Validation of the Professional Identity and Values Scale Among an Athletic Trainer Population

Professional Identity

Professional identity has been defined as an individual's professional self-concept based on beliefs, values, motives, attributes, and experiences and has been explored significantly in the literature.^1–7 Nugent and Jones⁸ defined professional identity as a combination of personal and training characteristics applied within the professional setting. Professional identity develops over time through interactions with other professionals and by gaining insight into professional practices and the development of individual skills and values of the profession.¹ Individuals with higher professional identities are able to articulate their roles as professionals, their professional philosophies, and their approaches to others, both inside and outside their fields.^9–11 Career success has been shown to positively correlate with successful professional identity construction.^4,7 The construct of professional identity relates to many aspects of a profession, including practices, philosophies and beliefs, ethics, and the requirements for success within the profession. Colley et al¹⁰ found that if personal values contrast with expectations of successful involvement in a profession, conflicts may arise as the individual attempts to define his or her place in the chosen profession.

Defining the Counselor and Athletic Training Professions

Both ATs and counselors are considered health care professionals. Health care professionals maintain health in humans through the application of evidence-based practice with the definitive goal of meeting the health needs of individuals and populations.^12,13 Professionally, the wellbeing of patients is the primary concern of any health care provider, and all health care professionals must comply with federal and state laws. Athletic training, similar to mental health counseling, is a relatively new field that has undertaken many initiatives to advance its status as a health care profession.

The National Athletic Trainers' Association (NATA) has defined an AT as a “health care professional who collaborates with physicians. The services provided . . . comprise prevention, emergency care, clinical diagnosis, therapeutic intervention, and rehabilitation of injuries and medical conditions. Athletic trainers work under the direction of physicians, as prescribed by state licensure statutes.”¹⁴ This definition matches well with the clinical tasks that are routinely performed by ATs, which are classified into 5 domains: (1) injury/illness prevention and wellness protection, (2) clinical evaluation and diagnosis, (3) immediate and emergency care, (4) treatment and rehabilitation, and (5) organizational and professional health and wellbeing. The 2009 Role Delineation Study¹⁵ noted the ability of ATs to empower patients in the improvement of their mental and social wellbeing, and task 0506 specifically addressed the need for ATs to support and refer individuals in order to address unhealthy lifestyle behaviors. Psychosocial strategies and referrals comprise a significant component of the educational competencies of ATs.

Similar to ATs, counselors work with individuals and groups to promote optimal health, though in mental health counseling, the primary focus is on mental and emotional wellbeing. These professionals are responsible for developing and implementing treatment plans; collecting information about their patients via interviews, observations, or tests; and maintaining the confidentiality of records relating to their clients' treatment. Beliefs related to the mental health counseling profession embrace clinical practice from a wellness perspective, advocacy for the profession as well as for patients, community and professional service, and engaging others from a holistic point of view.¹⁶

Professional Values of Counselors and Athletic Trainers

The NATA has also established 4 principles of ethical behavior as part of their Code of Ethics¹⁷ that ATs should follow in practice. Similarly, the American Counseling Association established 5 core professional values of the counseling profession: (1) enhancing human development throughout the life span; (2) honoring diversity and embracing a multicultural approach in support of the worth, dignity, potential, and uniqueness of people within their social and cultural contexts; (3) promoting social justice; (4) safeguarding the integrity of the counselor-client relationship; and (5) practicing in a competent and ethical manner.¹⁸

Development of Counselors and Athletic Trainers

An extensive amount of research has examined the professional development of counselors.^9,19–24 Gibson et al¹⁹ determined that new counselor trainees relied on external references, such as professors and textbooks, for understanding their professional identity compared with advanced counselor trainees, who incorporated more of their own personal attributes into their professional identity. New professionals are able to move from an external to an internal locus of evaluation, from a dependence on experts to a reliance on their own training and experiences.^9,19,24 Moss et al²² reported that integration of the personal and professional selves occurs in the later stages of a counselor's career. Developing a professional identity throughout a career does not come without its challenges. Skovholt and Rønnestad²⁴ reported that counselor trainees experienced anxiety stemming from the ambiguous standards in their training program, and Moss et al²² found that new counseling professionals struggled with unrealistic expectations of what it meant to be a professional counselor.

Although counselors are currently required to obtain a master's degree, both professions need to complete work experience, pass a certification examination, and apply for state licensure. Students in both fields are exposed to professional mentors in their clinical work experiences that help shape their professional development. Licensed professionals in both fields must abide by state regulations. Therefore, it is appropriate to use these 3 developmental stages in an exploratory factor analysis within athletic training.

The Uniqueness of Athletic Training

Unlike mental health counselors and many other health care professionals, ATs provide health care within a sport organization. A sport organization creates a unique work environment and can be identified by 5 key elements: (1) social entity, (2) involvement in the sport industry, (3) goal-directed focus, (4) consciously structured activity systems, and (5) identifiable boundary.²⁵ Working within a sport organization means that athletes are the primary patient population of ATs. Brewer et al²⁶ identified a concept known as athletic identity in which an individual identifies with the role of the athlete, which affects how the person views himself or herself. Similar to professional identity, athletic identity is developed through the acquisition of skills and social interaction. The benefits of an athletic identity include a salient self-identity, self-confidence, health and fitness, and performance enhancement. The potential risks include emotional difficulties when dealing with injuries and difficulty adjusting to the end of an athletic career. The concept of athletic identity creates a unique set of circumstances for the health care professional interacting with athletes on a daily basis.

Although ATs work in a variety of settings, the majority of NATA members work in college or university, professional sports, or secondary school settings, all of which constitute sports organizations.²⁷ The college or university setting represents the largest job setting of certified NATA members, employing almost a quarter of certified members.²⁷ The college or university setting also creates the “perfect storm” of unique workplace challenges for the AT, which may include atypical hours, long road trips (extended nights away from home), pressure to win, supervision of athletic training students, long competition seasons, last-minute schedule changes, and organizational structures in which supervisors may not be medical professionals.^28–30 These individual concerns may arise in other job settings and professions, yet we do not see them in combination as frequently as in the college or university setting. Athletic training as a profession is unique because it is a health care profession functioning within a sport organization. The goals of athletic training departments often focus on improving the health and wellbeing of their patients, whereas the workplace goals of coaches and sport organizations may focus more on success and profit.

Professional Identity and Values Scale

Healey¹⁶ developed an instrument known as the PIVS that assesses the attitudes, beliefs, and practices regarding counselors' roles within their profession. The PIVS is a 32-item measure of professional identity among counselors and was created based on information gathered through a qualitative research process that involved female counseling professionals serving in various roles within their field.¹⁶ Healey and Hays⁴ demonstrated face and content validity and reported a total subscale score Cronbach α of 0.80. The PIVS consists of 2 subscales: Professional Orientation and Values (18 questions) and Professional Development (14). The Professional Orientation and Values subscale gauges agreement with beliefs that are commonly held with regard to the counseling profession and were directly assembled from qualitative data collected via interviews and focus groups. Prior preliminary and exploratory factor analyses⁴ established 5 groupings within the Professional Orientation and Values subscale: (1) advocacy and community engagement; (2) holistic, contextual, and relational approach; (3) professional engagement and collaboration; (4) personal wellness; and (5) meaning and values. The Professional Development subscale represents 3 stages of professional development through which a counselor progresses during identity development. Stage 1 involves imitation and internalization of expert beliefs. Stage 2 consists of acceptance of one's inner voice as expert and role exploration. Stage 3 describes individualization of professional beliefs. Although these 3 developmental stages were established via research in the counseling field,^20,31 the education and training requirements of both professions are similar, as previously explained.

Participants

The participants in this study (n = 299) identified themselves as ATs employed in National Collegiate Athletic Association Division I, II, or III or National Association of Intercollegiate Athletics colleges or universities. Athletic trainers employed in the college or university setting were purposefully chosen as they represent the largest population of NATA members.²⁷ The inclusion criterion was employment in the college or university setting. Participants were excluded from the study if (1) they were graduate assistant or (2) intern ATs. Our participants were 33.6 ± 8.3 (range, 22–61) years old, with 10.3 ± 7.6 (range, 0.5–37) years of experience working as an AT. They worked 60 ± 12.1 (range, 10–100) hours a week during their in-season, 45.8 ± 10.6 (range, 5–85) hours a week during their off-season, and 21.3 ± 16.1 (range, 0–70) hours a week during the summer. The majority of our participants were contracted for 12 months (n = 183, 61.2%) and on average traveled with 1.8 ± 1.4 (range, 1–13) teams as part of their work responsibilities. A comparison of the demographic information of our participants and NATA membership statistics can be found in Table 1. Our sample represented diversity in demographic variables as compared with the NATA membership statistics. Most of our participants were single (n = 161, 53.8%) and did not have children (n = 204, 68.2%). All of our participants who reported having children also reported being married. Additional demographic information can be found in Table 2.

Table 1.  Comparison of Participant Demographics and National Athletic Trainers' Association (NATA) Membership Statistics, %

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Table 2.  Participants' Demographic Information

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Procedures

After receiving institutional review board approval, we contacted the NATA to provide us with a list of ATs currently employed in the college or university setting. The NATA provided us 2000 e-mail addresses. Of these, 1653 were viable (for those that were not, either e-mail addresses were inactive or individuals replied to let us know they did not meet the inclusion criterion). Initial e-mail recruitment, which consisted of an overview of the study as well as a link to the online survey (Qualtrics, Provo, UT), was sent out in mid November 2015. Subsequently, 2 e-mail reminders were sent to all participants asking them to complete the survey if they had not yet done so and thanking them for their participation if they had already completed it. The first reminder went out 2 weeks after initial recruitment (the end of November 2015), and the second reminder was sent 4 weeks after initial recruitment (middle of December 2015). Of the 1653 viable e-mails that were sent out to participants, 487 surveys were started (29.4% response rate) and 299 surveys were finished (39% dropout rate). Accounting for the large percentage of incomplete surveys, our overall response rate was 18.1%. The online survey included demographic questions, 9 Likert-scale surveys, and open-ended questions. This study was part of a larger investigation of the career intentions of collegiate ATs from a multilevel perspective. For the purposes of this study, only demographic information and responses to the PIVS⁵ were analyzed (open-ended questions and the other 8 Likert-scale surveys were not assessed).

Measures

Data Analyses

All statistical analysis was completed using SPSS (version 22; IBM Corp, Armonk, NY). Our first step was to examine the dimensionality of single survey items by inspecting interitem correlations. Ideally, the average interitem correlation should be between 0.20 and 0.40.³² Pett et al³³ suggested that correlations of items intended to measure the same construct should range between 0.30 and 0.60. These values suggest that scale items are reasonably homogeneous yet still provide sufficiently unique variance, meaning they are not isomorphic.³²

Exploratory factor analysis was conducted using principal axis factoring as our reduction approach, which is recommended if the data violate the assumption of multivariate normality.³⁴ Additionally, we chose to rotate the matrix of loadings to obtain oblique factors (direct oblimin rotation) because we expected factors to be correlated. Eigenvalues were set at 1 in order for item groupings to be retained as a factor. A significant contribution to a factor within the pattern matrix was considered to be an r > 0.30, which has been recommended in the athletic training literature.³⁵ Items were removed from the analysis if (1) they had communalities (estimated proportion of variance free of error and shared with other variables) <0.40; (2) they had factor loadings >0.30 on more than 1 factor (cross-loading); or (3) they did not fit conceptually with other items loading on a factor, as determined by expert review. Based on results from the exploratory factor analysis, we reduced the Professional Development subscale to 13 questions and removed 6 questions from the Professional Orientation and Values subscale.

Content validity for the items remaining from the PIVS was ascertained through expert review of the instrument. Conceptual definitions for the 4 stages of professional development as well as definitions derived from the NATA Code of Ethics¹⁷ and Role Delineation Study¹⁵ were provided to the reviewers. The expert reviewers were 5 certified ATs currently employed as ATs who were identified as having knowledge related to the topics of professional development and professional values specific to athletic training. The reviewers were asked to rank each item with regard to how well it fit each dimension, without knowledge of the subscale for which each individual question was specifically designed. Reviewers rated each item from not at all (0) to excellent (7). The criteria used to retain each item depended on overall reviewer agreement with regard to the strength of the item as well as the opinions of the authors.

Limitations and Future Directions

The results of this study may not be generalizable to all athletic training professionals because we included only ATs employed in the college or university setting. The job demands and patient populations of other athletic training clinical settings may affect ATs' professional identities. Additional testing of ATs employed in different clinical settings is warranted to provide solid indications of professional identity and values across the profession. Further content validity should be established by athletic training professionals. In order to advance validation of this scale, a confirmatory factor analysis is needed to solidify the items, subscale components, and potential applications within the athletic training profession. This scale also needs to be examined for test-retest reliability.