms (eg, Facebook and Twitter). Those who were interested in participating contacted a member of the research team to obtain the consent form. Once we received the signed consent forms, we scheduled interviews on a first-come, first-serve basis and ceased scheduling interviews upon data saturation. We reached data saturation with all 3 stakeholder groups, as theoretical redundancy had been met. To confirm, we completed all scheduled additional interviews when we felt we reached saturation. At the end of the interview, we asked participants to forward information about the study to others who were members of the stakeholders we sought (EPs, supervisors of EPs, faculty, and preceptors) to improve recruitment efforts.

We analyzed data using the consensual qualitative research technique, which is an inductive approach used to study experiences and attitudes while integrating multiple viewpoints.^14,15,17  First, 3 research team members coded 5 transcripts from each stakeholder group and created an initial codebook. Next, the research team members met to review the codebooks and negotiate over the coding scheme until we reached 100% agreement on a final codebook to be used when coding all remaining transcripts. Two research team members coded all remaining transcripts using the final version of the codebook. A third team member acted as a tiebreaker (internal auditor)¹⁵  for any disagreement between the primary 2 coders, and we used the code selected by 2 of the 3 coders. After the initial coding, research team members condensed the codes into categories upon additional reads of the data. Finally, we further condensed categories into themes to allow for an organized presentation of the results. Participants from each group spoke to the categories from the group’s perspective, but as the themes were condensed, similarities were apparent. For example, supervisors and mentors discussed various aspects that affect integration, such as real-life experience, and educators and EPs discussed role engagement and living the role as ways to help increase confidence. Thus, the codes were condensed to the theme of role integration. Table 2 demonstrates how the codes from each group were condensed to the categories that represented each stakeholder group.

Multiple-analyst triangulation (n = 3), as discussed earlier, was a key component in the analysis and maintaining the trustworthiness of the data. We also completed narrative accuracy member checks as a trustworthiness strategy.¹⁶  We sent the transcripts to the participants and asked them to verify the accuracy. Finally, we used external auditing as our third trustworthiness technique.^14,15,17  We asked an external auditor with consensual qualitative research experience to review the coding structure and confirm the accuracy of the presentation of the results.

After completing the thematic analysis iterations (Table 2), we identified 4 themes (Figure 1) that defined the integration of EPs during role transition. Support for the themes traversed the stakeholder groups (Figure 2). The integration of EPs was facilitated through role inductance, as some responsibilities had to be learned by performing the duties of the position. All stakeholder groups noted that EPs needed to perform the roles of autonomous clinical practice to successfully transition. Mentoring provided support for EPs as they struggled with navigating job-related challenges, including difficult clinical decision-making, diffusing conflict with stakeholders, and developing clinical skills. Early professionals struggled to find work-life balance as they were new to the profession and felt obligated to exceed coverage expectations rather than focusing on the quality of care supplied. Finally, stakeholders suggested a timeline by which EPs became fully integrated into autonomous professional practice, which most participants felt ranged from 6 months up to 2 years. However, some employers believed it took up to 5 years. Participants thought EPs were integrated in their role when they understood all aspects of their role, found identity as ATs, and were confident in fulfilling their roles. The themes are defined and supported with participant quotes in the following sections. Additional supplementary quotes can be found in Table 3.

Almost all participants believed that “living” as ATs was critical to EPs transitioning into autonomous clinicians. Because the accreditation standards for athletic training professional education require direct supervision,⁶  a “safety net” always existed for students, and they failed to experience the entirety of professional responsibilities. Ray, a supervisor of EPs in the secondary school setting, explained the challenges of full integration due to direct supervision of students:

Several participants noted that EPs typically “lack confidence” due to a paucity of experience and suggested that role inductance is key to improving self-assurance. Becca, who served as a preceptor at a secondary school, alluded to the need for “experience” for EPs to settle in during the transition period. She said,

Early professionals agreed that confidence needs to improve, but it will take “some time” and “experience” to allow continued learning. Although he felt prepared to enter independent clinical practice, John, an EP, knew he had more to learn and that it would happen via role inductance. He explained,

Although participants agreed that role inductance was critical to EP integration into the profession, they also believed the process could start before graduation. Many thought that immersive clinical education experiences played a critical role in preparing EPs for the transition to practice. Grace, a preceptor and rehabilitation coordinator in professional sports, said:

Finally, Sara, an EP, agreed that immersive experiences were critical to her development by providing her with more experience:

Participants felt EPs had more to learn to become comfortable in their new roles. Role inductance offered additional experiences for newly credentialed ATs that led to successful transitions to practice. Immersive clinical experiences supplied experiences during professional preparation that assisted in preparing students for the workforce.

Every participant noted the importance of mentorship during the transition to practice. They noted the “powerful” effect of effective mentors in navigating the transition to practice and becoming integrated into the profession. Beyond discussing the general importance of a mentor, participants commented on the importance of mentor selection and having mentors for both personal and professional needs to help overcome the ups and downs associated with professional practice. Cary, an assistant professor in an athletic training program, stated,

Lana, a program director, described key personal and professional characteristics she considered important when setting EPs up with mentors:

Owen, a preceptor, discussed the importance of having a mentor who can provide a safe space for asking questions without judgment:

Kalinda, an assistant professor, spoke about how demanding the secondary school setting can be because clinicians are isolated, often being the only health care providers within the school. She provided suggestions for how EPs working in secondary schools can find mentors:

Lucca, a program director, agreed with Kalinda and further addressed the importance of mentoring, especially the support of a supervising physician:

Similarly, Sara, an EP, explained the importance of fostering a network of mentors because the person she goes to for mentoring differs depending on the situation:

Every participant in our study specifically recognized the importance of mentors in assisting EP ATs’ integration into the profession. Some identified scenarios when mentorship was more important to those transitioning. Several participants also gave advice on who should be selected as mentors for EPs.

Many participants noted the importance of finding work-life balance during professional integration to avoid burnout. When asked what skills EPs need to improve, Marissa, a program director, replied,

Lucca explained that setting boundaries is an important aspect of becoming a professional and finding work-life balance. She said, based on her role as a program director,

Early professionals may struggle with work-life balance due to the disconnect between their desire to set boundaries and the view from supervisors to ensure event coverage. Several supervisors voiced concerns about the work ethic of EPs. Jake expressed,

Participants appreciated the importance of finding work-life balance early in professional practice. Setting boundaries to assist in preventing burnout was important to both EPs transitioning and those who mentor them. However, employers stated that EPs needed to be flexible and realize that schedules often change in athletics.

We asked participants how long it typically takes EPs who are starting their first job to successfully transition. A range from no sooner than 6 months up to 5 years was cited. Eric, a supervisor working in occupational health, suggested it is possible to transition in 6 months but that a year is more customary:

Twyla agreed. She supervised newly credentialed EPs in secondary school settings and had a range of experiences mentoring EPs through the transition to practice, similar to Eric. She responded,

At the hospital setting where ATs are outreached to secondary schools, Stevie, an employer, thought it might take a bit longer to find an “identity.” She observed, “For me, it is 2 to 3 years. That’s enough time that you feel that you could be on your own and that you can find your identity and no longer be tied to your student identity.” Finally, Diane proposed the highest amount of time for full transition. She served as a program director and associate clinical professor. In her experience, newly credentialed ATs needed support as they initiated transition and into the first 5 years of clinical practice to improve retention within the profession:

Most participants agreed 1 to 3 years would be necessary for EPs to feel comfortable and confident working autonomously.

Our purpose was to examine the perceptions of EPs’ integration during role transition from 3 stakeholder groups (EPs, supervisors and mentors of EPs, faculty, and preceptors). After interviewing multiple participants, we found 4 themes that described the transition period for EPs. Our study builds on the current literature^1–5,7–13  regarding the transition to practice by providing multiple perspectives. To our knowledge, we are the first to examine preceptor perceptions of transition to practice, and our findings extend the current literature on the transition process.

Participants in all groups concurred that role inductance is a critical step in the transition to practice process for newly credentialed ATs. Consistent with previous literature,^3,5  many believed “living the role” was critical to developing the confidence and skills required to complete daily job duties because accreditation standards⁶  require preceptors to be physically present to intervene on behalf of patients or students. Although graded autonomy¹⁸  and situational supervision,¹⁹  for which the level of supervision changes depending on the clinical scenario, have been suggested, others have argued for increased student independence to align with other professional health care programs.²⁰  Indeed, our participants felt that the safety net of direct supervision hampered students from truly developing confidence in their clinical skills and clinical decisions while appreciating the totality of the roles and responsibilities of ATs. Some authors^1,4,7  demonstrated similar findings in which students lacked the confidence to make quick clinical decisions and that a period of role inductance was required for a full transition to autonomous clinical practice.^3,5 

Immersive clinical education experiences have recently been added to the accreditation standards⁶  for professional athletic training programs. An immersive experience is defined as “a practice-intensive experience that allows the student to experience the totality of care provided by athletic trainers. Students must participate in the day-to-day and week-to-week role of an athletic trainer for a period of time identified by the program (but minimally one continuous four-week period).”²¹  Immersive clinical education experiences are intended to provide students with a more holistic view of the profession. Students believed that immersive experiences did, in fact, lead to greater preparation for transition to practice because of the exposure to the full responsibilities of autonomous clinical practice.²²  In particular, students perceived greater exposure to administrative expectations, communication with stakeholders, interprofessional health care, quality patient encounters, and teachable moments with preceptors.²²  Preceptors displayed similar thoughts and also discussed the upside to immersive clinical education experiences for preparing students for the transition to practice.²³  However, preceptors need to be trained appropriately to fully appreciate the expectations for mentoring immersive experiences.²³  Finally, although athletic training educators reported similar benefits of immersive clinical education experiences, they recognized certain challenges, such as having sufficient time to cover the didactic material required by accreditation standards, increases in preceptor workload, students’ inability to bridge didactic and clinical education content, and additional obstacles such as timing, faculty workload increases, and administrative support.²⁴  Despite the challenges of implementing immersive clinical education experiences,^24,25  they appear to be critical in developing confidence and a full appreciation of the athletic training profession and ultimately creating a smoother transition to practice.^22–24  Our results suggest that the requirement of immersive clinical education experiences may assist students in successfully transitioning to autonomous clinical practice. However, it is also important for newly hired EPs to be properly onboarded so that they can apply their knowledge and skills adequately within the workspace and supply appropriate patient care.^12,13 

The importance of mentoring during the transition to practice has been well established.^1–5,8  Nonetheless, our study revealed important nuances in mentoring that have not been identified in athletic training to our knowledge. Our participants noted the importance of having both professional and personal mentors. Professional mentors offer EPs support, guidance, and advice on current clinical cases and job expectations. Personal mentors can assist in providing a support system for the difficult decisions EPs must make daily. Our respondents believed a solid personal support system was essential and would provide comfort during times of stressful clinical decision-making and when mistakes were made. Previous researchers acknowledged the value of securing mentors who were not medical providers, such as athletic directors, coaches, student-athletes, and parents.²⁶  Our participants felt that having the support of others during clinical decision-making and being part of a community were both important when considering role fulfillment and overall job satisfaction. Securing support staff as mentors was critical to navigating the system and facilitating the day-to-day obligations of ATs as perceptions and understanding regarding responsibilities was facilitated by coworkers.²⁷ 

Participants also noted the importance of matching EPs with mentors who they could build “relationships” with and help them feel “comfortable.” One individual commented on mentors who “look like them” as 1 example that could affect mentor-seeking behaviors and communication styles and ultimately facilitate relationship building. Early professionals who are Black, indigenous, or people of color (BIPOC) may desire diverse mentors who can relate based on shared experiences and reflect longevity in the profession.²⁸  Early professionals may find comfort in talking to someone who understands the cultural challenges BIPOC face, especially in health care settings.²⁹  African American nursing students felt more comfortable talking with mentors who shared their cultural identity,²⁹  a result similar to ours. Furthermore, pairing EPs with mentors who share cultural identity can assist with validation³⁰  of EP membership in the profession. However, to date, most head ATs identified as White,³¹  which may limit opportunities for BIPOC EPs to locate mentors who share their cultural identity. Despite these challenges, the NATA has created the Ethnic Diversity Advisory Committee and LGBTQ+ Advisory Committee and developed a “Diversity, Equity, and Inclusion Response Plan” to illustrate the importance of diversity to the Association.³²  The NATA Ethnic Diversity Advisory Committee also has a mentor database to assist BIPOC EPs in finding mentors.

Several participants mentioned the importance of mentoring in the secondary school setting. Secondary school ATs are often the sole health care providers at after-school events, which can leave them feeling isolated.²⁶  When EPs are secluded and the only health care providers, they may need reassurance that they are making the best clinical decisions. Mentors can offer support for clinical decision-making while enhancing EPs’ knowledge and confidence, as discussed by previous researchers who examined the transition to practice for graduate assistant ATs working in the secondary school setting.²⁶  Athletic trainers in the same athletic district or region could be helpful mentors due to their knowledge of district policies and community resources. In some areas, ATs at geographically adjacent secondary schools may be the closest sources of support, guidance, and mentorship.

Several respondents observed that mentors should not be involved in performance evaluations. Our participants thought that if a mentor was also evaluating an EP’s performance, the EP might be less likely to ask questions regarding clinical practice, policies and procedures, or managing challenging relationships. Instead, mentors should be chosen or assigned by avoiding those who evaluate EPs in an effort to provide “safe spaces” for asking questions without fear of judgment or subpar performance evaluations.

Work-life balance is the ability to engage in multiple roles, such as employee, parent, and spouse, among others, with satisfaction in each role.³³  The quest for work-life balance is an important component of every AT’s life, as it has been linked to professional commitment, burnout, job satisfaction, and career longevity.³³  Finding balance during the first few years of clinical practice by engaging with supervisors in a discussion regarding priorities may help prevent burnout. Participants stressed the importance of setting boundaries. Indeed, setting boundaries is an important strategy for maintaining work-life balance in the workspace.³³  Learning to say “no” early in their careers would allow EPs to demonstrate boundaries regarding what they will and will not do as part of their formal responsibilities. The NATA position statement on work-life balance³³  provided additional suggestions for achieving work-life balance, including prioritizing essential professional and personal tasks, effectively communicating with coworkers and others, setting goals and planning responsibilities according to those goals, and self-reflecting on time demands and responsibilities.

Although setting boundaries and learning to say “no” are critical skills that EPs must learn, the willingness to be flexible and eagerness to be considered a team player are also critical.³⁴  Program directors pinpointed dependability and responsibility as the most valuable soft skills that students need to master during professional preparation.³⁵  Work expectations of ATs are often dynamic and ever-changing, as scheduling modifications occur due to weather and other factors outside stakeholder control. Early professionals must learn to be flexible, versatile, and adaptable as they set boundaries. Perhaps EPs should seek insight from their mentors on the balancing act of being a team player while integrating work-life balance strategies. Supervisors also should encourage teamwork among staff members when possible and respect the importance of work-life balance.³⁴  However, we concede that teamwork is often difficult, especially at the secondary school setting when only 1 clinician is employed. Engaging with stakeholders in identifying workplace priorities is critical to avoid conflict when clinicians uphold boundaries, especially in settings with limited staffing. Administrators, coaches, and other stakeholders will need to also appreciate flexibility, versatility, and adaptability as situations arise that change initial plans for ATs’ workplace responsibilities.

Transition is a normal and necessary requirement that involves an understanding of new work roles and responsibilities via personal and professional growth.¹  The process of transition begins as EPs discover a “clash of culture”¹  when starting professional practice. During the transition process, EPs must resolve expectation differences between delivering health care as students and as professionals. Participants agreed that the transition process takes time, which was consistent with the nursing literature,³⁶  indicating that the transition process allowed EPs to embrace the role of health care providers. Therefore, EPs should be given advice on weathering the transition period, rather than avoiding it, including finding personal and professional mentors,^1–5,8  self-reflecting on performance,¹  and using trial and error to determine best practices and what works for them.¹ 

The time required to fully transition to autonomous clinical practice varied widely from our respondents’ perspectives. Early professionals working in secondary school settings may need more time to become comfortable in their new role mainly due to potential isolation at their site as the only AT. Individuals felt it would be more difficult for EP ATs to transition when there was no other AT physically present to bounce ideas off, gather advice from, and teach policies and procedures specific to the workplace. Similarly, participants also believed that a lack of mentorship could lengthen the time needed to successfully transition. A strong mentor can positively affect the transition and may reduce the time to transition for reasons similar to having another AT on site.

Supervisors should align expectations of EPs with entry-level knowledge while appreciating that they will require time to be properly onboarded, learn site-specific policies and procedures, obtain mentoring during difficult clinical decision-making, and build confidence via patient care experiences, leading to a successful transition into autonomous practice. Expecting EPs to function as experienced clinicians can frustrate supervisors while disenfranchising EPs. However, affording EPs support during the transition enables them to meet workplace expectations without causing burnout. Establishing criteria for evaluating EPs’ completion of duties and responsibilities and periodic performance evaluations to discuss progress can also aid in role transition and integration.³⁷  For example, the recently validated “Athletic Training Milestones” can help supervisors develop entry-level expectations for clinical practice and allow EP ATs to identify specific indicators for advancing clinical practice over time.³⁸  Formative performance reviews may demystify role ambiguity and provide an opportunity to address concerns before situations become problematic.

Although we recruited a diverse set of participants (role, geographic location, age, experience level) from 3 stakeholder groups, a common limitation to qualitative research is generalizability. Our findings are grounded in the data collected from our participants, yet they may not represent the thoughts, opinions, and feelings of all stakeholders in athletic training. We only recruited participants who were NATA members, which may have altered our findings. However, we believe our study is an important step in continuing to determine how EPs can be supported and nurtured through the transition to practice. Future researchers should investigate the transition to practice for EPs in specific work settings, such as secondary schools, as the process likely differs based on our results. Most of our EPs and supervisors were in the secondary school and college or university setting. Future authors should evaluate other settings, such as professional sports, performing arts, public safety, military, and occupational health.

Clinicians’ comfort levels affect patient care, and our findings suggest several ways to prepare EPs for and support them through the transition to practice. Early professionals should have clinical education experiences with appropriate graded autonomy to assist in the development of clinical reasoning skills and confidence. Immersive clinical education experiences facilitate professional integration, which also offers a mentoring network of past preceptors. Expectations for EPs should be reasonable to allow for adequate work-life balance and integration into the profession without guilt. Early professionals typically become fully integrated after a period of time that depends on their prior learning experiences and the support received during their transition to practice. Supervisors and employers should recognize that the transition takes time, and EPs should be supported throughout the transition with mentoring.