Racial Microaggressions During Clinical Education Experiences of Professional Master's Athletic Training Students

Study Design

We used qualitative methods to achieve our purposes and to better understand students' experiences of racial microaggressions. The phenomenology approach allowed us to examine themes as they emerged from the data, providing a rich understanding of the participants' thoughts and opinions regarding the meaning of human experiences¹⁰ during clinical education. Our overall outcome goal was to provide a description of the meaning of the experiences in which students engaged during clinical education.¹¹ We consulted a previous study¹² as a quality assessment tool to ensure that we addressed the necessary elements of our design. A flow diagram of the study methods can be found in Figure 1.

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Participants

We recruited second-year ATSs enrolled in Commission on Accreditation of Athletic Training Education (CAATE)–accredited professional master's programs to complete this study. Inclusion criteria included students in the second year of a CAATE-accredited athletic training professional master's program. Exclusion criteria included students who were not in the second year of their program. Participants included 115 second-year master's students (80 female, 33 males, 1 nonbinary/third gender, and 1 did not wish to disclose; age = 23.67 ± 3.41 years). Approximately 67% (n = 77) were White, Not Hispanic/Latinx, 19% (n = 22) of participants were Black or African American, Not Hispanic/Latinx, 6% (n = 7) were Asian, Not Hispanic/Latinx, 5% (n = 6) were Hispanic/Latinx of any race, and 2% (n = 2) were Multiracial. One participant wished not to disclose race/ethnicity (Figure 2). College/university and high school athletics tended to be the most popular clinical education settings for our participants over the course of their educational experiences (Figure 3).

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Instrumentation

To gather perceptions regarding racial microaggressions among professional master's ATSs during clinical education, we created a 14-item online questionnaire (Table). The participants were required to provide demographic information and to identify whether racial microaggressions had been experienced during their clinical education experiences. We also asked participants how they defined racial microaggressions. After obtaining their responses, we provided the definition⁸ of racial microaggression before asking them to answer questions related to their experiences of racial microaggressions during their clinical education experiences. The questionnaire contained a series of qualitative questions based on the current literature.^5,8,13 We validated the tool via peer and expert review before the initiation of the study. First, we asked a peer with extensive qualitative research experience to review the questionnaire for content, clarity, comprehensiveness, and flow. After we made the requested edits, we sent the revised questionnaire to 2 athletic training scholars and educators we identified as experts based on their experience in publishing qualitative studies or their involvement in justice, equity, diversity, and inclusion initiatives via the NATA Ethnic Diversity Advisory Committee. We asked the experts to review the questionnaire for relevance to the research questions, clarity, and importance to the purpose of the study and to score each question using a Likert scale (4 = Very Relevant/Clear/Important, 3 = Quite Relevant/Clear/Important, 2 = Somewhat Relevant/Clear/Important, and 1 = Not Relevant/Clear/Important).^14,15 For a question to be included in the final version of the questionnaire, it had to have an average score greater than or equal to 3. If a question had an average score of less than 3, we revised or removed it based on expert feedback.¹⁶ We revised 6 questions and removed 1 after considering the expert feedback. After making the needed edits, we asked the experts to regrade the questions to ensure scores were greater than or equal to 3 before inclusion in the final questionnaire.¹⁶ We pilot tested the instrument with 2 students meeting the inclusion criteria and initiated recruitment after they provided no additional edits.

Table Questionnaire

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Procedures

The institutional review board approved our study before recruitment began. After receiving institutional review board approval, we sent a recruitment email to program directors from all 209 CAATE-accredited professional master's programs in the United States as of May 2020. Our email detailed the purpose and methods of the study and asked the program directors to distribute the questionnaire link to all second-year students enrolled in the professional programs they led. As a reminder to participate, we sent 3 follow-up emails to program directors every 10 days. We used Google Forms (Google LLC, Mountain View, CA), a Web-based questionnaire collection service, for questionnaire administration. Each participant agreed to the terms of an electronic informed consent form before entering the survey by clicking “I agree.” Saturation of the qualitative data drove recruitment for this study and was satisfied (ie, theoretical redundancy had been met).

Analysis Strategies

We used an interpretative phenomenological approach to analyze the qualitative data because we wanted to examine the “lived experiences” of the research participants.¹⁷ The purpose of using an interpretative approach was to allow research findings to manifest via themes that emerged from the raw data. We started the analysis process, as described by Giorgi,¹⁸ by reading the transcripts multiple times to gain a sense of the phenomenon, followed by dividing the data into meaning units pertaining to the phenomenon. Then we related the meaning units to athletic training education. Finally, we organized the findings to create an exhaustive description of the lived experiences of the participants. We define participants in the Results section by number, sex (M = male; F = female), and racial identity (eg, #34, F, Black/African American).

We used multiple-analyst triangulation and peer review to provide credibility.¹⁷ To fulfill multiple-analyst triangulation, 2 research team members (Z.I.G., T.G.B.) coded the data independently and discussed the coding structure until we reached 100% agreement.¹⁷ The negotiation process involved combining and renaming codes as needed to reach a consensus on specific theme and subtheme names. Finally, a third researcher (R.L.C.), an expert in qualitative methods, examined the coding structure and verified the study results' final presentation during peer review. The peer (R.L.C.) also reviewed the questionnaire before participant recruitment.

ATSs Experienced Forms of Microaggression

Our results showed that participants who experienced racial microaggressions were judged based on race, ethnicity, nationality, and/or appearance. One participant (#34, F, Black/African American) explained how an interaction with a coach made her feel uncomfortable based on her race/ethnicity. She explained that she felt stereotyped, stating:

I've had multiple different experiences dealing with racial microaggression but only one that made me very uncomfortable .... The site was a private secondary school setting. One of the coaches there, a white male, constantly made mean remarks about black hair. He would make fun of the black females with Afros or wearing their natural hair. He often tried to use Ebonics with me because he thought that's [how] he should talk to me. [He was] often making jokes and mocking black athletes when we used it [Ebonics]. He would make assumptions that I was too poor to buy anything and that I lived in the hood because that's where Black people normally stay. And when I talked in a “proper” way, he called me white.

In this case, the participant was microinsulted, microassaulted, and stereotyped based on the association that African Americans live in inner-city areas and are low on the socioeconomic ladder. The participant identified talking “proper” as a comment an aggressor made against her, alluding to code-switching. Code-switching is the process of shifting between formal and informal conversation depending on the social or conversational setting.¹⁹ Code-switching is a “common” dialect shared between BIPOC.¹⁹ Another participant (#32, F, Black/African American) identified code-switching as a culture shared between African Americans. She explained a microinsult associated with code-switching:

I often code-switch when talking to my white preceptors and coaches, they felt I was being unprofessional for speaking in AAVE [African American Vernacular English] with my black athletes. They could not/would not understand that we share a common culture and are therefore more comfortable with each other.

Overall, participants thought microaggressions in the form of microinvalidations were based on appearance in the clinical setting. One participant (#93, M, Black/African American) explained how his appearance was stereotyped during a clinical experience: “I was with the football team, and one of the coaches expected me to do something with an athlete because he thought I played football because of the color of my skin.”

Microaggressions happened not only in the clinical setting but also within the athletic training program in the form of behavior from other students. One participant (#10, F, multiracial) expressed that classmates had passed judgment on her. She explained, stating her microinvalidation:

I feel I have classmates that identify me as one race or the other (I'm half black and half white, so I have olive-colored skin and curly hair), and I'm judged as being privileged even though I've had to face just as many discriminatory behaviors as any person of color.

Another participant (#34, F, Black/African American) voiced the same judgment and felt classmates were insulting different cultures. She explained by describing her microassault:

There have been incidents where I have experienced microaggression from classmates who aren't very experienced with being around black people. I have heard fellow white students [classmates] try to use Ebonics, thinking that it's cool as well as stereotyping black people, mocking our [African American] culture.

Interestingly, one international participant (#23, F, Asian) expressed her encounters with racial microaggression experiences based on ethnicity and nationality because of the Coronavirus pandemic of 2019 (COVID-19). She explained:

I came across a COVID-19 symptom clearance document developed by a PT [Physical Therapy] clinic. The date that I saw [on it] was September 10 [2020], and the date that the form was created was March 10 [2019] … The document's first question was “Have you ever visited the following countries below: China, South Korea, Iran, Italy, and Japan.” It made me uncomfortable that this question is still used as a first question in September when virtually all countries have been affected by the virus. It would've made sense back in March, although the daily positive cases in Japan back in [March 10th] were below 50 [cases], and the cases started to ramp up to 100 [cases] in early April. I have heard of increased racism against [the] Asian community since the pandemic, which personally affected me so much that I was afraid of going outside alone.... But as an international student from South Korea, that one question was disturbing at the moment.

Overall, participants faced racial microaggressions during clinical education. The racial microaggressions ranged from microassaults to stereotyping based on race, ethnicity, nationality, and/or appearance. Participants agreed that they had been victims of racial microaggressions from different people with whom they interacted while enrolled in athletic training programs, ranging from peers or preceptors to coaches.

Lack of Action

Participants often failed to act when microaggressed out of a perceived lack of formal mechanisms for reporting racial microaggressions, which caused students anxiety and required self-coping measures. Numerous participants stated that they “did not have any resources” or “did not know of any resources” with which to report racial microaggressive incidents. The lack of resources created a sense of normalization within one participant (#42, F, Black/African American) while she was experiencing racial microaggressions, which led her to do nothing in response. She explained how racial microaggressions affected her:

I notice the action [racial microaggression] and I don't take them on because racism still exists and I know that I can't do anything about it. It bothers me at the moment, but I'm easy to brush it off and keep it professional because this is something I expect as a black female .... [I didn't report the situation because I] didn't think anything would be done. Racism does not go away overnight.

In this experience, the participant normalized the judgment that was passed on to her. The creation of “I know that I can't do anything about it” is the effect of the perceived lack of resources in times of racial microaggression. Another participant (#10, F, Black/African American) echoed the same normalization: “It occurs pretty frequently; I usually ignore it and keep a mental note in the back of my head.” Normalizing racial microaggressions can cause reinforcement of racism.²⁰ One participant (#30, F, Hispanic/Latina) described how she would prefer to do something but typically does not. She said,

Sometimes it comes unexpected, and I am a very shy person, so I do not always know how to respond. The moment does upset me, and I always wish I could do something about it. I do wish I knew more about resources and how to respond to people [who commit microaggressions].

Interestingly, a Caucasian student (#37, F, White) illustrated a desire to learn how to become an ally. She stated, “I would love more resources to be available so I understand what is a universal abnormal behavior and exercises to cope with them. Also, how to professionally deal with them.”

When asked how participants responded to the act of racial microaggressions, numerous participants expressed the anxiety of being isolated or even being dismissed from their respective athletic training programs if they reported the racial microaggressions. One participant (#32, F, Black/African American) explained,

I was nervous that I would be isolated from the program or removed from the clinical experience. Instead [of reporting the incident], I talked to a Black AT outside of the university and asked for guidance.

Another participant (#91, F, Black/African American) stated, “I don't [respond] because I have to remain professional and don't want to ruin my professional reputation. I doubt my preceptor would've cared.”

One participant (#112, M, Black/African American) stated that “Responding to it [racial microaggressions] makes things worse.” Several additional participants echoed the sentiment of one (#93, M, Black/African American) who said, “It's not going to make the situation better by reacting.”

The stress and anxiety associated with reporting microaggressions led some participants to seek guidance outside of the program, as explained above (#32, F, Black/African American). Some participants who were victims of racial microaggressions found comfort in telling friends, family, significant others, classmates, or others of the same race or ethnicity. One participant (#35, F, Asian) stated that, “I would tell some of my classmates and those who are of color especially. It's more comfortable speaking with someone who would have been in the same position as me.” Although she did not formally report the incident, she talked to others about the situation. In addition, she attempted to educate the perpetrator. She explained,

Sometimes teaching people who genuinely do not know that they are doing this would help them be more open minded. I am the type to give that person some knowledge and if they accept it, fine. But if they were to reject it, that is totally on them for how they react.

Another participant (#23, F, Asian) stated the following:

I reached out to my fellow friends who have experienced similar microaggressions. I don't think there are any other resources that I could've used because people will never understand until they are in the minority's situation .... I did not respond to the majority of microaggressions I've experienced because I thought they did not mean to offend me and I'm tired of explaining what bothers me.

Both ATSs found comfort in external sources and identified that people from different backgrounds might not understand how they feel in a situation. One participant (#103, M, Black/African American) found comfort in expressing his feelings to “other AA [African American] Athletic Trainers, other AA [African American] professionals and friends.” He went on to say, “I just know that there needs to be more education, and there needs to be more people of color in the AT profession.”

Overall, most participants failed to formally report racial microaggressions within their athletic training programs. The reasons for the lack of action included a lack of knowledge of reporting procedures for incidents of microaggressions or a lack of identified personnel willing to help students cope with racial microaggressions. One participant (#92, F, Black/African American) noted, “I wish there was an AT-specific resource besides the EDAC that discussed diversity and inclusion and racial microaggressions in the workplace.” Participants agreed that they “wished” that there were “resources” available to help them cope. The coping mechanisms participants found on their own included finding African American ATs or finding someone who could “relate.” Several participants voiced that they did not formally report any racial microaggressions because of the possible “consequences” they might face, such as being removed from their respective athletic training programs.

Career Reconsideration

As participants felt “hesitation” regarding continuing with the athletic training profession after racial microaggressions, they also experienced additional anxiety related to career commitment. One participant (#44, F, Black/African American) explained how the effects of racial microaggressions caused career reconsideration: “… it [racial microaggression] ruined my entire experience. It made me question if this profession [athletic training] was for me and led me to take a year off.”

Interestingly, another participant (#64, M, White) mirrored the effects of a racial microaggression on his career: “It [racial microaggression] pushed me away from the secondary school setting.” Additionally, one participant (#34, F, Black/African American) expressed that being uncomfortable created hardships going to school: “Being around these types of people makes me very uncomfortable, and it became hard to want [to] go to school and be around them.”

Participants expressed their discomfort and uneasiness regarding athletic training clinical environments because of the microaggressions they had experienced. The emotions were made clear by one participant (#112, M, Black/African American), who stated “It [racial microaggression] made me feel uncomfortable and [I did] not want to be in the environment.” The participant described his reluctance to enter clinical practice because of experiences with racial microaggressions. Overall, participants shared how they were negatively affected and questioned their ability to continue pursuing the athletic training profession because of several emotions that occurred after exposure to racial microaggressions.

ATSs Experienced Forms of Microaggression

Experiencing racial microaggressions during clinical education indicated that ATSs are witnesses to hostile environments. Our findings mirror those from nursing and medical students^21,22 and faculty.²³ Comparable to our findings, microaggressions have been found to hinder learning, decrease academic performance, and degrade overall well-being of nursing and medical students from historically marginalized groups.²² Health care students who have been victims of microaggressions have described increased feelings of stress, anger, and frustration, analogous to those reflected by the participants of our study.²²

Many ATSs suffered from microinvalidations, microinsults, microassaults, and stereotyping based on race, ethnicity, nationality, and appearance. Microinvalidations tended to make ATSs feel as though they had done something incorrectly or even caused insecurity.⁸ Microinvalidations amounted to denial of the occurrences and cultures of the ATSs.⁸ Microinsults can be nonverbal or verbal (through body language or physical words) that the ATSs faced during clinical education. Although our participants did not note nonverbal examples of microaggressions, they did perceive verbal microinsults through statements by others, such as those referring to “talking proper.” Nonverbal microaggressions can be identified by perpetrators looking away or turning away.⁸ Microassaults are the most serious and most violent microaggression; some may define them as traditional racism.⁸ Microassaults usually look like jokes by the aggressor, which allows the harm of the behavior to be concealed behind humor.⁸ The learning environment created psychological and physiological stress responses in the ATSs, including feelings of “nervousness,” “awkwardness,” “anxiety,” and “fear,” which align with the results of previous research.²⁰ Participants displayed signs of perseverance through racial microaggressions when they were experienced.

Victims of microaggressions are often placed into “pitfall” situations.⁸ First, victims have to recall if the microaggression has happened; secondly, they take action and finally counter the incident.⁸ When deciding if a microaggression has occurred, victims “connect the dots'' to every meeting with the perpetrator.⁸ Many ATSs chose not to respond to the racial microaggressions that they faced during clinical education. Based on our results, reacting to microaggressions looked very different from student to student. One concern for victims of microaggressions was that African Americans who reacted to the incident may be labeled as “unprofessional.” Many ATSs stressed that they must keep a level of professionalism and do what is needed to succeed. When victims of microaggressions respond, it is likely to end in negative consequences.⁸ Many ATSs wanted to stand up to the aggressor; however, many were faced with “anxiety” and “fear.” Unfortunately, ATSs believed that they would be removed from clinical rotations and/or their actual athletic training programs if microaggressions were reported.

Lack of Action

Many ATSs did not know what resources were available to them, which caused them not to act in response to microaggressions. Many ATSs found resources outside of their athletic training programs, and they found support within other students who had undergone similar experiences. Patricipants suggested that responding to racial microaggressions made situations “worse,” and ATSs also believed that conditions would “not change.” When faculty/staff or preceptors interact with ATSs, they should communicate with microinterventions. Microinterventions are the everyday words or actions, whether deliberate or accidental, that authenticate victim reality and the victims' worth as people, approve their racial or group identity, provide support and encouragement, and reassure them that they are not alone.²⁴

Faculty and staff professional development, student orientation sessions, and preceptor training should include information regarding what microaggressions are, how to serve as an ally for students of historically marginalized groups, and how to provide victims with microinterventions. Faculty and staff whose institutions have offices dedicated to justice, equity, diversity, and inclusion should connect with the professionals and ensure students know about the resources available to them. Faculty, staff, and preceptors should work to provide an inviting environment in which all students feel welcome. In addition, students should be provided with clearly defined reporting mechanisms and environments in which safety and comfort are perceived, thereby allowing them to disclose incidents of racial microaggressions. Athletic training program administrators must choose future and current clinical preceptors and sites attentively⁷ to ensure appropriate professional role models are mentoring students while they develop into autonomous clinicians. Placements of ATSs should be analytical and intentional decisions by program administrators.⁷ Athletic training program administrators should consider justice, equity, diversity, and inclusion training for all preceptors as a part of preceptor training or other requirements. Training should be developed through the justice, equity, diversity, and inclusion office in partnership with athletic training program administration. Students must be provided with policies and procedures on how to handle microaggressions, including reporting mechanisms and a list of resources the institution offers to students. Education is an extensive process and will allow for an opportunity for profound conversation and microinterventions to plant seeds for future achievable change.²⁴

Career Reconsideration

ATSs reconsidered the profession of athletic training after exposure to racial microaggressions. Some ATSs reported being “pushed away” from different clinical settings where ATs find employment based on their experiences. Career reconsideration is likely multifaceted, and a lack of BIPOC mentors may also contribute to the feelings of our participants. Unfortunately, membership statistics show the lack of BIPOC ATs in the athletic training profession. Based on the Ethnicity Demographic Data of 2021, the athletic training profession is 82.0% White (Not of a Hispanic origin), 5.2% Hispanic, 4.2% Asian or Pacific Islander, 3.8% Black or African American (Not of a Hispanic origin), 2.1% Multi-Ethnic, 0.5% American Indian/Alaskan Native, and 2.2% other (M. Daniels, email communication, April 2021). Based on current demographics of ATs, students from historically marginalized groups may lack athletic training mentors who look like them. BIPOC mentors can build profound relationships with diverse students based on shared experiences and provide evidence that success in the profession is possible,²⁵ potentially leading to persistence of ATSs. Therefore, perhaps career reconsideration has had a negative impact on the diversity of the athletic training profession because it begins during athletic training clinical education experiences. Faculty, staff, and preceptors should validate²⁶ ATSs sense of belonging in the profession and encourage them to persist. Confirming victims' feelings and taking action against perpetrators can potentially assist in facilitating persistence into the profession.

Recommendations

Historically marginalized students encounter stress related to unfriendliness, cultural conflict, coping, lack of resources, mistrust, racism, and a lack of social support.²⁷ Previous research^7,13,24 highlights the need for reinforcement of stable, trusting relationships between faculty/staff and students, through which students attain comfort and support.²⁷ The relationships may be viewed as safe spaces for coping with racial microaggressions. Creating safe spaces for student deliberation about difficult professional experiences is important for developing professional identity.²⁸ However, safe spaces are not necessarily free of discomfort, which is critical to learning how to tackle racial microaggressions.²⁸ Creating brave spaces, unlike safe spaces, produces discussions through which students are empowered to speak honestly and openly about their experiences²⁹ without fear of judgment or retribution. Creating safe spaces or brave spaces is important to helping historically marginalized students manage their experiences of racial microaggressions.²⁷Counterspaces are defined as spaces where BIPOC students can be supported and in which a positive institutional racial climate can be created and facilitated.²⁷ Such counterspaces can provide an alternative to pitfall situations. The safety in counterspaces can provide sanctuaries for students to (a) clarify their experiences on campuses and identify if a racial microaggression has happened, (b) find resources and justification for their reality, and (c) establish substitute ways for responding to microaggressions.²⁷ In creating these different spaces in athletic training programs, ATSs, faculty, staff, and preceptors can lean on microaffirmations. Microaffirmations refer to small, involuntary acts that can make students feel accepted, appreciated, and supported.³⁰ By modeling microaffirmations, faculty, staff, and preceptors can promote a supportive environment that encourages learning.³⁰

Limitations and Future Directions

There were limitations to our study that should be considered when interpreting our findings. We relied heavily on the program directors to share the questionnaire with all second-year ATSs. It is possible that some program directors did not forward our questionnaire to students or even open the email. We are unaware how many participants attended the same institution, which limits generalizability. We did not ask what institution students attended to protect their identities. We also had a limited number of respondents from several BIPOC categories. As programs recruit, enroll, and retain more diverse cohorts, future studies should gather data with larger sample sizes of BIPOC students. We only sought experiences from ATSs. Future studies should be conducted to determine experiences of racial microaggressions in clinicians and to determine how educators and preceptors handle incidences of racial microaggressions toward students during clinical education experiences. We also asked students if they had experienced racial microaggressions before providing them with the definition of the term. We concede we should have provided the definition before asking them if they had experienced racial microaggressions.