Portability of United States Athletic Training Education in an International Setting

KEY POINTS

• There are minimal differences in the practice patterns and perception of Japanese athletic trainer educated in Japan and those educated in the United States.

• The result indicated that US athletic training education prepares Japanese students well to work in the Japanese environment.

• This result suggests US athletic training education model may be portable internationally and play a key role in global standardization of athletic training education.

INTRODUCTION

As athletic training and therapy (ATT) is becoming more global, US-educated athletic trainers (ATs) are expected to have more opportunities in the international environment. However, it is necessary to examine whether current US athletic training education is portable. Further, does it prepare students to experience international opportunities to meet the health care needs of athletes and physically active populations in different countries?

In 2005, under initiatives of the World Federation of Athletic Training and Therapy (WFATT), for further expansion of knowledge and understanding of the ATT profession, a mutual recognition agreement (MRA) was signed by the Board of Certification, Inc (BOC) and Canadian Athletic Therapists Association.¹ On September 4, 2014, Athletic Rehabilitation Therapy Ireland also officially signed the MRA with BOC and Canadian Athletic Therapists Association in Dublin, Ireland.² The MRA has now become a trilateral agreement regarding athletic training credentials across the United States, Canada, and Ireland. This trend is expected to continue to grow in the future.^3,4 The MRA has recognized international credentials for ATT professionals, granting them eligibility to challenge national certification exams in each partner jurisdiction. United States-educated ATs are expected to have more international opportunities; however, US athletic training education is designed based on information from a practice analysis conducted domestically, rather than internationally.^5,6 Consequently, in their programs, students are not required to complete any specific courses as preparation for work in an international environment. To date, no research has been conducted to assess the portability of US athletic training education programs to prepare students for working in another country.

For many years, international students have had the opportunity to enroll in US athletic training education programs, which are currently known as Commission on Accreditation of Athletic Training Education accredited programs. Many graduates of these programs have since returned to their home countries to work as ATs. Since the 1970s, many former Japanese students have studied in the United States, and Japan has the largest number of US-certified ATs living there.⁷ In fact, more than 250 Japanese certified ATs now work in their home country.⁸ However, no prior study has compared the practices and perceptions of US-educated Japanese ATs with those of Japan-educated ATs to identify the international portability of US athletic training education. Therefore, the purpose of the study was to determine if any differences existed between the 2 groups in terms of their practices and perceptions of ATT tasks. A hypothesis of this study is that the practices and perceptions of both groups would be comparable, and US athletic training education would be portable for an international environment.

METHODS

PROCEDURES

Regarding the JASA dataset, information for this study was extracted only from those respondents who indicated that they had trained and practiced in Japan. Regarding the JATO dataset, this study used the data of regular members who had received athletic training education in the United States and chose to practice in Japan. Only data from those who identified their profession as athletic trainer or athletic therapist were extracted. Ultimately, 217 individuals responded to the GPA Survey and met all of our inclusion criteria (ie, 34 US-educated Japanese ATs [US-JAT] and 183 Japan-certified ATs [JAT]). For this study, each participating organization was asked to provide members' demographic data, including gender and age, to test the representativeness of the data. Japan Sports Association provided age and gender information for their registered JASA-ATs, but JATO only provided gender information for its members. The representativeness of each sample was tested using a χ² test (α < .05). Regarding the representativeness of the data, no differences were observed for US-JATs. However, there was a significant difference among male participants who were JATs compared to the general membership (JAT: χ² = 4.70, P = .03). Regarding age, no differences were observed for JATs. Since the ages of US-JATs were not provided, we could not compare age information (see Table 1).

Table 1.  Sex and Age Information of Participants and Population With χ² Test Results for Representativeness

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DATA ANALYSIS

Descriptive statistics were calculated to report demographic and background information. In this study, calculations performed using descriptive data were based on the number of responses per question since responses to some of the questions were missing.

In this study, frequency data for practices and criticality and importance data related to perceptions of ATT tasks performed by US-JATs and JATs were analyzed. The first calculation was the sum of the ratings when more than 80% of the tasks were rated by individuals. For comparison, according to dimension and domain, the total score by dimension and the total score by domain in each dimension were tested using the Kruskal-Wallis test (α < .05) to measure differences between the 2 groups.

Fisher exact test was used to compare each of the task ratings between the 2 groups (α < .05). Because data from each of the task ratings included 4-point ordinal data and some of the cell counts were less than 5, the χ² test was less accurate.

Tasks were ranked from first (highest priority) to 24th (lowest priority) in each dimension based on mean scores. The highest- and lowest-ranked tasks for each group were compared, and relationships of the rankings between groups were also examined using a Spearman's ranked correlation; the α level was set at .05. For our analysis, the JMP Pro (version 9.02; SAS Institute, Cary, NC) statistical software package was used.

RESULTS

Demographic and Background Information

Regarding gender, both groups were male dominated; however, the JATs had a greater percentage of males than the US-JATs (85.8% versus 67.7%). Regarding age, more than three-fourths of US-JATs (76.5%) were at least 36 years old, whereas more than half of JATs were 35 years old or younger (57.9%). Regarding the highest level of education, more than 40% of JATs selected other, whereas none of the US-JATs chose this category. Furthermore, half of the US-JATs selected master's degree in response to this question.

Regarding sports levels and job titles, there were fewer differences between the groups, although some unique characteristics were noted. Approximately one-third of US-JATs selected collegiate (37.5%) as their sports level; in contrast, high school/secondary was identified predominantly for JATs (27.2%). More than 10% of the participants of both groups were working with elite athletes (pro/pro club/Olympic; US-JAT: 20.8%; JAT: 16.0%). In terms of job title, US-JATs had the highest percentage of participants listed as head athletic trainer/therapist (41.2%). Athletic trainer/therapist represented the largest group of JATs (33.9%). Table 2 summarizes participants' demographic and background information.

Table 2.  Demographic and Background Information of Participants

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Comparisons by Dimension and Domain

Table 3 shows the results of the comparisons for summed rating scores in the 3 dimensions of criticality, importance, and frequency. The Kruskal-Wallis test indicated that there were no significant differences in ratings in any of the 3 dimensions of criticality [χ² = 0.12, P = .719], importance [χ² = 0.24, P = .624], and frequency [χ² = 0.95, P = .331]. Table 4 demonstrates the results for group comparisons in terms of differences by domain in each dimension (based on the Kruskal-Wallis test). The results showed no differences by domain.

Table 3.  Comparisons of Sum of the Ratings by Dimensions (Criticality, Importance, and Frequency) Between Athletic Trainers Educated in the United States (US-JAT) and Athletic Trainers Certified in Japan (JATs)

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Table 4.  Comparisons of Sum of the Ratings by Domain (Assessment, Intervention, Administration, and Education) in Each Dimension Between Athletic Trainers Educated in the United States (US-JAT) and Athletic Trainers Certified in Japan (JATs)

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Comparisons of Task Rating

Further comparisons of task ratings with Fisher exact test revealed that there were significant differences between groups in 2 tasks (2.8%, 2 out of 72 tasks [24 tasks over 3 dimensions]) for all 3 dimensions. One task differed in criticality, and the other task differed in importance.

In terms of criticality, Task No. 20, “Execute communication responsibilities to the patient and other professionals to ensure quality health care,” was identified as having a significant difference in ratings. For this task, more US-JATs chose either causing extreme harm (41.2% [14/34]) or causing substantial harm (35.3% [12/34]) than JATs: causing extreme harm (50.8% [93/183]), causing substantial harm (17.5% [32/183]). Therefore, the task of communicating with patients and other professionals was more critical for US-JATs than JATs.

Regarding importance, Task No. 13, “Use standard techniques to prevent or minimize risk of injury using taping, bracing, immobilizing/splinting, and/or protective equipment,” was identified as having a significant difference in ratings. More US-JATs considered this task to be either extremely important (55.9% [19/34]) or very important (44.1% [15/34]) than JATs: extremely important (61.2% [112/183]) or very important (25.1% [46/183]). These results indicate that the application of taping/bracing for injury prevention was more important for US-JATs than for JATs. Please refer to Table 5 for descriptive data associated with task rating comparisons.

Table 5.  Descriptive Statistics of Ratings of Tasks with Statistical Significance (α < .05)

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Comparisons of Highest- and Lowest-Ranked Task Rank for Criticality, Importance, and Frequency

Criticality

Concerning criticality, the top-ranked task differed for the 2 groups of participants, whereas the lowest-ranked task was common for the 2 groups. Task No. 16, “Execute emergency action plans to facilitate efficient patient care in catastrophic situations,” was ranked first by US-JATs, but third by JATs. Task No. 24, “Educate appropriate individual(s) about risks associated with participation and specific activities using effective communication techniques to minimize the risk of injury and illness,” was ranked first by JATs, but ninth by US-JATs. On the other hand, Task No. 18, “Use a human resource and fiscal management system to manage personnel and execute budgeting, accounting, and billing responsibilities,” was the lowest-ranked task for both groups. The Spearman's ranked correlation between US-JATs and JATs was r = .92 (P < .01) for criticality rankings.

Importance

In terms of importance, the top-ranked tasks were the same for both groups, although the lowest-ranked task differed. Task No. 8, “Employ lifesaving techniques through US standard emergency care procedures to reduce morbidity and the incidence of mortality,” and Task No. 16, “Execute emergency action plans to facilitate efficient patient care in catastrophic situations,” were ranked first (with the same mean among US-JATs) and second for both groups, respectively. The lowest-ranked task for US-JATs was Task No. 19, “Design and use a facility management plan to control environmental injury risk, waste disposal, biohazardous waste removal, and equipment maintenance,” whereas Task No. 18, “Use a human resource and fiscal management system to manage personnel and execute budgeting, accounting, and billing responsibilities,” was ranked the lowest by JATs. The Spearman's ranked correlation between the 2 groups for importance was r = .93 (P < .01).

Frequency

Regarding frequency, the lowest-ranked task was common to both groups, but the top-ranked task differed. The common lowest-ranked task was Task No. 8 (stated previously). The top-ranked task for JATs was No. 5, “Palpate the involved area(s) using standard techniques to assess the injury, illness, or condition,” whereas Task No. 7, “Administer conditioning, prehabilitation, rehabilitation, and functional exercise using appropriate methods and techniques to facilitate recovery, function, and/or physical performance,” was ranked highest by US-JATs, but second by JATs. The Spearman's ranked correlation for frequency was r = .92 (P < .01).

Table 6 provides a summary of the means and task rankings for each dimension. Spearman's ranked correlation coefficients for criticality, importance, and frequency are summarized in Table 7.

Table 6.  Means and Rank (1−24) of Each Athletic Training/Therapy Task Rating in Criticality, Importance, and Frequency Between Athletic Trainers Educated in the United States (US-JATs) and Athletic Trainers Certified in Japan (JATs)

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Table 7.  Spearman's Ranked Correlation Coefficients for Criticality, Importance, and Frequency Between Athletic Trainers Educated in the United States and Athletic Trainers Certified in Japan

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DISCUSSION

This was the first study to compare practices and perceptions of ATT tasks by US-JAT and JAT groups using standardized research methodology. Using the GPA as the basis for country comparisons, it was remarkable that the practice frequency and perceptions of ATT tasks between the 2 groups were minimally different.

Of the 3 dimensions examined—criticality, importance, and frequency—no differences were found. The results of comparison of the various dimensions demonstrated that there were no country-specific response patterns to the GPA Survey. Previous research has shown that there was a country-specific pattern of responses based on country bias when cross-cultural comparison studies were conducted using the Likert scale.¹¹ However, the results of this study indicated that there were no effects of country-specific ratings in the comparison of the 2 groups that shared the same culture or ethnicity. This finding suggests that educational experience did not change the style of response of the US-JAT group compared to the JAT group.

This study demonstrated no differences in the practices or perceptions in domain-level comparisons and a few differences in each dimension's task-level comparisons. Correlation studies indicated that task rankings in practices and perceptions were very similar. Comparisons of task rankings revealed some commonalities in each dimension. These results indicate that there were minimal differences in frequency and perceptions of ATT tasks between the 2 groups.

Although most results in this study showed few differences between the 2 groups, it is plausible that the uniqueness identified in task rankings by US-JATs was possibly influenced by their US education. The largest difference between highest- and lowest-ranked tasks was found in the dimension of criticality. Patient education and education of appropriate individuals were much less critical for US-JATs (ninth ranked) than for JATs (first ranked). Emergency care was more critical for US-JATs than JATs. Most of the initial Japanese ATs were licensed therapists, such as massage and acupuncture therapists, and their education did not require emergency care. Their primary role was therapy in a therapy room rather than emergency care on the field of play.¹² On the other hand, the traditional job setting in the United States is college, high school, or professional sports, and ATs are the first responders for emergency care on the field of play or practice.¹³ These varying histories of the developing roles of ATT professionals in Japan and the United States might have influenced the perception of emergency care tasks.

Another task with differences among the highest- and lowest-ranked tasks was clinical evaluation, ranked fourth by US-JATs and first by JATs. This finding suggests that the evaluation task has higher priority and is more frequently performed by JATs than US-JATs. One reason may be the regulations related to athletic training practice in Japan.

United States-educated ATs may face obstacles in performing certain ATT tasks in foreign countries; in fact, they may need to have a legal background to practice clinical tasks. In Japan, ATs are not recognized as health care professionals and are not regulated. Practicing ATT is often regarded as a “gray zone” in the Japanese health care system. Under these circumstances, those who wish to work as ATs often seek licenses in related health care professions such as physical therapists, massage therapists, or acupuncture therapists.¹⁴ In fact, 72% of full-time ATs certified in Japan have licenses in other health care professions.¹⁵ Education for other health care professionals does not require a bachelor's degree. Instead, they complete a 3-year noncollege degree professional school in Japan. Our demographic data indicate that many JATs chose other to describe their highest level of education, which was consistent with this analysis. There are still a limited number of countries with credentialing systems for ATT professionals and other licensed health care professionals, such as physical therapists and nurses. In the countries where athletic training is not recognized and not regulated by the government, individuals with other health care professional licenses may be practicing as ATT professionals. This situation can be confirmed by member organizations of WFATT that include various health care professionals.¹⁶ A US-educated AT without a license in a related health care area may practice in strength and conditioning, injury prevention, or first aid, which are unregulated areas in Japan. Therefore, US-educated ATs may not have the same priorities, particularly in clinical tasks, as JATs.

LIMITATIONS

This study has many limitations that might have affected the analyses. The first limitation relates to the influence of the sample's nationality on the results. This study involved a comparison of JATs with US-JATs returning to Japan, their home country. However, there was no comparison of these groups with ATs of other nationalities, such as American ATs who were practicing in Japan, because of an unavailability of samples. The native origins of the subjects, rather than their educational differences, might have influenced their rating patterns in the GPA Survey results, although having the same nationality helped to avoid a country-specific rating bias in our study. In addition, there is the possibility that the comparisons observed between the 2 groups might only be applicable to the Japanese. Thus, a further study is needed with a sample of ATs who practice in nonnative countries for generalizable findings applicable to ATT professionals from other countries. The second limitation relates to the influence of the experience in Japan on perceptions and practices of US-JATs, who are more experienced than JATs. As a result, there is a possibility that their perceptions may be influenced by their experience. This study did not include a postanalysis using years of experience. Furthermore, US-JATs with more years of experience might have already adapted to the environment in Japan.

Even with these limitations, this study was unique in its examination of the portability of US athletic training education to an international setting. The study findings are encouraging for US athletic training educators and athletic training students who study in the United States and wish to collaborate with ATT professionals in other countries or work in an international setting.

CONCLUSIONS

To sum up, the findings of the current study point to negligible differences in the practice patterns and perceptions of those trained in Japan and those trained in the US, indicating that US athletic training education prepares Japanese students well to work in the Japanese environment and may be portable internationally. This conclusion will encourage the global application of the US model of education and play a key role in global standardization of athletic training education.