Development of the athletic training major and curriculum, development of the NATA Board of Certification

Secondary-School Administrators Knowledge and Perceptions of Athletic Training TRENTON E. GOULD, MS, ATC, and RICHARD G. DEIVERT, PhD, ATC Ohio University The National Athletic Trainers Association (NATA) recently celebrated its 50-year anniversary as the national governing body of the U.S. athletic training profession. According to O Shea, the NATA was established to build and strengthen the profession of athletic training through the exchange of ideas, knowledge, and methods of athletic training (as cited in Delforge and Behnke 1,p53 ) Many events have occurred over those decades that have contributed to the maturation of the athletic training profession. Development of the athletic training major and curriculum, development of the NATA Board of Certification exam, and accreditation requirements for all entry-level athletic training programs through the Commission on Accreditation of Allied Health Education Programs have advanced the profession. 1 As a result, the athletic trainer s job has evolved into that of a highly technical, well-educated, allied health-care professional, recognized by the American Medical Association in June of 1990. 1-3 Key Points Athletic trainers need to understand the knowledge and perceptions of secondary-school administrators. This information is critical for future employment and the quality of health care that is available to student athletes at our nation s secondary schools. Concern about legal liability is an important issue for secondaryschool administrators, but they have an inaccurate perception of the role and importance of athletic trainers in reducing liability. The NATA Secondary School Athletic Trainers Committee should focus more efforts on secondary-school administrators and the positive impact that certified athletic trainers can have on students and health care in secondary schools. Key Words: survey, high school, liability The Problem The National Federation of State High School Associations (NFSHSA) issued a press release on September 14, 1999, 4 stating that the number of students participating in athletics in our nation was at an all-time high. Currently, there are approximately 6.7 million student athletes participating in interscholastic athletics. 5 It is the position of the NATA that all secondary schools should provide the services of a fulltime, on-site, certified athletic trainer (ATC) to student athletes. 6 According to the December 2001 NATA membership statistics, there are approximately 7,564 ATCs employed in either the high-school or the high-school/clinic setting. 7 The disproportionately large number of sports participants in relation to these secondaryschool employment statistics provides evidence of the need for ATCs at the secondary-school level. A thorough investigation should be conducted of the knowledge and perceptions of the secondary-school administrators who would hire athletic trainers at these institutions. These administrators include superintendents, principals, and athletic directors. Accurate knowledge and positive perceptions on their part could have a major impact on job growth in this market. Likewise, inaccurate knowledge coupled with poor perceptions of the athletic training profession could lead to lack of growth of employment in this setting. Therefore, the purpose of this study was to determine the extent of knowledge and the nature of perceptions about the athletic training profession among secondary-school superintendents, principals, and athletic directors in NATA District Four. The Ohio University Institutional Review Board approved this project. 2003 Human Kinetics ATT 8(1), pp. 57-62 ATHLETIC THERAPY TODAY JANUARY 2003 57

Instrument Methods The instrument was designed to measure knowledge and perceptions of athletic training among secondaryschool superintendents, principals, and athletic directors. Ray 8 and Pinciaro 9 developed the questions included on the survey used in this study. We updated some of the questions to more accurately depict the knowledge and perceptions held by the sample (e.g., the salary ranges were inconsistent with the NATA salary survey). Two content-area specialists reviewed the survey to ensure content validity. The questionnaire was pilot tested for reliability on a group of 18 ATCs. The first five questions dealt with the knowledge base of the administrators: acknowledgment of the athletic training profession, personal contact with an athletic trainer, familiarity with an athletic trainer s job functions, awareness of the goals of the NATA, and the acknowledgment of professional recognition by the American Medical Association. The next 13 questions dealt with the administrators perceptions of the job tasks, salary, liability, and the most accurate name for the profession. Answers to the last seven questions provided demographic information about the administrators and their schools: age, gender, years of experience in the position, estimated number of athletes injured, sponsorship of football as an interscholastic sport, number of interscholastic sports, and size classification of the school. Sample We enlisted the assistance of Clell-Wade Industries, a national publisher of all state high school athletic associations handbooks for coaches. NATA District Four consists of six states: Illinois, Indiana, Michigan, Minnesota, Ohio, and Wisconsin. We obtained handbooks from each state s high school associations, selected a simple random sample of 10% of the public secondary schools in each state, and mailed survey packets to the chosen schools. Procedures The survey instrument, consisting of 25 questions, was mailed to 1,095 administrators (10% of the public secondary-school administrators in each state in NATA District Four). A packet of three surveys was mailed to each school, one each for the superintendent, the principal, and the athletic director. Each survey included an attached explanation of the study and was given a letter designation for classification of administrative position (i.e., superintendents, S; principals, P; and athletic directors, A). The administrators were instructed to return the surveys in the self-addressed, postage-paid envelope that was provided. The state s initials were coded on each return envelope so that the survey could be entered into the statistical software program by state and job description. Data Analysis Statistical Package for Social Sciences (version 10, SPSS, Inc., Chicago) software was used to generate descriptive statistics that formed background profiles of the respondents and to provide a summary of the questionnaire responses. Multiple Kruskal Wallis H tests, matching the category of administrative position with each question of the survey, were performed to test for significant differences. For each significant difference, pairwise comparisons between group medians (Mann Whitney U tests) were calculated to determine which administrative groups were different. We set alpha at.05 and performed a Bonferroni correction to control for overall error rate. Results Of the 1,095 surveys that were administered, 234 usable surveys were returned (21% response rate). Crosstabulation frequency reports (chi-square) were used to calculate percentages and to identify significant associations within the data (Table 1). Ohio provided the largest percentage of responses. The administrators most familiar with the functions of an ATC were the athletic directors (74%). There were 217 (93%) administrators who reported personal contact with an athletic trainer. We asked what tasks were required of an ATC. The principals and athletic directors consistently responded with the greatest frequency of correct responses for the most relevant tasks of athletic training. The Kruskal Wallis ANOVA function revealed a significant difference (p <.05) between the job-description variable and the survey questions Familiarity with job functions of an ATC and Perception that hiring an 58 JANUARY 2003 ATHLETIC THERAPY TODAY

Table 1. Cross-Tabulation Frequency Chart of Job Description With Selected Questions Superintendent Principal Athletic Director Total State IL 14 18 15 47 IN 10 10 10 30 MI 9 17 18 44 MN 7 7 10 24 OH 16 18 17 51 WI 9 14 15 38 total 65 84 85 234 Most relevant tasks taping and bandaging a 56 81 81 218 ordering equipment 19 34 39 92 rehabilitation of injuries 64 83 80 227 fitting equipment a 32 44 30 106 laundering uniforms 65 84 1 150 evaluating athletic injuries 63 81 82 226 field maintenance 65 1 1 67 Education level high school/some college 1 0 1 2 associate s degree 17 20 21 58 bachelor s degree 40 53 53 146 master s degree 7 11 8 26 total b 65 84 83 232 Salary required to employ ATC a <$20,000 3 6 17 26 $20,000 24,999 13 13 18 44 $25,000 29,999 15 27 24 66 $30,000 34,999 18 18 16 52 >$35,000 4 8 1 13 total b 53 72 76 201 a x 2 test of independence values was significant at p <.05. b Valid n of less than 234. continued ATC would reduce risk of liability (Table 2). Pairwise comparisons demonstrated significant differences between superintendents and athletic directors for both of these questions (Tables 3 and 4). A significant difference was also found between principals and athletic directors for the survey question Perception that hiring an ATC would reduce risk of liability (Table 4). We asked the respondents what level of education they thought was needed to be an ATC. Most thought that a baccalaureate degree was needed. According to individual total responses, both the principals and the athletic directors thought that a baccalaureate was required (Table 1). Superintendents thought that a higher salary would be required to hire an ATC than did principals and athletic directors. All administrators thought that an athletic trainer is the most qualified person to treat athletic injuries and chose the title athletic trainer as the name that best describes the profession. When asked how concerned they were about legal-liability issues in their schools, most administrators responded that they were very concerned. The administrators most concerned with these issues were the athletic directors (Table 1). Furthermore, we asked ATHLETIC THERAPY TODAY JANUARY 2003 59

Table 1. Cross-Tabulation Frequency Chart of Job Description With Selected Questions Superintendent Principal Athletic Director Total Most qualified person athletic trainer 58 75 79 212 coach 0 3 2 5 health/physical educator 1 1 0 2 school nurse 2 1 0 3 other 2 2 2 6 total b 63 82 83 228 Title best describing the profession athletic-injury specialist 7 10 11 28 athletic therapist 3 2 3 8 athletic trainer 47 59 65 171 massage therapist 0 1 1 2 physical trainer 2 4 2 8 sports therapist 4 5 1 10 trainer 0 1 1 2 total b 63 82 84 229 Concern about liability very concerned 46 58 65 169 somewhat concerned 18 24 19 61 unconcerned 1 2 0 3 no response 0 0 1 1 total 65 84 85 234 Belief that hiring ATC reduces liability a high reduction 8 23 45 76 moderate reduction 36 45 31 112 low reduction 18 13 9 40 no reduction 3 3 0 6 total 65 84 85 234 School should hire ATC yes, full-time 9 14 18 41 yes, part-time 16 33 33 82 no 35 33 34 102 total b 60 80 85 225 a x 2 test of independence values was significant at p <.05. b Valid n of less than 234. the administrators whether they thought that hiring an athletic trainer would reduce the risk of liability in their schools. Almost half indicated that they thought it would moderately reduce their risk. The athletic directors thought that hiring an ATC would make a high reduction in risk. When asked whether they currently employed a full- or part-time athletic trainer, 45.3% (n = 102) of the administrators answered no. Discussion Although we should not ignore the fact that the response rate was low, much information can be obtained from 60 JANUARY 2003 ATHLETIC THERAPY TODAY

Table 2. Kruskal Wallis H-Test Results Perception That Hiring an ATC Familiarity With Would Reduce Risk of Liability Job Functions of an ATC x 2 30.066 21.094 df 2 2 p.000**.000** **p <.01. Table 3. Results of the Group Comparisons for Familiarity With Job Functions of an ATC S P S A P A Mann Whitney U 2,317.50 1,724.00 2,803.50 Z 1.802 4.596 2.883 p.072.000**.004** Note. S P = superintendents compared with principals; S A = superintendents compared with athletic directors; P A = principals compared with athletic directors. **p <.01. Table 4. Results of Group Comparisons for Perception That Hiring an ATC Would Reduce Risk of Liability S P S A P A Mann Whitney U 2,141.50 5,711.50 2,598.50 Z 1.802 4.596 2.883 p.013*.000**.001** Note. S P = superintendents compared with principals; S A = superintendents compared with athletic directors; P A = principals compared with athletic directors. *p <.05. **p <.01. these results for practical use. Two previous studies have examined the knowledge and attitudes of secondary-school administrators. Ray 8 investigated the knowledge of superintendents in Michigan about athletic injuries, athletic trainers, and legal liability, and Pinciaro 9 investigated the knowledge and attitudes of secondary-school athletic directors in Pennsylvania. Ray found that over 75% of superintendents perceived athletic trainers as the people most qualified to prevent and treat athletic injuries. In our study, over 92% (n = 57) of the superintendents in NATA District Four perceived athletic trainers as most qualified. This suggests that NATA District Four, as a whole, has a better perception of athletic trainers than do superintendents in Michigan. Ray and Pinciaro found that most superintendents and athletic directors, respectively, in their studies were very concerned about legal-liability issues in their schools. Our study revealed that more than half the surveyed superintendents in NATA District Four (n = 46) were very concerned about legal-liability issues. It appears likely that secondary-school administrators in District Four are as concerned about liability as administrators in Michigan and Pennsylvania are. Pinciaro 9 found that Pennsylvania athletic directors had a reasonably accurate perception of the job functions of athletic trainers. According to our results, athletic directors in District Four also have a reasonably accurate perception of those job functions. Both Ray 8 and Pinciaro 9 found that few school districts employ an athletic trainer (19.5% and 46%, respectively). More than half the administrators we surveyed in District Four (54.7%, n = 102) answered that they currently employ either a fullor a part-time athletic trainer. In the decade that separates these studies, employment of athletic trainers appears to have increased. Administrators in Michigan and Pennsylvania, as well as those surveyed in NATA District Four, have an accurate perception of what athletic trainers do and how ATCs can reduce their schools risk of liability (Table 1). Although 55% of the surveyed administrators represented school districts that employed an athletic trainer, there were still a large number (45%) that did not. The high number of responses indicating that schools do not employ ATCs suggests that administrators for those schools have not established studentathlete health care as a priority. Employment in the secondaryschool setting has always been an ATHLETIC THERAPY TODAY JANUARY 2003 61

important topic in the athletic training profession. The large number of secondary-school athletic programs in the nation that lack professional injury-prevention and -management services demonstrates the need for ATCs at the high school level. The number of students participating in high school athletics is now well over 6 million. 10,11 A 1999 NFSHSA press release stated that for the 10th consecutive year, participation in athletics had risen. 4 Coincidentally, four of the six states in NATA s District Four are represented in the top 10 schools according to the NFSHSA participation totals. These states are Ohio (4), Illinois (5), Michigan (6), and Minnesota (8). The large number of athletes participating in high school athletics, specifically in NATA District Four, further establishes the need for ATCs at secondary schools. Injury is an inherent risk of participating in sports. 11 With an increase in participation in high school athletics, there would also be an associated increase in the number of athletic injuries. 12,13 Because more than 6 million students participate in athletics at nearly 20,000 schools each year, it has been estimated that these athletes account for more than 2 million injuries, 500,000 doctor visits, and 30,000 hospitalizations each year. 12,14 Despite the apparent need for student-athlete access to an ATC in the high school setting, many school administrators either do not recognize that need or do not consider it a high priority. The NATA 1998 salary-survey results indicate that the average salary for a District Four athletic trainer (all clinical settings included) was $35,220. The average salary for a high school athletic trainer (inclusive of all districts) was $30,533. Our survey revealed that $25,000 29,999 was the most often-reported salary range that the administrators thought would be adequate to employ a certified athletic trainer in District Four. Unwillingness to provide a higher salary might be a contributing factor to the lack of ATC employment in 45.3% of the surveyed schools. Conclusions The salary that administrators in District Four are willing to allocate for employing ATCs is insufficient. We are compelled to believe that this is a major factor contributing to the low employment rate in this setting. We think that this study has shown that administrators possess accurate knowledge of the athletic training profession, but we believe that they have an inaccurate perception of the value of athletic training, as evidenced by inadequate compensation and low employment rates. Further research in this area is needed to characterize perceptions and opinions of administrators in other NATA districts as efforts continue to expand the number of ATCs working in the high school setting References 1. Delforge GD, Behnke RS. The history and evolution of athletic training education in the United States. J Athletic Train. 1999;34(1):53-61. 2. Arnheim DD, Prentice WE. Professional development and responsibilities. In: Principles of Athletic Training. 8th ed. New York, NY: McGraw-Hill; 2000:26. 3. National Athletic Trainers Association. AMA endorses athletic training as allied health profession. NATA News. 1990, September 4. 4. National Federation of State High School Associations. High school athletics participation reaches all-time high. Available at: http:// www.nfhs.org/pr-survey. Accessed October 23, 1999. 5. National Federation of State High School Associations. 2001 athletics participation totals. Available at: http://www.nfshsa.org/participation/ SportsPart01.htm. Accessed March 3, 2002 6. National Athletic Trainers Association Secondary School Athletic Trainers Committee. Official statement. Available at: http://www.nata.org/ contact/secondaryschools.htm. Accessed February 28, 2002. 7. National Athletic Trainers Association. NATA total membership by job setting for January 2002. Available at: http://www.nata.org/membership/membstats/2002_january.htm. Accessed March 3, 2002. 8. Ray R. A survey of Michigan school superintendents knowledge of and attitudes toward athletic injuries, athletic trainers, and legal liability. J Athletic Train. 1987;22(4):311-315. 9. Pinciaro PJ. Knowledge and Attitudes of Pennsylvania Public High School Athletic Directors Toward Athletic Trainers, Sport Injury Care, and Legal Liability [master s thesis]. State College, Pa: Pennsylvania State University; 1988. 10. National Federation of State High School Associations. 1999 high school athletics participation survey. Available at: http://www.nfhs.org/ 1999_part_index.htm. Accessed October 23, 1999. 11. Powell JW, Barber-Foss KD. Injury patterns in selected high school sports. A review of the 1995 1997 seasons. J Athletic Train. 1999;34(3): 277-284. 12. National Federation of State High School Associations. 1996 General Football Survey. Kansas City, Mo: Author; 1996. 13. National Federation of State High School Associations. 1996 1997 General Basketball Survey. Kansas City, Mo: Author; 1997. 14. National Federation of State High School Associations. National Federation of State High School Associations Handbook: 1996 High School Athletic Participation Survey. Kansas City, Mo: Author; 1997. Trent Gould is a doctoral candidate in curriculum and instruction at Ohio University. His graduate assistantship allows him to work with the Ohio University Club Ice Hockey Team. He has been certified in the field for 5 years. Rich Deivert is the coordinator of athletic therapy and the graduate program director at Ohio University. He has been certified in the field for 20 years. 62 JANUARY 2003 ATHLETIC THERAPY TODAY