Perceptions of Leadership Competency Among Doctorate in Athletic Training Graduates

Design

We used a cross-sectional design to assess perceived importance and confidence toward certain leadership competencies for DAT degree holders, with 3 primary goals: (1) to identify perceived leadership competencies that DAT degree holders indicate are important, (2) to identify the level of confidence that DAT degree holders have to perform these personal leadership competencies, and (3) to identify the level of influence the DAT degree holders believe their degree program had on their perceived influence and confidence of the personal leadership competencies. The study was deemed exempt by the Indiana State University Institutional Review Board.

Participants

Participants were included if they were a credentialed AT (Board of Certification certified, state licensed, or both) and a graduate of a DAT program. If participants did not meet both inclusion criteria, they were excluded from the study. Before the start of data collection, participants provided informed consent to participate.

Instrument

We used a 73-item Web-based survey (Qualtrics). The survey included demographic questions (7 items) as well as a section focusing on personal leadership competencies (22 competencies). Each personal leadership competency was defined and had 3 associated items (Table 1). Definitions of each leadership competency were based off previous work in athletic training⁷ and can be found in the Appendix. The first question asked participants to rate their perception of importance on each personal leadership competency. These questions were rated on a 5-point Likert scale ranging from (1) unimportant, (2) somewhat important, (3) neither important nor not important, (4) important, and (5) very important. The second associated item, listing the same leadership competency, asked participants to rate their confidence in performing the personal leadership competency. These items were also rated on a 5-point Likert scale: (1) not at all confident, (2) slightly confident, (3) moderately confident, (4) very confident, and (5) extremely confident. The final associated item asked what level of influence the DAT program had on participants' perceptions of importance and confidence in performing the personal leadership competency. The associated 5-point Likert scale was (1) not at all influential, (2) lightly influential, (3) somewhat influential, (4) very influential, and (5) extremely influential.

Table 1 Example of a Leadership Competency⁷ With the Competency Defined and Each of the 3 Associated Questions on Importance, Confidence, and Influence

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The 22 personal leadership competencies were adapted from the Leadership Development in Athletic Training (LDAT) instrument.⁷ This instrument had been previously validated, consisting of a list of personal leadership competencies or competencies considered important for each level of athletic training education as well as research doctoral programs (Doctor of Philosophy [PhD] and Doctor of Education [EdD]).⁷ Previous research of the LDAT indicated internal consistency at α = .83–.97 and concurrent, construct, and convergent validity for the tool.⁷ Validity of the LDAT was established in 2 phases of a Delphi technique in which phase 1 established content validity (through literature review and athletic training experts) and convergent validity which demonstrated a positive relationship between important leadership competencies for athletic training education and those important for clinical practice (r = 0.74, P = .001).⁷ Phase 2 established convergent validity which demonstrated a strong relationship between important leadership competencies for athletic training education and those important for clinical practice (r = 0.94, P = .001).⁷ Phase 2 also established construct validity (exploratory factor analysis, eigenvalues ≥ 1.0) and concurrent validity which established significantly varied levels of importance in leadership competencies within different levels of athletic training education (independent t tests, 1-way analysis of variance, repeated-measures analysis of variance, P ≤ .05).⁷ The personal leadership competencies chosen for this study consisted of those indicated as important for postprofessional master's programs in athletic training and academic doctoral programs (Appendix).⁷ These leadership competencies were chosen because, at the time of creation of the LDAT tool, DAT programs were not included. Our adapted tool was content validated by 2 external reviewers not associated with the research team who have served as researchers and clinicians with expertise in leadership and survey development. The reviewers completed a content analysis rubric in which they provided comments on item modifications. We collected the feedback and made appropriate revisions to the survey. Internal consistency was calculated using Cronbach's α for each of the main outcome measures: importance (α = 0.895), confidence (α = 0.876), and influence of the DAT program (α = 0.917).

Procedures

Each of the current 6 DAT program directors (as of spring–summer 2019) were sent a recruitment e-mail that included a link to the informed consent and the survey. We asked the program directors to forward the email to graduates of their respective programs. The recruitment e-mail was sent out 2 weeks in a row. It was confirmed through e-mail that 4 of the 6 program directors forwarded the recruitment e-mail to their graduates. One program director indicated that he or she did not have any graduates at the time of the data collection, and 1 program director did not respond to our request to forward the e-mail and instrument. Since we did not have confirmation that the email was sent to all DAT graduates, we also posted on social media (Twitter) to supplement the recruitment process. Two recruitment tweets were used daily for 5 weeks to increase participation. The recruitment email contained information about the survey as well as a hyperlink to the survey. The survey was completed on a Web-based survey system (Qualtrics; Figure).

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Statistical Analysis

Descriptive statistics were used to identify characteristics of central tendency (mean, mode, frequency) and variability (standard deviation) for the demographic characteristics of the participants and variables of interest. These variables included importance of leadership competencies, level of confidence in performing the competencies, and level of influence the DAT program had on perception of importance and confidence of competencies. Partial data analysis was conducted for items that participants chose to omit from the demographics section. All included participants completed the demographic items. However, some participants chose not to respond to select survey items, consistent with voluntariness in human subject research.

Perceptions of Importance

In previous research, a delineation of leadership competencies has been found in which some are perceived as more or less important at various stages of AT education.⁷ Some leadership competencies such as advocate, credible, delegates effectively, disciplined, and applies known and attained knowledge were considered important for inclusion within both professional-level and postprofessional master's of athletic training programs.⁷ In addition, other leadership competencies like critical thinking, courageous leadership, and cultural sensitivity were rated as more important for postprofessional master's programs than the professional level.⁷ Similarly, within our study, DAT graduates rated some leadership competencies such as credible, knowledgeable, advocate, and applies known and attained knowledge as important. Other leadership competencies such as critical thinking, courageous leadership, and cultural sensitivity were rated even higher, indicating a greater level of importance for DAT graduates. Some leadership competencies considered important for AT education may be shared across the professional level, postprofessional master's, and DAT programs, as all 3 types of programs are focused on the clinical growth of an AT, whether foundational or advanced.¹⁵

Also, similarity exists among the leadership competencies rated important for DAT graduates and those considered important in other allied health professions. Critical thinking was thought to be the most important competency by the participants in this study, which has also been considered important for nurses and physicians.^4,23 Critical thinking was described as an essential skill that enhances nursing practice by leading to a more creative and meaningful decision-making process.²³ Critical thinking, whether used alone or in combination with other leadership competencies, helps give a more meaningful assessment of information and refines the solution process to specific problems when other solutions or interventions are not effective.²³ Other leadership competencies such as being decisive, having a strong knowledge base, applying knowledge and evidence, and fostering vision were also considered important for other health professions³ at a rate like those described by the DAT graduates (knowledgeable, future minded, and applies known and attained knowledge). These similarities are expected, as leadership competencies may be transferable across a variety of health care disciplines. Shared leadership competencies across health care professions may be necessary, as effective collaboration is expected among health care providers.²⁴ As the number of ATs in health care administration continue to rise, it is imperative that DAT graduates share similar personal leadership competencies as leaders within other health care professions.¹⁶

While in this study, we show similarities of important leadership competencies across other stages of AT education,⁷ variability is also present when comparing competency ratings between the DAT and academic doctoral programs.⁷ While a few leadership competencies such as advocacy, applies known and attained knowledge, knowledgeable, and open minded⁷ are shared among our results, differences remain in perceived importance of leadership competencies between academic doctoral and DAT programs. One competency, demonstrates scholarship, is rated important for academic doctoral programs⁷ but was not rated as important among DAT graduates. This can be attributed to the different purposes of each degree, as academic doctoral programs are typically focused on research or education, while DAT programs advance a practicing clinician's level of knowledge and skillset to better their patient care.¹⁵ The variability in perceived importance of leadership competencies between these 2 types of programs indicates a discipline-specific awareness of leadership that is necessary when creating program content and curricula. Within curricula, leadership competencies can be selected for a variety of reasons. Some reasons may include the program's accreditation standards, anticipated circumstances of the students,²⁵ career or professional expectations, and previous needs or outcomes assessments from similar disciplines. While general leadership competencies may benefit graduates of both a DAT and academic doctoral program, adapting leadership curricula to the needs of the DAT degree may enhance the formation of an advanced clinical leader.

Perceptions of Confidence

We found that DAT graduates rated themselves higher in confidence on leadership competencies they perceived as more important. Such shared leadership competencies of credible, open mindedness, critical thinker, and knowledgeable were rated high in confidence and have also been associated with advanced practice leadership within nursing and physician practice.^4,23 Other leadership competencies, such as ensures an awareness of mission, willing to take appropriate risk, utilizes appropriate leadership styles, and delegates effectively were rated lower in confidence. Overall, the application of leadership competencies may affect confidence of performing said leadership competencies. While the sample in this study was only about 1-year post-DAT graduation, the graduates indicated several years of experience (8.69 ± 5.6) and years employed at current job (3.00 ± 4.04), which can be a factor in their levels of confidence with each leadership competency. The graduates may have had the opportunity to clinically practice while completing their DAT program, which in turn gives them the ability to practice emphasized leadership competence to one's work setting. This can provide an opportunity to either enhance or change leadership behavior²⁶ due to the variety of experiences. While we did not measure application of the leadership competencies in this study, positive correlations have been found between clinical experience and levels of confidence in other health care disciplines.²⁷ Experience allows for different leadership competencies to be used while facing adversity, being exposed to a variety of people, problem solving, making mistakes, and struggling with unfamiliar situations.²⁸

Perceptions of Influence

Leadership training is often aimed at the ability to learn, differentiate, and refine different leadership competencies within different settings.^29,30 It is imperative to provide additional leadership development for both clinical and academic leaders in health care to better prepare them for new leadership roles.²⁹ Learning environments that incorporate effective leadership development strategies may have strong influence on individuals' perceptions and confidence of different leadership competencies. As previously mentioned, the purpose of the DAT degree is to develop clinical leaders, demonstrated by several DAT programs' mission statements. Programs describe themselves as a place to develop advanced practice leaders,^15,16,31 professional leadership,³² and clinical or academic leaders.³³ Therefore, advancing leadership competence is an objective of DAT programs, and those programs should be influential in the leadership competencies they choose to emphasize.

One of the aims of our study was to explore the perceptions of influence of the DAT programs on leadership competencies, and differences between graduates' ratings existed. We found that graduates rated leadership competencies such as future minded, demonstrates scholarship, intentional leadership, open mindedness, and knowledgeable as more influenced by their DAT program than others. This result indicates that programs may have influenced a higher level of perceived importance and confidence for those leadership competencies. One factor that may affect the DAT programs' influence on perceptions of certain leadership competencies is the use of their curricula and the incorporation of developmental strategies. In other health professions, specifically nursing, programs describe how specific leadership development strategies may begin at the novice levels and include team-building activities and quality improvement strategies.³⁴ Leadership development at the expert levels may incorporate close interaction with other departments and disciplines, hands-on experiences, advanced staff development skills, retention and recruitment skills, mentoring, etc.³⁴ Other general strategies that have been used in nursing, with or without a specific curriculum, have included structural and psychological empowerment framework strategies that helped nurses practice self-confidence, change leadership styles, change perceptions of staff recognition, and reflect on practices.³⁵ Activities such as mentorship, interprofessional collaboration, hands-on skill sessions, and reflection practices may all be ways to formally influence leadership competencies throughout DAT programs.

Another factor that may affect the influence DAT programs have on leadership competencies is the graduates' clinical experiences as they complete the program. Behavior modeling training (BMT) is like the social learning theory with an emphasis on the transition of learned behaviors to the work situation.³⁶ The strategy of BMT ensures meaningful practice and multidimensional context for leadership application by presenting guidelines for emphasized leadership competencies, creating environments of observation of effective modeling of said competencies, practicing with the opportunity for feedback, and transferring leadership competencies to the work setting.³⁶ Doctor of Athletic Training programs have the capability of using BMT as students are credentialed and can immediately apply emphasized leadership competencies in their work settings. However, the relationship between the program and the student's workplace is often tangential and out of the program's control. As such, formal leadership development activities should be incorporated throughout the curricula. To intentionally choose activities or content in curricula that can emphasize leadership competencies means that program faculty must understand what leadership competencies are perceived as most important for that level of AT education. Although the DAT degree is a novel degree and the potential of the leadership competencies in such programs may not have been fully realized in this sample, the results of this study can assist in providing a foundation for bettering leadership development for AT education.