Frequency of Leadership Behaviors Among Athletic Trainers in University Settings

Respondents

Invitations to participate in this study were sent to university-based athletic trainers who instruct and evaluate entry-level athletic training students at various institutions throughout the United States. E-mail invitations were sent to all entry-level program directors listed on the Commission on Accreditation of Athletic Training Education (CAATE) Web site. Program directors were chosen because their e-mail contact information was easily accessible. Clinical coordinators' e-mail information was not available at the CAATE Web site and therefore they were excluded. Additionally, to capture clinical preceptors, e-mail invitations were sent to head athletic trainers and full-time staff athletic trainers from several National Collegiate Athletic Association athletic conferences (eg, Southeastern Conference, Atlantic Coast Conference, Western Athletic Conference, Mid-American Athletic Conference, Big East, Big Ten, Pac-12, Big 12, Conference USA). E-mail addresses for university-based clinical athletic trainers were acquired through their respective university's Web site and chosen based on convenience.

Statistical Analysis

Statistical analysis was conducted using SPSS 22.0 (SPSS Inc, Chicago, IL). Differences between respondents were evaluated using independent-samples t tests and 1-way analyses of variance (ANOVAs) followed by Tukey post hoc comparisons. The Cronbach α with item analysis was used to test the internal consistency reliability and validity of the Frequency of Leadership in Athletic Training Scale (FLATS) instrument. The instrument was developed for this research project based upon previous athletic training literature^2,19,23 on important leadership behaviors. Convergent validity was evaluated by using Pearson r correlations between different scale dimensions (within and outside), and criterion-related concurrent validity was evaluated by comparing differences between demographic characteristics using independent-samples t tests and ANOVAs with Tukey post hoc comparisons. Paired-samples t tests were used to determine frequencies of leadership behaviors in athletic training roles when compared with out of athletic training roles, and the Cohen d was used to determine effect size of any differences in FLATS dimensions. When necessary, frequencies and descriptive statistics (central tendency) were also reported.

Instrumentation

Frequency of leadership behavior by athletic trainers was assessed using FLATS. Table 1 includes a description of the leadership behaviors originally described by Kutz.²³

Table 1.  Alphabetical Listing of Leadership Behaviors Important for Athletic Training Practice

View Fullscreen

The FLATS was based on athletic training leadership behaviors, which were delineated through a multiple-phase study consisting of a Delphi technique (phase 1) and national survey (phase 2).²³ The internal consistency of the original instrument used to assess important leadership behaviors for athletic trainers was estimated using coefficient α followed by item analysis (α = 0.96). Convergent validity for this instrument was established using Pearson r correlations (r = 0.94; P = .001), demonstrating a strong relationship between leadership behaviors important for practice and those leadership behaviors important for inclusion in athletic training education. Construct validity of this instrument was established by exploratory factor analysis using a maximum likelihood extraction and promax rotation that extracted 4 factors (eigenvalues were ≥ 1.0). Reliability of the 4 leadership factors originally identified was estimated with coefficient α ranging from 0.83 to 0.93 (factor 1 [α = 0.93], Personality Characteristics, had 15 items; factor 2 [α = 0.91], Diagnosing Context and People Skills, had 16 items; factor 3 [α = 0.88], Communication and Initiative, had 12 items; and factor 4 [α = 0.83], Strategic Thinking, had 6 items.²³ Criterion-related concurrent validity was established using independent t tests, 1-way ANOVA (Tukey post hoc), and repeated-measures ANOVA (Sidak post hoc adjustment) and it was found that there were significantly (P ≤ .05) different levels of importance between leadership behaviors according to 4 different levels of athletic training education (ie, baccalaureate, entry-level masters, postcertification masters, and doctorate).

For this investigation, the FLATS consisted of 3 sections. The first section contained questions about respondents' demographic characteristics (eg, sex, age, ethnicity, years' experience, work setting, highest degree earned, major of master's degree); section 2 consisted of 47 items pertaining to the frequency with which leadership behaviors were practiced within their formal athletic training roles and responsibilities; and section 3 consisted of the same items pertaining to the same leadership behaviors practiced outside of their athletic training roles and responsibilities (eg, social and personal contexts). From the original 49 behaviors, 1 was eliminated (leads quietly) because it was not significant in importance and 2 were combined (resilience and flexible/adaptable) to eliminate redundancy, leaving 47 items for the FLATS. For the FLATS instrument, within the athletic training context was described to respondents as the behaviors used in their current athletic training role. Outside of athletic training was described to respondents as non–athletic training roles, and they were given cues of nonwork scenarios such as social and personal settings. Psychometric characteristics of the FLATS instrument used in this study are reported in the Results section and in Table 2.

Table 2.  Psychometric Qualities of the Frequency of Leadership in Athletic Training Scale (FLATS)

View Fullscreen

Respondents were asked to rate the frequency with which they performed each of the leadership behaviors identified in the FLATS (Table 1) on a 4-point scale twice, once for within their formal athletic training context and again when outside of their formal athletic training context. The FLATS frequency scale ranged from 0 to 3 (0 = never, the athletic trainer does not perform this behavior at all; 1 = sometimes, the athletic trainer sometimes performs this behavior; 2 = often, the athletic trainer often performs this behavior; 3 = always, the athletic trainer always performs this behavior).

Psychometric Qualities of FLATS

The Cronbach α for the FLATS was 0.96, and item analysis if item was deleted ranged from α = 0.958 to α = 0.964. The FLATS psychometric analysis yielded satisfactory internal consistency reliability and validity for FLATS Within and FLATS Outside sections (α = 0.91 and 0.94 respectively); correlations between the individual scale items for within and outside ranged from r = 0.39 to r = 0.87, P ≤ .05; and concurrent validity was supported by differences (P ≤ .05) between scale items of selected demographic characteristics. Convergent validity for the FLATS is demonstrated with a Pearson r correlation between the aggregate mean totals of all within and outside items (r = 0.76, P = .000). Content validity was established based on scale items from previously reported research.²³

Frequency of Leadership Behaviors

For leadership behaviors practiced within athletic training roles, 5 leadership behaviors were practiced always (scale range 0–3, always = mean ≥ 2.50); credible (mean = 2.78 ± 0.42), ethical (mean = 2.70 ± 0.52), thrives on responsibility (mean = 2.64 ± 0.59), communicates verbally (mean = 2.55 ± 0.56), and knowledgeable (mean = 2.52 ± 0.58), representing behaviors from Kutz's²³ factors 1, 2, and 4. For leadership behaviors practiced outside athletic training roles, credible (mean = 2.72 ± 0.47) was the only leadership behavior practiced always. Of all leadership behaviors, practices scholarship was the least frequently practiced leadership behavior in both settings (means = 1.54 ± 0.82 and 1.04 ± 0.89).

Forty leadership behaviors (85%) were practiced often or always (mean = 2.05–2.78) by athletic trainers within their formal athletic training role. Seven (15%) were practiced sometimes (mean = 1.54–1.95) and none were practiced never. Of the 40 most frequently practiced behaviors within the athletic training role, all (100%) of Kutz's factor 4 (Strategic Thinking), 93% of Kutz's factor 1 (Personality Characteristics), 83% of Kutz's factor 3 (Communication and Initiative), and 69% of Kutz's factor 2 (Diagnoses Context and People Skills) were represented.

Twenty-four leadership behaviors (51%) were practiced often or always (mean = 2.01–2.72) when outside the formal athletic training role. Twenty-three (49%) were practiced sometimes (mean = 1.04–1.99) and none were practiced never. Of the 24 most frequently practiced behaviors outside the formal athletic training role, 63% of those in Kutz's factor 3 (Communication and Initiative), 53% of Kutz's factor 1 (Personality Characteristics), 50% of Kutz's factor 4 (Strategic Thinking), and 38% of Kutz's factor 2 (Diagnoses Context and People Skills) were represented.

The mean score for 44 FLATS items (94%) was significantly higher for within versus outside the athletic training role (P ≤ .05). A paired-samples t test indicated aggregate mean of leadership behaviors practiced within athletic training was significantly higher than that of those practiced outside of athletic training (mean = 2.24 ± 0.33 versus 1.98 ± 0.38, P = .000). Because of the small return rate, the Cohen d was used to determine effect size: d = 0.73, indicating a good effect size. Table 4 is an alphabetical side-by-side comparison of frequency means for leadership behaviors within and outside of athletic training roles, their Pearson r correlations, and respective domain factors.

Table 4.  Comparisons of Leadership Behaviors Between Within and Outside the Athletic Training Role

View Fullscreen

Frequency of Leadership Behaviors According to Job Title

Within their athletic training role, program directors demonstrated 9 behaviors—written communication, socially responsible, provides scholarship, future minded, mission minded, change agent, consensus builder, empowers others, and assertive—more often compared with university-based clinicians (mean = 2.28 ± 0.31 versus 2.14 ± 0.36, t₉₉ = −2.053, P = .043). Of these, 4 (44%) represented behaviors from factor 2 (Diagnosing Context and People Skills).

Outside of their athletic training role, program directors also demonstrated 9 behaviors—organizational savvy, written communication, use of body language, consensus builder, identifies leaders, empowers others, influencer, advocate for others, and change agent—more often than university-based clinical athletic trainers (mean = 2.03 ± 0.39 versus 1.87 ± 0.33, t₉₉ = 1.980, P = .05). Of these, 4 (44%) represented behaviors from factor 3 (Communication and Initiative). No leadership behaviors were demonstrated more frequently by clinical athletic trainers in either setting. Tables 5 and 6 include comparisons between program directors' and university-based athletic trainers' frequency of leadership behaviors.

Table 5.  Independent t Tests Between Program Director and University-Based Clinical Athletic Trainers for Leadership Frequency Outside the Athletic Training Role

View Fullscreen

Table 6.  Independent t Tests Between Program Directors and University-Based Clinical Athletic Trainers for Leadership Frequency Within the Athletic Training Role

View Fullscreen

Frequency of Leadership Behaviors According to Graduate Major

Athletic trainers whose graduate major was athletic training practiced 4 leadership behaviors more frequently within their athletic training role than those whose major was in a discipline other than athletic training: organizational savvy, 2.50 ± .68 versus 2.08 ± .73, P = .013; empowers others, 2.07 ± .58 versus 1.92 ± .75, P = .042; uses influence effectively, 2.33 ± .61 versus 1.97 ± 62, P = .009; and improves morale, 2.50 ± .63 versus 2.19 ± .67, P = .04. These data are summarized in Table 7.

Table 7.  Independent t Tests Between Major of Graduate Study for Leadership Frequency Within the Athletic Training Role

View Fullscreen

Frequency of Leadership Behaviors According to Sex

Male athletic trainers reported practicing verbal communication more often than females within and outside of their athletic training roles (2.27 ± .66 versus 2.00 ± .69, P = .05; 2.65 ± .52 versus 2.43 ± .58, P = .042, respectively). Males also identified leaders more often outside of athletic training roles than females (1.63 ± .77 versus 1.31 ± 78, P = .040). These data are summarized in Table 8.

Table 8.  Independent t Tests Between Sexes for Leadership Frequency of Athletic Trainers in Various Roles

View Fullscreen

Frequency of Leadership Behaviors According to Degree Level

Within their athletic training role, doctoral-educated athletic trainers practiced provides scholarship, future minded, and change agent more often than athletic trainers with lesser degrees (F_2,96 = 4.15, P = .004 and F_2,97 = 5.76_, P = .019, respectively). Outside of their athletic training role, doctoral-educated athletic trainers practiced written communication more often than those with lesser degrees (F_2,98 = 3.54, P = .033).

Frequency of Leadership Behaviors According to Age and Years of Experience

Older athletic trainers (51 years or older) practiced cultural sensitive and multicultural leadership more often than their younger (all those <51 years old) counterparts (F_2,95 = 2.04, P = .018, and F_2,98 = 3.32, P = .040, respectively).

Athletic trainers with 10 to 15 years of experience demonstrated 3 leadership behaviors (ambitious, nurtures professional relationships, and leadership planner) within their athletic training role more frequently than those other experience levels (F_3,96 = 2.76_, P = .010, and F_3,96 = 3.98, P = .046, respectively). Outside of their athletic training role, athletic trainers with 10 to 15 years of experience and 21 or more years of experience reported demonstrating time manager more frequently than those with 16 to 20 years of experience and athletic trainers with 10 to 15 years of experience reported demonstrating leadership planning more frequently than those with 21 or more years of experience (F_3,94 = 3.47, P = .019, and F_3,95 = 3.61, P = .016, respectively). Tables 9 and 10 are descriptions of 1-way ANOVA followed by Tukey post hoc analysis of leadership behaviors between athletic trainers within athletic training roles among different demographic characteristics.

Table 9.  One-Way Analysis of Variance for Within Athletic Training Roles

View Fullscreen

Table 10.  One-Way Analysis of Variance for Outside Athletic Training Roles

View Fullscreen

Athletic trainers <51 years old reported demonstrating use of body language more frequently outside of their athletic training role than athletic trainers over 51 years old (F_2,96 = 3.71_, P = .018). Tables 9 and 10 delineate the specific ages where differences were noted.

Other findings included young professionals, that is, athletic trainers under the age of 35, reporting significantly higher frequency than older professionals (≤36 years old) in demonstrating innovation and creativity and applies knowledge outside of athletic training roles (t₉₉ = 2.022, 2.12 ± .67 to 1.82 ± .61, P = .042, and t₉₆ = 2.063, 1.85 ± .97 to 1.41 ± .93, P = .046, respectively).

Practice Frequency of Leadership Behaviors by Athletic Trainers

Our findings show that athletic trainers do practice the behaviors Kutz²³ reported to be important for athletic training practice. For example, of the top 10 most frequently practiced leadership behaviors, 9 (90%) were identified in Kutz's²³ original research as either extremely or very important. These findings contribute to a usable leadership taxonomy in athletic training. A taxonomy is a formal system for classifying multifaceted, complex phenomena according to a set of common conceptual domains and dimensions.³² The development of any taxonomy is an ongoing process that describes complex real-world phenomena. The Figure is an introductory leadership taxonomy for athletic training practice and education. Although this is a promising first step, it is a long way from explicit. Future research on leadership should confirm these behaviors and factors with a larger sample from more diverse practice settings.

View Figure

• Download as Powerpoint
• Download Figure

There are further implications of these findings for athletic training education. Kutz's²³ original research reported leadership behaviors important for practice and for inclusion in athletic training education. The behaviors included in education were anecdotal, based on a perception of importance. These findings support those perceptions with evidence that they are actually being practiced with a high degree (always or often) of frequency. Bos³³ reported that nursing students demonstrated improved critical thinking, technical skill, resource allocation, and prioritizing after focused leadership training. If implemented into athletic training education, the frequently practiced leadership behaviors described in this study may also serve to generate similar outcomes with athletic training students. Unfortunately, students are typically trained for context-specific leader roles (eg, to manage a facility) and are not intentionally educated to practice leadership in general.³⁴ Athletic training must avoid this mistake. Therefore, it is our recommendation that educators begin to evaluate the proposed leadership framework for use in leadership development and assessment, but more importantly as a springboard for additional research on leadership within athletic training. These findings can be useful in helping educators begin to evaluate how leadership is being defined, instructed, and assessed in athletic training programs. It is imperative that as athletic training education continues to evolve, leadership becomes a point of intentional instruction not to be dismissed by educators as a vague or nebulous construct that can be learned only by trial and error. Rather, leadership must be recognized as a construct that includes evidence-based competencies that can be incorporated into curricular development.

Other athletic training research⁶ reported that athletic trainers with master's degrees in athletic training view leadership to be more important than athletic trainers with master's degrees in other disciplines. Our finding that athletic trainers with master's degrees in athletic training practice certain leadership behaviors more frequently than those athletic trainers with degrees in other disciplines lends support to that claim. Nursing research also suggests that advanced-practice clinicians practice leadership more effectively than less-educated nurses.³⁵ Therefore, leadership instruction may be more sustainable and have a greater impact on the clinician (and ultimately the profession) if introduced and evaluated in an athletic training curriculum as opposed to some other program or source.

According to this investigation, athletic trainers report a high practice frequency (13% always and 85% always and often) of the leadership behaviors within their athletic training roles and much less frequency (<1% always and 51% always and often) outside of their athletic training workplace. Of those behaviors, there was a marked decrease (100% within versus 50% outside) in behavior frequency from Kutz's factor 4 (Strategic Thinking), indicating that athletic trainers are not comfortable using strategic thinking outside of the workplace or they do not think it is necessary. Future investigations should explore these and other possible rationales behind this decrease.

Although athletic trainers do practice leadership in both contexts, these findings may indicate that athletic trainers are more comfortable or familiar with leadership behaviors within their work setting. This finding was expected, as Kutz's leadership behaviors were identified by athletic trainers for use in clinical practice. However, leadership behaviors have value beyond the workplace. There is a large body of literature in a variety of disciplines to suggest that leadership behaviors should transcend the workplace.^{10,12–15,36} Quality affirmation theory, described in the athletic training literature by Raab et al,¹⁶ suggests that athletic trainers who demonstrate leadership-like behaviors might be perceived as better professionals. Therefore, unless leadership behaviors are practiced outside with greater frequency, there is a possibility of losing this benefit. As athletic training education evolves, it is necessary for educators to require leadership education with outcomes associated with “multi-, inter-, and trans-disciplinary” success.¹⁰

Additionally, there were several leadership behaviors practiced at significantly different frequencies relative to the respondent's demographic characteristics. For example, when combining both within and outside behaviors, athletic training program directors practiced 14 leadership behaviors (30%) more frequently than university-based clinical athletic trainers. Of those, when outside their athletic training role, program directors claimed to practice the behaviors in factor 4 (Communication and Initiative) more frequently; within their role, program directors claimed to practice behaviors belonging to factor 2 (Diagnosing Context and People Skills) more frequently. Given the differences in the roles of program directors and clinical athletic trainers, this is not surprising. Furthermore, it supports Laurent and Bradney's⁵ findings of differences in leadership practices between program directors and head athletic trainers. Research in nursing has also reported that advanced clinical specialists demonstrate leadership to a higher degree than clinical specialists and suggest closing this gap by encouraging additional training in leadership.³⁵ We would recommend a similar strategy for athletic trainers, with the caveat that it begin more intentionally in early stages of entry-level education.

Athletic trainers reported practicing 94% of leadership behaviors more frequently within their formal athletic training roles as compared with outside. Only 3 leadership behaviors, advocate for others, influencer, and protector, were practiced with similar frequency within and outside of their athletic training role. No leadership behaviors were practiced more frequently outside of the athletic trainer's role compared with within. Many leadership behaviors identified by Kutz²³ and other researchers^1,2,37 (eg, culturally sensitive, verbal communication, ethical, time management, emotional stability, social responsibility) included on the FLATS are not unique to a job or role. For example, effective verbal communication is needed regardless of context or workplace. Therefore, it is possible that respondents may not think of themselves as leaders outside of their athletic training role or that someone else is responsible for demonstrating these specific leadership behaviors in settings where they have no formal authority or expertise.

Epistemology and Ontology of Leadership in Athletic Training

The fact that leadership is practiced more frequently in one setting over another may indicate a deeper issue for athletic training education: an issue that points to an absence of an epistemological understanding of leadership, which may be detrimental to advancing the profession. Epistemology is the study of how knowledge is formed and accepted. It is how one comes to know something or the rules for how to know something and is entirely “a matter of perspective.”^38(p372) To develop an epistemology, one undergoes a process to be able to justify (presumably with empirical evidence or direct experience) a held belief as opposed to an opinion. Therefore, it is the belief about how knowledge occurs, what counts as relevant knowledge, and how knowledge is evaluated.³⁹

Without an epistemological framework for leadership, it is impossible to know if leadership is occurring or even learnable. For instance, if there is no process for verifying leadership knowledge, how can students say they are learning it? Even more dramatic, how would students know they have demonstrated it, especially if it is arbitrarily defined and haphazardly instructed, evaluated, and practiced? Therefore, supposing an absence of an epistemological framework for leadership in athletic training, it is reasonable that leadership would be practiced only as a duty of the job and not beyond it. Without an epistemological framework for leadership, the only recourse is for athletic trainers to consider leadership a job responsibility equivalent to managing, administrating, budgeting, etc, as a formal responsibility is something relegated to perform a job, not something that someone is or can become, and therefore is rarely if ever performed off the clock.

To begin to have athletic trainers think of themselves as leaders needing to demonstrate leadership everywhere as part of who they are personally and professionally, an epistemology of leadership needs to be integrated into athletic training education. Athletic training educators and scholars should work to establish a consensus on what leadership is and how it can be learned. Future research should explore whether athletic trainers believe leadership is learnable, and if so how and under what conditions. It is important to note that having an epistemology of leadership does not mean that learning leadership has to occur in the classroom, but the learner does have to believe learning leadership has occurred, and therefore athletic training educators should at the very least confirm it has taken place even if they are not the ones teaching it. Therefore, athletic training educators and scholars should begin the long process of developing an epistemology of leadership by intentionally introducing leadership and should facilitate the belief that the athletic trainer (and student) is capable of learning leadership and ultimately becoming a leader.

Ontology explores the defining features or fundamental realities of being⁴⁰—in a word, identity. A simple illustration would be the response to the question, what are you? One might answer, “I'm an athletic trainer,” “I'm a professor,” “I'm a human,” “I'm a program director,” or “I'm a leader.” An ontological framework requires knowing when (after what professional experiences/milestones) an athletic trainer feels comfortable saying, “I am a leader” without feeling the need to justify it. Ironically, the milestones along this journey are personal and idiosyncratic to families, cultures, professional organizations, industries, and even nations. Therefore, it is possible that an athletic trainer may be a leader without any formal authority or positional power in a job or professional association.

One additional explanation (an ontological one) for why leadership is demonstrated less frequently outside of athletic training roles is that athletic trainers do not believe they are leaders. This raises the question, is it possible to be a leader in one setting and not another? This is an ontological question and a matter of personal identity. Obviously, one can demonstrate leadership behaviors in one setting and not another; that is exactly what our findings show. However, an ontological understanding requires the distinction between leadership and leader. Therefore, to answer this ontological question, future researchers could ask, “Why do athletic trainers practice leadership behaviors, but fail to recognize themselves as leaders?” Our findings seem to indicate this is true, but certainly further study and dialogue are required to assert it.

Therefore, athletic training educators and scholars should begin to delineate a process for becoming a leader who is recognized not only within the profession, but also by athletic training's stakeholders. The process starts with delineating what leadership is, how we know what it is, and how to become a leader. It ends when one goes through the process, a process which is deemed credible by stakeholders, and ends with an identity as a leader. The leadership taxonomy (Figure) is a start. Hopefully additional research will develop, refine, or replace this model over time. It is incumbent upon athletic training educators and recognized leaders within the athletic training profession to create an environment where this is understood; otherwise, any leadership development within athletic training will be haphazard and unpredictable.

Perhaps it is time that athletic trainers enter the dialogue with our nursing and medical colleagues on the importance of leadership on the identity, meaning, and establishment of a profession and professional. Avoiding this conversation could hinder the development of athletic training in general, but more importantly, by engaging in the conversation athletic training could quickly advance the profession's reputation. This could prove a crucial strategy given the current transition to entry-level graduate education.

Therefore, future researchers should investigate how athletic trainers perceive their context (ie, what constitutes an athletic trainer's work environment or when they are [or aren't] in their “athletic training mindset”) and why they believe they are practicing leadership more within it as compared with outside. For example, it is possible that some athletic trainers consider every place they go within their athletic training role, because they believe they are an athletic trainer regardless of their context, and others may not. The obvious conclusion from this investigation is that there is a perception among respondents that leadership is not needed or used as much outside of their work context.

Work-Life Integration

Another possible explanation for this may be a consequence of misapplying the work-life balance concept. Recently, it has been suggested that a more healthy aspiration is work-life integration.⁴¹ Munn⁴¹ reported that work-life–balance research has demonstrated that one's life cannot be sufficiently isolated between different contexts, and the very idea that you can isolate aspects of life from one another would be to “perpetuate what Kanter referred to as the myth of separate spheres.”^41(p402)

Therefore, future researchers must also undertake the difficult task of answering the question in athletic training: is leadership a job responsibility that is demanded only when on the clock or an aspect of an athletic trainer's identity regardless of what the athletic trainer is currently doing? We would argue that the professions with the most credibility in society are those whose professional members see themselves as capable and trained leaders and not merely practitioners. As an example, it is not uncommon to see physicians occupying leadership roles in their communities and society that have little direct relationship to their medical practice. The value of engaging in these leadership roles without any direct relationship to medicine should be self-evident. Likewise, athletic trainers, when demonstrating leadership in the community, may indirectly advance and promote athletic training.

Other Outcomes of Leadership Education

Furthermore, practicing leadership has been reported to have significant impact on patient outcomes. For example, nursing students who participated in leadership activities reported a greater sense of responsibility to their patients.³⁷ Other scholars^27(p222) report that there is “strong and growing evidence” that links good patient outcomes to leadership behavior. In a systematic review of the relationship between leadership and patient outcomes,²⁶ it was reported that practicing leadership improves patient outcomes (eg, patient satisfaction, patient mortality, complications of immobility, adverse events). Furthermore, leadership by clinicians can enhance the overall quality of care that patients receive and improve patient satisfaction.³⁷ In summary, the increased leadership behaviors within athletic training observed in this study may benefit patients, but demonstrating leadership outside the formal athletic training workplace could also engage the quality affirmation theory,¹⁶ which could contribute toward realizing positive outcomes within society.