Stephanie H. Clines, PhD, LAT, ATC
Sacred Heart University, Fairfield, CT.

Cailee E. Welch Bacon, PhD, ATC
A.T. Still University, Mesa, AZ.

Christianne M. Eason, PhD, ATC
Lasell College, Newton, MA.

Kelly D. Pagnotta, PhD, LAT, ATC, PES
Jefferson University, Philadelphia, PA.

Robert A. Huggins, PhD, LAT, ATC
Korey Stringer Institute, University of Connecticut, Storrs, CT.

Bonnie L. Van Lunen, PhD, ATC, FNATA
Old Dominion University, Norfolk, VA.

Corresponding author:
Stephanie H. Clines, PhD, LAT, ATC
Sacred Heart University
5151 Park Ave
Fairfield, CT 06825
Phone: 203-365-4475

Stephanie Clines, PhD, ATC is a Clinical Assistant Professor in the College of Health Professions at Sacred Heart University in Fairfield, CT. She also serves as the Clinical Education Coordinator for both the Bachelor of Science and Master of Science in Athletic Training programs at the University.

Influencing Factors and Rationale for the Use of Athletic Trainers in Secondary School Athletic Programs

Purpose: Secondary school student-athletes often lack appropriate medical care during school sponsored sport participation. Athletic trainers (ATs) are qualified healthcare professionals that can fill this need. Barriers to hiring ATs have been identified, however the rationale regarding the use of ATs in schools remains unexplored. Understanding this phenomenon has the potential to guide strategies to improve access to ATs, thus improving athlete safety. Our objective was to explore high school athletic directors’ perceptions of the roles and services provided by ATs working in the secondary school setting and to understand the needs of the athletic program and school regarding the use of athletic training services.

Methods: Following a qualitative methodology, ten high school athletic directors employed by schools with full-time ATs completed telephone interviews. All interviews were recorded and transcribed verbatim. Data analysis followed the consensual qualitative research (CQR) approach.

Results: Procurement of athletic training positions was influenced by various personnel, community organizations, and policy. Rationale for requiring ATs within athletic programs included specialized training by ATs which was perceived to enhance safety and decrease liability. Participants viewed ATs as ideal athletic healthcare providers. Coaches were not supported as appropriate staff to fulfill this role. Financial and logistical challenges to the initiation and maintenance of AT positions were also discussed. Conclusions: The decision to utilize ATs is complex and influenced by multiple factors. Applications in Sport: Consideration of these factors may improve the success of athletic director’s efforts to initiate or maintain athletic training positions to support the safety and well-being of student-athletes within secondary school athletic programs.

Keywords: sport safety, athletic healthcare, high school, staffing, educational administration.

Participation in high school sports has reached an all-time high with the number of athletes growing consecutively for the past 28 years to 7.96 million participants (30). Even at the high school level, athletic participation comes with associated risks for injury. As participation rates rise so do sport related injuries within this population, with approximately 1.16 million sport related injuries reported in high school athletes during the 2016-2017 season (10). While most injuries are not life-threatening, fatal and catastrophic injuries have also occurred in the secondary school setting (13, 22). However, current evidence suggests that many of the risks associated with sport participation can be mitigated with proper prevention, assessment, and treatment by a qualified healthcare provider (9, 11, 23, 27).

Several leading organizations, including the American Academy of Pediatrics (AAP) (2, 3) have provided “best-practice” recommendations for appropriate healthcare for student-athletes within the secondary school setting. Among these recommendations includes the hiring of at least one athletic trainer (AT) by all secondary schools that sponsor an athletic program to address the medical needs of student-athletes (1, 8, 25). Athletic trainers are nationally certified healthcare professionals who specialize in the assessment, prevention, treatment, and rehabilitation of athletic related injuries (29). Additionally, 49 states and the District of Columbia currently require ATs to be licensed or registered as a healthcare provider in the respective state in which they practice (5). Within the secondary school setting, ATs provide a wide variety of services to student-athletes including, but not limited to, rehabilitation, assessment, injury prevention, treatment, education, game preparation, event/practice coverage, administrative work, teaching classes, oversight of student clubs, performance enhancement training, and off-season conditioning (19, 24, 28, 36).

Despite the availability of these highly skilled healthcare professionals to protect the safety of youth athletes, less than 50% of secondary schools in the United States have regular access to an AT (34). Factors such as budgetary restrictions and misunderstanding of the profession have been identified as reasons schools do not hire an AT to provide care for student-athletes (26, 32, 34). However, within the secondary schools that utilize athletic training services, no research has been conducted to identify the rationale and facilitators supporting the inclusion of ATs as members of their athletics programs. Therefore, the objective of this study was to address the current gap in knowledge through the exploration of the athletic director’s perceptions of the role of ATs in the secondary school setting and provide an understanding of the needs of the athletic program and school in terms of the utilization of athletic training services.

The best way to explore a phenomenon is through qualitative investigation, particularly when minimal research is available on a topic (14). Therefore, a qualitative methodology was selected to explore the perspectives of athletic directors regarding the utilization of secondary school ATs. Due to the rigorous nature of consensual qualitative research (CQR) and the emphasis on consensus development between team members, this tradition served as the best method to generate unbiased results and was used in this investigation (15, 16). Developed from principles of phenomenology and grounded theory, the CQR tradition serves to help explain participant experiences and associated phenomena through descriptive analysis. The building of consensus is an integral component of the CQR methodology which requires a team of analysts to develop emergent themes through rigorous constant comparison and repeated analysis of data (15, 16).

Participants included secondary school athletic directors throughout the United States employed in a school that currently utilizes the services of a full-time, Board of Certification (BOC) credentialed AT. Athletic directors were required to be employed within their current school for a minimum of two academic years. Additionally, schools were limited to those that had a history of provision of athletic training services for at least one full year prior to the time of interview. The employment model of the AT was not limited; therefore, ATs were employed under both the direct employment and clinic-outreach models. Duties of the ATs could be completed in any capacity and may include responsibilities such as the provision of athletic training services and teaching. Other demographic factors such as institutional type and school or athletic program size were not restricted during participant recruitment.

The use of open-ended questions, such as interview protocols or questionnaires, to facilitate data collection is characteristic of the CQR approach (15). Due to the lack of a preexisting interview protocol that addressed the specific aims of this investigation the research team developed a unique interview protocol based on current literature regarding the utilization of secondary school ATs (26, 32, 34) and principles of organizational role theory (18). The interview guide consisted of three main sections: 1. basic demographic information, 2. open-ended questions regarding the athletic director’s overall perceptions and experience regarding the utilization of an AT within their athletic programs, and 3. open-ended questions pertaining to the athletic director’s perceptions of the roles and services provided by the AT. The interview guide was given to an independent qualified researcher for peer review to provide feedback on content accuracy of the instrument, logical flow of questioning, and to reduce researcher bias within the questions. The interview guide was then pilot tested with a representative sample of athletic directors. No changes were made to the interview guide after pilot testing. Data from the pilot study were not included in the final analysis.

Participants were recruited purposefully via criterion sampling (31). Schools that met the inclusion criteria were identified through the Athletic Training Practice Based Research Network (AT-PBRN) database (36). A list of schools that utilize the CORE-AT (4) electronic medical record (EMR) program was requested in May of 2016 from the AT-PBRN and contained the names of 71 schools. The list of schools was then cross referenced with the National Athletic Trainers’ Association (NATA) Athletic Training Locations and Services (ATLAS) database (21) to identify schools with at least one full-time AT that had completed the ATLAS survey. Per ATLAS, full-time status of an AT is defined as an AT that provides athletic training services to only one school for a minimum of 30 hours per week, no less than 5 days per week, for at least 10 months of the calendar year (21). A total of 36 potential schools (32 public, 4 private) were identified as having a full-time AT. School websites were then utilized to locate the contact information for the athletic directors. Email addresses and phone numbers were collected from these websites and an email detailing the purpose of the study along with the contact information of the investigators was sent to potential participants. Participants received a maximum of three emails at least one week apart. If no response was made to all email attempts potential participants received one phone call from the primary investigator one week after the final email was sent. Those interested in participating either replied to the contacting investigator’s email or verbally agreed over the phone to schedule a telephone interview. All participants received a $50 gift card for their participation in this investigation.

One-on-one, in-depth phone interviews were conducted with participants following a semi-structured interview guide. This methodology provided the best environment to allow participants to share and elaborate upon their individual experiences (35). The primary investigator conducted all phone interviews in order to maintain consistency. All phone interviews were digitally recorded with the consent of the participant and were transcribed verbatim by a professional transcription service. Once transcription was complete, the individual transcripts were sent to all 10 participants for voluntary review of their respective transcript for accuracy and clarity prior to data analysis. Interviews lasted approximately 40 minutes. Participant recruitment and data collection were guided by data saturation (14).

Consistent with sample size recommendations for CQR methodologies to achieve data saturation (16), a total of 10 secondary school athletic directors participated in this investigation (male = 7, female = 3). Our participants had an average of 9.4±5.5 years of experience as a secondary school athletic director with an average of 8.5±5.3 years of experience at their current school. Duration of athletic training service provision within the schools ranged from 1.5 to 20 years, averaging 9.6±6.1 years of AT utilization. Eight of the 10 participants reported having previous experience with an AT prior to becoming an athletic director as either a high school athlete, collegiate athlete, high school coach, or combination of former athlete and coach. The majority of participants (7/10) reported previous employment in a school that did not utilize an AT. Only one (1/10) participant held a dual role as coach and athletic director. All participants were employed in public schools. The average school enrollment size was 1,666±1,000.1 with 570.4±329.2 athletes based on overall roster numbers. The number of ATs providing services within the schools ranged from one (8/10) to two (2/10). Individual participant demographics can be seen in Table 1.

Table 1

Data Analysis
Data analysis followed the methodology of the CQR approach (15, 16) with four experienced qualitative researchers forming a consensus team consisting of two core researchers, an internal auditor, and an external auditor. Data analysis began with the core team and internal auditor simultaneously and independently coding three randomly selected transcripts. Once independent analysis was complete, the three researchers discussed the codes until a consensus was reached, creating a codebook. The codebook included all themes and subthemes generated during the initial analysis. Using this codebook, two additional transcripts were reviewed to ensure completeness and accuracy of the established themes. Once the codebook was verified using the two transcripts the primary investigator coded the remaining transcripts. After the primary investigator completed coding of the remaining transcripts the core team discussed the transcripts to confirm consensus on coding. Once consensus was reached between the core team members three randomly selected transcripts were sent to the internal auditor for cross-analysis to ensure correct coding. Finally, one additional randomly selected transcript was sent to the external auditor to ensure reliability through independent analysis of the codebook and transcript.

When cross-analysis was finalized, frequency counting was conducted to characterize the prevalence of each identified category, allowing the researchers to gauge the representativeness of the data to the sample population. The use of frequency counts also supported the confirmation that data saturation had been met. Frequency categories are traditionally divided into four categories: 1. General, 2. Typical, 3. Variant, and 4. Rare, where general categories apply to all or all but one case, typical categories apply to more than half of the cases, variant categories apply to less than half of the cases, and rare categories apply to only two to three cases (25).

Four main strategies were utilized to secure data credibility (14, 33): 1. Peer review, 2. Field notes, 3. Member checks, and 4. Intercoder reliability. First, the peer reviewer, an experienced researcher with content expertise in the area of sport safety, reviewed the interview guide for accuracy. Second, during the phone interview field notes were taken by the interviewer as a means to capture key points raised during the interview process. The notes aided in the analysis process as a means to identify emergent, dominant themes. Third, participants were asked to evaluate the accuracy of the transcription process to help establish credibility of the textual data in a process known as member checking. Member checks were voluntary and completed by six of the 10 participants. None of the six participants provided additions to the original transcript during the member check process. The final strategy of intercoder reliability is established through the rigorous consensus process of the CQR approach (15, 16).

Five themes emerged from the data that describe athletic directors’ perceptions of the utilization of athletic training services in the secondary school setting (Figure 1). For the purposes of this study we focused on athletic director’s experiences with the utilization of ATs in the secondary school setting with emphasis on the initiation and maintenance of athletic training positions within their school. Supporting quotes for all subthemes can be seen in Table 2. The frequency of participant cases for each subtheme all aligned with the general or typical categories (Table 3).

Table 2

Table 3

Influencing Factors
Factors related to the decision to utilize ATs within secondary school athletic programs were discussed by our participants and were organized into two subthemes: 1. People and Organizations, and 2. Policy.

People and Organizations. Athletic directors identified several groups that played a role in influencing the decision to utilize the services of an AT including the school board or district, superintendent, booster club members, athletic directors, parents, and local hospital organizations and rehabilitation clinics. Several participants also discussed how the partnership with an outside organization helped facilitate the establishment of the AT’s position due to the opportunity to share the costs associated with the employment of the AT. Our participants identified that while many different groups provided a unique influence on the decision making process, administrators within the school board or district made the ultimate decision to approve the use of an AT within the school.

Policy. Athletic directors identified that various policies and regulations also influenced the decision to utilize ATs within their schools. Most commonly, our participants identified athletic league or conference rules regarding required medical care for student-athletes as a reason their school chose to use the services of an AT. Participants who were affiliated with larger school districts discussed the requirement of reciprocity among the schools as a factor for approval of an AT position within their athletic program. Some athletic directors also discussed reciprocity between districts explaining how having ATs in the high schools within their districts set a precedent for the area and influenced the use of ATs in athletic programs in neighboring districts.

The theme justification relates to reasons athletic directors would use to defend or justify why they use ATs within their athletic programs and is divided into three subthemes: 1. Safety, 2. Liability, and 3. Trained Medical Professional.

Safety. All participants revealed that the safety of student-athletes was an important aspect of their athletic program’s success. By hiring ATs, athletic directors felt that the safety of their student-athletes was enhanced. This increased sense of safety was frequently discussed in the context of concussions and concussion management, where participants discussed how having an AT on staff improved both the assessment of head injuries as well as the execution and management of their concussion policies. Some participants also felt that improving safety by employing an AT made their athletic program more successful because others in the community would view the program in higher regard.

Liability. Legal issues that may result from lack of care or improper care for student-athletes was another factor athletic directors reported as to why they felt ATs are important to their athletic programs. Liability was also identified as a supporting factor our participants would use to defend the AT’s position in the event the position was at risk of being eliminated for budgetary reasons.

Trained Medical Professional. The ability to have a trained medical professional on staff was identified as a strong rationale for having an AT within secondary school athletic programs. Athletic directors demonstrated a great appreciation for the knowledge and training ATs have regarding athletic injuries. The significance of eliminating unqualified or lesser trained individuals such as parents, officials, or coaches from situations where medical decisions need to be made was also of high importance to athletic directors. This rationale for requiring appropriately trained medical professionals within athletic programs was particularly true in the context of management of concussions in student-athletes. Additionally, allowing coaches to focus on coaching related tasks and removing the role of medical provider from the coach’s daily roles and responsibilities was also viewed as an important benefit to our participants, as several athletic directors discussed how having an AT on staff facilitates the ability for the appropriately qualified personnel to assume the proper respective roles within the athletic department.

Athletic directors also identified some challenges related to the use of ATs within their schools. Challenges were perceived to occur both in the process of trying to initially create the AT position as well as currently maintaining the AT’s position within the school. Two subthemes of challenges were identified: 1. Financial and 2. Logistics.

Financial. Funding for the AT’s position was discussed by all participants as a challenge that effected the initiation and/or maintenance of the AT’s position within the school. Several athletic directors identified that obtaining funding from the school board or district was a prominent barrier to the approval of the use of ATs within their school. Our participants also expressed awareness of and concern for budget cuts that could result in the loss of the AT’s position within their school. Additionally, several of our participants expressed appropriate pay for ATs as a challenge to utilizing athletic training services in the secondary school setting, identifying their concerns that the ATs working within their schools may leave for better paying positions.

Logistics. Logistical issues were also experienced by our participants who described operational and facility related challenges to the utilization of ATs. Appropriate space was described as both a barrier to approving the position of an AT as well as a current difficulty faced by the athletic department.

The desire to have better facilities and equipment available to the ATs was also an issue identified by several of our participants who described inadequate our outdated space for the AT’s to conduct their daily operations, with limitations such as small space, no air conditioning, or lack of therapeutic exercise and modality equipment as prominent responses.

The majority of our athletic directors identified the logistical struggles associated with having one AT to provide services to an entire athletic program. While most acknowledged that they felt their ATs were providing adequate services to the student-athletes, they recognized the limitations of having one professional to care for all athletes, using phrases such as “spread thin” to describe the working environment of their ATs.
The final logistical issue our athletic directors discussed was retention of ATs within their schools. Many of our participants identified that turnover rates for ATs were high within their athletic programs, with one participant indicating that his school went through “four [athletic] trainers in four years.” Despite high turnover rates, our participants expressed gratitude for the ability to have an AT on their staff.

In the current state of sport culture, the desire to reduce injury risk and improve sport safety is a high priority (17). With more attention on the risks of sport participation at all levels of competition it is not a surprise that athletic directors recognized these increased risks and emphasized the importance of mitigating them, particularly through the services provided by an AT. When discussing the need for appropriate on-site medical coverage for student-athletes, ATs were viewed as the ideal professional to fulfill the role of athletic healthcare provider within the secondary school setting. Despite the prevalence of coaches assuming the role of primary care provider (26, 32, 34), participants identified that they believe coaches are not qualified to serve as the primary medical provider to student-athletes, as most coaches are only trained in first-aid and CPR. The specialized training ATs receive in injury prevention, emergent care, and injury assessment were roles and responsibilities athletic directors emphasized to support the preference of ATs as healthcare providers within their athletic programs. Additionally, the benefit of allowing coaches to focus on coaching related responsibilities by removing their role as healthcare provider emerged as an unprecedented rationale for employing ATs in secondary schools. This discrepancy between findings from previous literature (26, 32) may allude to a better understanding of the roles and responsibilities of an AT exhibited by the athletic directors interviewed, as participants in this investigation were employed by schools that currently utilize the services of an AT.

Similar to the findings of previous authors (26, 32), finances were identified as the predominant challenge to both initiating and maintaining the AT’s position within the schools. Uniquely however, the barrier of financial support was perceived to be easily overcome by the establishment of a partnership with local hospital networks or rehabilitation clinics to provide athletic training services which enabled schools to employ an AT due to a smaller impact on their budget resulting from sharing the associated costs. While it is not uncommon for secondary school ATs to be contracted through a clinic-outreach model, this study specifically identified this partnership as a facilitator to gaining access to athletic training services within the secondary school setting. Additionally, all participants who discussed a clinic-outreach model of AT employment identified that the initiation of the partnership occurred by the hospital network or clinic rather than by the school board or district. This unidirectional initiation may indicate a lack of awareness regarding available resources, including different AT employment models, which could aid school boards in the ability to afford the addition of ATs to support their athletic programs. Further education of school board members regarding the various community resources, including clinic-outreach athletic training employment opportunities, may encourage more schools to utilize athletic training services. It should be acknowledged that the dynamic of the clinic-outreach model can pose challenges for the secondary school AT (26), and may not serve as the best means of athletic training service provision for all athletic programs. While this study identified this arrangement as a facilitator by athletic directors, many in the athletic training profession have discussed the positives and negatives associated with this model in terms of the quality of the care provided, which is outside the scope of this study Future research exploring the different employment models and their associated benefits may assist school boards currently employing or seeking to employ an AT in determining which employment model will best serve the needs of their schools.

Lastly, consistent with previous literature (26) participants reported that members of the school board or district have the ultimate authority in the decision making process regarding the use of ATs within the school. Although some athletic directors felt they had an influence on school board matters pertaining to the athletic department, the benefits of having an AT identified by participants related mostly to individuals affiliated with participation in school sponsored athletic programs. It is unknown at this time whether these perceived benefits held by athletic directors will resonate with decision makers such as school board members who are assessing the budget and needs of the school from a broader perspective (20).

School board members are elected or appointed officials who represent the highest level of administrators within public education. Working as part of a governance team with the superintendent the school board is responsible for establishing educational priorities and setting local policies (6). While recommendations provided by superintendents have traditionally been a key source of influence on school board decisions (12), the functions of the school board are further complicated by the political nature of the board member’s positions which allows for the susceptibility of influence from various political pressures on the decision making process (37). For example, in a unique case study (7) parents served as a significant catalyst in the development and enactment of state legislation to provide funding for ATs in public secondary schools in Hawaii. This unprecedented case demonstrates how community advocacy can provide beneficial support for encouraging the creation and maintenance of athletic training positions within high school athletic programs. Similarly, parents of student-athletes were identified as an influential group regarding school board member decisions within this investigation, potentially because of their role as tax payers and voters within the community. Due to their important role in the decision making process of the utilization of ATs, future research is needed to explore how administrators at higher levels within education view the role of the AT as well as to gain a better understanding of the complex decision making process and influencing factors that affect the determinations made within educational administration.

Limitations and Future Research
This study was not without its limitations. Due to time constraints surrounding this project prolonged engagement with participants was not possible at this time. The lack in diversity of the participant population is the result of the inclusion criteria, most notably relating to the use of the CORE-AT EMR program (4) and the completion of the ATLAS survey (21). Information acquired from the ATLAS database (21) is self-reported and may contain errors in the interpretation of the questions. For example, while all of the athletic directors worked in schools where the AT identified themselves as providing services to the school in a full-time capacity, some athletic directors referred to their ATs as part-time due to the split nature of the AT’s role within a rehabilitation clinic or hospital network and the school.

Future research should consider utilizing participants with a wider demographic range such as multiple geographic regions, institution types (i.e. public vs private), and AT employment models (i.e. direct hire vs clinic-outreach, part-time vs full-time) to provide a broader range of experiences that could potentially provide different perspectives on the topic. Additionally, while the objective of this study was to explore schools that currently utilize the services of an AT, it may be beneficial for future investigations to explore schools at various states of AT utilization such as schools that actively seek to employ an AT, formerly employed an AT, and never employed an AT, to discern any differences between populations.
Expanding the target population of participants to explore other stakeholder’s views on the roles of the AT may also garner valuable information, as multiple individuals were identified as having a role in influencing the decision to use the services of an AT within the schools. As discussed previously, school board members were identified as the final decision makers regarding the use of ATs within the schools. Future explorations aimed at understanding the needs of the school board and the factors that affect the decision making process may be of key importance in the ability to justify the utilization of athletic training services within the secondary school setting.

Athletic directors viewed ATs as the ideal professionals to provide healthcare services to student-athletes, describing not only the benefits ATs can provide to their personal role as athletic director, but also the benefits of athletic training services that extend to coaches, student-athletes, and parents as well. Contrary to previous literature (26, 32), athletic directors are recognizing the specialized training completed by ATs and are rejecting the premise that coaches have comparable healthcare provider abilities. School board members were confirmed as the final decision makers regarding the use of ATs within high school athletic programs with multiple stakeholders, including parents and individuals affiliated with outreach programs, having influence on the decision making process. Several challenges still remain for athletic departments even after establishing the AT’s position within the school. Concerns regarding funding continue to persist, however athletic directors believe that factors such as continued community support, enhanced student-athlete safety, and reduced liability will help maintain these athletic training positions within their athletic programs.

Athletic administrators have identified the challenges in garnering support from school boards to acquire resources, particularly in the hiring of ATs. Understanding the factors that influence the school board’s decision making process, such as community support and policy, may help athletic directors secure and maintain athletic training positions within their programs. Additionally, the examples set by athletic programs who have identified the benefits of on-site care provided by ATs may help inform schools that do not currently utilize the services of ATs on how to enhance their athletic programs and provider a safer environment for sport participation.

This study was partially funded by the National Athletic Trainers’ Association Research & Education Foundation. The authors would like to thank Dr. [non-author], [Institution], for their guidance and support throughout this project.

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