Factors in and Barriers to Engagement and Service Within Athletic Training Association Leadership

Participants

After the study was approved by the university institutional review board, a purposeful sampling was performed. Although it can be difficult to find informal leaders, participants who chose to lead and serve within the profession in an elected position were identified. Participants were identified by their state athletic training association's website, and 2 random states within each NATA district were initially selected. Participants who had been Board of Certification–certified athletic trainers for 5+ years and were currently serving on their state's executive board in the role of president, vice president/president-elect, secretary, or treasurer for 1+ years were recruited. Five years was selected as the minimum time needed to allow the athletic trainer time to establish their professional identity. Participants must have had at least 1 year of experience on the executive board, regardless of role transition. Participants were excluded from the study if the inclusion criteria were not met or the participant declined consent to the recorded interview. Interviews were performed until data saturation was reached. Seventeen athletic trainers were recruited for this study; however, 2 were excluded as 1 did not meet the minimum time of 1 year needed on the executive board, discovered during the interview, and 1 discussed leadership out of context to the purpose of this study (Figure 1). Fifteen participants remained to be included in this study (11 men, 4 women; age = 42.7 ± 7.8 years). Table 1 provides participant demographic information and Table 2 details participant characteristics.

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Table 1 Participant Demographics

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Table 2 Participant Characteristics

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Procedures

To ensure representation of participants and experiences across the country, 2 states within each NATA district were randomly selected for identification of participants. Participants were identified from their state association's website, where their email was obtained. A random selection was performed from the executive board and then an email was sent explaining the study's purpose, inclusion criteria, and informed consent form. Participants who replied to the initial email and returned the written informed consent form were scheduled for a Zoom interview. If there was no response from the participant within 7 days, a reminder email was sent. If the potential participant still did not respond after the second 7 days, another participant was recruited by selecting another state within the same NATA district. This process was repeated until enough participants were recruited to establish data saturation. All interviews with participants were audio recorded. Before the recording of the interview, the principal investigator reviewed the purpose of the study, reviewed issues related to confidentiality, anonymity, and the handling of the recorded interviews, and informed the participant of the option to cease the interview if needed. Once oral consent was given, the recording was started. Each interview lasted approximately 30 to 45 minutes. Participant recruitment continued until data saturation was reached. Some memoing was completed by the primary researcher after the completion of each interview.

Instrumentation

A semistructured interview guide (Table 3) was created addressing the athletic trainer's view of leadership and their motivations to pursue leadership opportunities. It also included questions regarding barriers to participation and how they overcame those barriers. As leadership is defined in various ways, we operationally defined leadership as “motivating a group of people to act toward achieving a common goal.”¹ Both investigators established the initial interview protocol, and it was then peer reviewed by another student researcher with no feedback. It was then reviewed by 2 experienced researchers in qualitative research, who found that some revisions were needed. After revisions were completed, the principal investigator (S.L.W.) conducted a pilot study with 2 participants (1 male, 1 female) who had leadership experience within their state executive board. This was performed to see if any questions needed to be added to help answer the research questions. No changes were made to the instrument after the pilot study was completed, and the pilot participants were not included as participants within the study. Because of the semistructured nature of the interview protocol, probing and clarifying questions were asked when necessary.

Table 3 Interview Protocol

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Data Collection and Analysis

A qualitative methods study in a grounded theory approach was used for this study.¹¹ Interviews were ongoing and conducted until data saturation was complete. Data saturation was determined when no more emergent themes were established. When it was believed that data saturation was complete, an additional 2 interviews were completed to ensure saturation. Data collection and coding occurred simultaneously. Once the interview was complete, the audio was transcribed verbatim by the principal investigator. Open coding was initially used, followed by axial and selective coding. Constant comparisons were made throughout the process. Transcripts were reread to ensure understanding of meaning. The codes were then placed in like categories and grouped by emergent themes and subthemes.

Trustworthiness of the data was established by using the following methods: (1) memoing, (2) member checks, and (3) peer review. Some memoing was completed after the participants' interviews. Transcripts were sent to all participants to ensure transcript meaning was accurate and any changes identified by the participant were made. Only minor changes from 2 participants were noted upon member checks. These changes were centered around the wording during the transcription process. A fellow student researcher and the second member of the research team with experience in qualitative research reviewed the data and coding to ensure accuracy.

Leadership Defined

Leadership was interpreted in many ways by participants with some responses similar to the definition provided within this study. As Deres stated,

Leadership means to be able to help direct people in either the direction that they may want to go or maybe the group needs to go or move towards. In my brief leadership experience, it has been more about just kind of corralling the group together and trying to keep focus on the main objectives.

Larry described leadership similarly: “Leadership does involve a lot of motivation. It is helping people find the vision and move toward that vision cooperatively.” Although many participants described leadership as working collaboratively towards progress or completion of a goal, other participants described leadership as displaying certain characteristics or behaviors. As Olivia mentioned, “It is being empathetic. It is being a good listener, a team player. Sometimes it is just about being a good delegator.” Brian echoed that leadership represented being a good listener. He stated,

I think a leader's main job is to listen. I think through listening you give your group, your colleagues, your people below you the ability to create their own ways to go about that mission or that goal. I think the leader needs to define the goal, but they also need to listen.

Although there were certain similarities among some of the participants' responses, each participant had their own view of what leadership was and what it represented.

Involvement in the Profession

The first theme that emerged from the data was the participants' desire to be involved within the profession. This theme included the 2 subthemes of advocacy and service. There was a great desire for participants to give back to others. Involvement in the profession served as a way for the participants to be involved in current issues facing athletic trainers and to create relationships with individuals that could be influential in their growth as a professional. Some participants described getting involved as a way to stop being one to complain about what was going on if they were not willing to contribute to the change. Brian stated,

What did I need to do to become a better leader and then as I learned those things, I felt I was able to give back more. And that's why I jumped into a leadership position. I wanted to be somebody who can help change and educate those around us. I wanted to be able to help educate the young professionals. And I wanted to be able to educate the ones that are my colleagues that are my age and older. I wanted to say hey listen, we're complaining so much but here's the reason why we need help. And here's the reason why we need to step in.

Being involved gave participants a sense of fulfillment in seeing the change they were involved in. Helping to make change themselves and then convincing others of the importance of the involvement was needed. Other participants described their reasons for getting involved as a way that was almost expected of them for the profession that they loved. As Josh stated, “I was taught when I was being ‘brought up' in the athletic training that you need to be involved. And I think that that pushed me to get into leadership roles and provide for our profession.” Being involved was also a way to make a difference where they were locally. This could lead to potential future opportunities in other areas within the organization or allow them to continue to move into larger roles within the district- or national-level organizations. As Deres stated,

It was kind of that inspiration that it's just something that is expected. Maybe as you learn and grow with the profession that you would want to be more involved in the state association and then moving up into the district association and then into maybe the national association.

Getting involved was a step for some participants to take in order to step up and help make change within their association that could lead to better recognition and future opportunities for athletic trainers.

Encouragement From Others

The second theme that emerged from the data was being encouraged by others. Many participants described their hesitation to get involved as they doubted their abilities. They found it easier to transition into a leadership role when someone acknowledged a skill or trait that they had that they felt would be influential. Pedro explained his experience:

So, I think for me, I'm always a little hesitant to maybe put that foot forward, but as soon as someone acknowledges that they see something in me and they believe I can do it, I typically run with that. And so I think that is really what held me back from maybe taking on some of those initiatives without that extrinsic motivation from perhaps the mentors who saw some things in me...It was that person saying “You got this like you can do this.”

Many participants stated they were not quite sure what other individuals saw in them that would lead them to believe they would be beneficial for a leadership position, but that it did play a role in their involvement in the organization. For some, it took others to point out certain characteristics in them before they started to see that in themselves. As Marcus explained,

I don't know for sure what each one of those individuals in those different environments, athletic training and otherwise, have seen in me that caused them to make that determination from their own vantage point, but that has been instrumental. Those interactions have been instrumental in driving me to give myself along those lines.

There could be potential for more leaders within the profession if we encourage each other to step up. Being encouraged by others and providing feedback helped give participants the courage needed to step into a leadership role. Furthermore, it was instrumental in helping participants identify additional ways they can be of service.

Fear

When identifying barriers to athletic trainers' involvement within leadership opportunities, the main theme identified was fear. Fear encompassed many emotions and feelings of exposing oneself and being vulnerable, not knowing what to do or how to complete the task at hand, and not understanding the full depth of what is asked of them in their role. For example, Deres described how being a leader resulted in others looking to you. The leader should exemplify someone who is strong and can handle many different situations; however, he felt like it conflicted with his personality type. He stated, “Again, there's the kind of fear that everybody's going to be looking to you to make the decision or to be the really strong personality kind of leader, which that's not my personality at all.” Although some participants did not feel like their personality lent itself to being a strong leader, others had preconceived ideas of what a leader does in their role, and this has lent to many individuals not taking a step to be involved. If participants do not understand the full capacity of that role, agreeing to take on a new position makes them vulnerable. Exposing themselves and being vulnerable to new situations where they were unsure what to do was addressed with many participants. For an athletic trainer who may have great clinical skills, learning how to run a meeting or an association is not something that is typically covered in ATPs. Numerous participants described their fear when considering and transitioning to leadership roles. Josh detailed his feelings by stating,

Fear of not knowing, you know, fear of exposing myself and being known as a very good athletic trainer...and then all of a sudden go into a situation where I'm an infant in knowledge compared to them.... We don't go to college to learn how to be a vice president of an association...I mean, people don't know what a motion is. You know what is the second, what's it called the question, what's an executive session, you know, these are all things that go on. You're in the meeting, you're kind of going, this is like a foreign language.

Many participants had limited knowledge on how organizations ran as the exposure was limited or nonexistent in their formal education. Charles explained his feelings as well addressing the lack of knowledge in what was going on and how long it took for him to feel competent in his abilities:

And one of the big challenges I faced early on was I had no idea what was going on. It was like this deer in the headlights look...I mean, all of a sudden, you're the new state president, we will see you at the district executive board meeting...and I'm like, what are you guys talking about? I don't have a clue what's going on, you know, all these states, and then we're voting on things and talking about things. I'm like, I don't have a clue what these people are talking about. And I'm voting on these issues.

Regardless of the level of knowledge a participant had, getting involved in leadership opportunities caused many participants to have to face their fear, to get outside their comfort zone. Although many aspects of fear were addressed by participants, Brian discussed how getting over that fear identified for him his readiness to take on a leadership role. He said,

I think fear drives everything that we do. Whether I was afraid of a time commitment, whether I was afraid of my own ability, whether I was afraid of the individuals in the room...that was always a big limiting factor for me to take that big step... And once I got over that hump of that fear, that's when I really noticed that I was ready for a leadership position.

Regardless of the specific role or level of leadership participants were involved in, fear was a contributing factor. Challenges still were evident during their transition into their new role. Marcus metaphorically explained how he felt during his transition to the executive board. He stated,

When I started a year and a half ago, I felt like a fish underwater. I felt like a kid that had never been in a swimming pool that was getting asked to swim in the Olympics. And be competitive, but you know, you jump in, to the deep end. And you hope that you swim.

Fear was the main barrier participants described when considering roles in athletic training leadership. The fear identified by participants included a false perception of what a leader should look like or how they should act that was not in line with their personality or leadership style. Furthermore, participants felt that the lack of knowledge of a specific leadership role or how to run an organization was a significant barrier they had to overcome.

Interpretation of Leadership

In our study, leadership was interpreted and defined in many ways. This can be attributed to the fact that there is not one agreed-upon definition of leadership that exists in the literature, as the concept can be hard to define.^14,15 Leadership is often defined by behaviors, attitudes, skills, effectiveness, and processes. Additionally, one must consider differences between what leadership is and who a leader is. An integrative definition used by Winston and Patterson states,

A leader is one or more people who selects, equips, trains, and influences one or more follower(s) who have diverse gifts, abilities, and skills and focuses the follower(s) to the organization's mission and objectives causing the follower(s) to willingly and enthusiastically expend spiritual, emotional, and physical energy in a concerted coordinated effort to achieve the organizational mission and objectives.¹⁴

Many of the definitions used by our participants encompassed many aspects of this definition by discussing the ability to help others find their motivation to move towards a goal. Having a group work collectively together to evaluate and set a plan in motion requires individuals to be good listeners to all the parties involved. Listening was used to describe leadership by a couple of our participants. Leaders must have the ability to hear what individuals are saying and work collaboratively to come to a solution.

Motivations to Participate

In this study, the primary motivator for participants to choose to get involved in a leadership position within their state association was an innate desire to get involved in the profession. Involvement in the profession allowed them to contribute to change within their state association and subsequently the profession. With approximately 57 000 certified athletic trainers, just under 40 000 of these individuals are members of NATA.¹⁶ Many athletic trainers are required or highly encouraged to become members of NATA during matriculation through their professional ATP, and thus recognize that involvement is a professional obligation. Early membership and involvement can contribute to career development by exposing students to a variety of experiences and resources.¹⁷

During professional education, participants' faculty members who were members of and actively involved in their association at any level helped to serve as a role model for them to emulate. Membership in various health care professional organizations provides many benefits, including continuing professional development, advocacy, networking, career development, leadership development, and increased awareness of current issues facing the profession.^18–20 Over half of all licensed occupational therapists join their professional association because of their willingness to get involved in the improvement of the profession.²⁰ Similarly, pharmacy students became involved because of the enjoyment they receive in giving back to others and the leadership growth they obtain by serving in a leadership role.¹⁹ The findings of our study are similar to those of occupational therapists,²⁰ who thought it was important to be involved and give back to the profession. It also gave the participants a sense of fulfillment.²⁰ Moreover, starting a leadership role in a smaller capacity allowed athletic trainers to get better acquainted with the roles and responsibilities required of them while gaining valuable leadership experience. The participants' experience can help them transcend into future roles they want to be involved in by providing more understanding of how to run an association and how to be an active member doing so. The foundation provided in an athletic trainers' leadership role helped to give them more confidence in seeking out additional leadership opportunities in other areas of their association. Learning the ins and outs of their leadership role and the function of the board overall provided athletic trainers a new perspective on how their tasks contribute to the mission of the association. As some athletic trainers complain about their association not fighting for a fair salary, being labeled an essential worker, providing member support, or making changes to impact all athletic trainers, many of our participants described how their perception of the association changed after getting involved. For many of them, seeing firsthand how the leadership team addresses issues facing athletic trainers in their state allowed them to see the positive impact the associations are making. Change comes from those who are willing to be involved. As many of the participants in our study chose to serve in a leadership role as a primary way to get involved in the profession, the new perspective they gained and the change that is being made in their association has been impactful in their professional development.

Many of the reasons for involvement given by participants are similar to those constructs identified by Inglis and Cleave,²¹ including career responsibility, contribution, professional and social relations, the value of helping others, and the enhancement of growth. Participants' decisions for involvement fell into 4 of the 5 constructs. The first construct, growth, referred to the opportunity to learn new skills.²¹ Responsibility reflected the participant's ambitions for a greater role. The construct of contributions allowed participants to have the opportunity to be involved in something and make a difference. Lastly, the construct of relations considered both the personal and professional interactions of working with others. Being able to work and give back to others from this construct provided a high level of commitment and fulfillment.²¹

Barriers to Involvement

Fear was a significant barrier that most participants addressed when wanting to get involved in a leadership position. Participants expressed insecurities about their ability to carry out the roles and responsibilities of their position, and therefore feared being perceived as inadequate. With trying to overcome gender stereotyping in today's society, some have the perception that a woman's ability to lead is not as strong as a man's or women have more family responsibilities, which could dissuade women from getting involved.^26,27 Women may feel more pressure to meet the demands of both work and family, and having children can lead to more work-life conflict.²⁷ This could potentially contribute to the lack of involvement of female athletic trainers in leadership roles. When transitioning into their new role, both male and female participants were challenged as they felt they had limited knowledge of the roles and responsibilities of their newly appointed position. This led many participants to feel incompetent for a period before they really started to understand their role.²⁸ These feelings are similar to those of newly credentialed athletic trainers when transitioning to practice. Many newly certified athletic trainers lacked confidence in their abilities and skills, and although they knew they were prepared for their role, it was difficult to trust themselves.²⁸ Additionally, newly certified athletic trainers struggled with role ambiguity regarding what was expected of them, including current policies and procedures for various tasks.²⁸ Additional leadership and management skills could be added to the current athletic training curriculum to ease some of these fears. This can include and provide more in-depth knowledge and skills within topics such as conflict resolution, communication, strategic planning, and personnel management. Additionally, addressing topics such as Robert's Rules of Order²⁹ and how to conduct effective meetings can be integrated into the curriculum or within student organizational meetings. Athletic trainers are equipped with various clinical skills; however, valuable leadership and management skills such as how to lead others and tasks such as conducting an association meeting are not a standard covered in athletic training education.¹ These are typically learned through experience or through additional education. All athletic trainers, regardless of their position, influence those around them.¹ With most primary leadership behaviors, including credibility, verbal communication, and strategic thinking, being practiced frequently by athletic trainers,³⁰ some may not make the connection between those behaviors within their current professional role and the implementation of those behaviors in a leadership role. Many courses have been developed by NATA over the years, including the NATA StarTRACKS program that was revamped into what is now the NATA Leadership Academy, that have helped to address these topics. The NATA Leadership Academy is divided into 4 modules, including vision, communication, collaboration, and strategic thinking, and aids the athletic trainer in understanding and implementing these topics into their clinical practice.

Improved education and training for new leaders could also improve newly credentialed athletic trainers' confidence and reduce role ambiguity as they progress into leadership roles. Role ambiguity due to unclear job descriptions, organizational charts, or daily tasks can lead to increased stress and uncertainty, thereby decreasing performance.³¹ Those with higher role ambiguity have shown to have lower leadership effectiveness, lower satisfaction, and more variation that the leader represents the collective identity.³² Although it is up to each state to develop its own bylaws that describe the general roles and responsibilities of the leadership board,³³ policies for training and transitioning the position to the newly elected leader are often not addressed. In order to have an effective board, there must be a continuous plan of succession with regular training and opportunities to grow as a leader.³⁴ Many participants identified having some ambiguity in their leadership role due to not understanding the full depth of their role or certain tasks or procedures they needed to perform. Only a small number of participants had a transition period of shadowing and training before taking over their role. The remaining participants had limited help from others, and it was more of a “learn as you go” experience. It is recommended to have a transition period where a clear path is identified to be able to take over full responsibilities of the role.³⁴ Because of the inexperience of new leadership board members and the lack of training many participants had once elected, we could suspect that the effectiveness of the board is stunted. The time taken to develop this knowledge can impact the synergy and progress of the board.

Implications for Practice

Understanding athletic trainers' motivations to get involved in leadership opportunities and the barriers they face can help us identify and implement strategies within a student's professional education and within state and regional associations to foster involvement within their membership. With many associations struggling to find candidates for various leadership positions, understanding these issues is critical for their growth and development. Involving students in association activities, such as board or business meetings, signing of a new state bill, or advocating for new laws, could allow students to see the impact of what is occurring and inspire them to get involved during their professional careers. Additionally, our participants' reports of those who recognized and encouraged their talents and abilities as students and served as mentors for them shows the influence mentors can have. Our findings may suggest more integration of leadership skills throughout the athletic training education curriculum may be needed. Although it is understandable that robust training of these skills may not be feasible by programs because of the limited time available, determining what skills are practiced most often by athletic trainers can be prioritized for integration and implementation within the current curriculum. Additional and more advanced training can be provided within continuing education, postprofessional education, or residency. Moreover, incorporating the basics of conducting a meeting and the common terminology within associations should be addressed. As most ATPs have a student organization, running meetings like those seen in professional associations can be beneficial for students to get insight and practice these skills. State and district associations should enhance the transition of leaders into their leadership roles by creating policies that allow a training period and formal mentorship for individuals to learn and become comfortable in their new roles. Associations should also ensure term limits are placed on all leadership positions to allow other individuals to get experience. New leaders will allow new ideas and perspectives to be shared among the board for the overall growth of the association.

Limitations and Future Research

Although there is limited research within this area in athletic training, our research findings contribute to better understanding the motivations of athletic trainers' involvement in their association. Understanding the full depth of motivators and barriers to involvement in leadership roles is critical to better address how associations can recruit and retain leaders. We acknowledge that there are many athletic trainers who are excellent leaders within their own job setting or community, as the term leader is not defined by a title. Therefore, the study findings can be generalized only to athletic trainers who serve within a leadership position on an association executive board. Many athletic trainers are also not members, or active members, of their state-, district-, or national-level associations. Barriers to becoming a member may impede their desire for involvement. The imbalance of gender representation within this study is also a limitation. Future research should identify more participants, including the purposeful recruitment of female leaders, to determine motivators for involvement and barriers to athletic trainers joining their professional association, and to understand if the barriers addressed impact their decision to serve within a leadership role. Furthermore, determining a way for athletic trainers to lead outside of formal leadership roles on the executive board is needed. In future research, the students' perspectives on leadership involvement and the value it has for them professionally and determining if and how athletic trainers' motivations change over the course of their career could also be beneficial. Finally, determining ways professional associations can promote and develop future athletic training leaders is crucial. This research helps to provide perspective on athletic trainers' leadership involvement and gives a foundation for future studies.