Exploring Predictors of Moral Disengagement in Collegiate Athletic Trainers

Moral Disengagement

Moral disengagement is a latent process whereby individuals convince themselves that ethical standards do not apply in a given context (Table 1).¹⁷ Whereas one's moral agency is the cognitive awareness of what is right or wrong, moral disengagement reflects subconscious justification of unethical behavior to protect individuals from self-condemnation.¹⁷ Therefore, this process involves the reframing of harmful behaviors as morally acceptable.¹⁸ Regarding the ethical nature of behaviors, moral disengagement assumes that one's context has a set standard, or “correct” behavior that one is expected to follow.¹⁷ Athletic trainers' moral behaviors are set by the NATA COE and the professional standards of the institution in which they are employed. Despite emerging interest in studying moral disengagement among athletes for behaviors such as injuring opponents or engaging in illegal doping,^19,20 researchers have not considered moral disengagement as related to the ethical behaviors of ATs.

Table 1 Components of Moral Disengagement^17,37

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Athletic trainers who engage in behaviors that fail to meet their duty of ensuring the well-being of student-athletes may subconsciously justify these unethical actions through moral disengagement. For example, if an AT fails to remove an athlete who reports concussive symptoms after a collision, the AT may use innocuous phrases to downplay the severity of the injury by stating that the athlete “just got his bell rung” as a subconscious means of convincing himself or herself that the injury is not serious—thereby justifying the unethical decision. Given that moral disengagement may negatively affect ATs' attitudes toward playing through an injury, this psychological process may have harmful downstream effects on decision making during critical injury evaluations. Identifying the psychological factors and other traits that may predict moral disengagement is a necessary step toward understanding ethical decision making among ATs. This topic is particularly timely considering the growing injury rates in the NCAA²¹ and numerous highly publicized incidents of ATs behaving unethically.^8–14 As such, the purpose of our study was to explore theoretically relevant factors that may explain variability in moral disengagement of ATs regarding student-athletes playing through injury.

Identifying Predictors of Moral Disengagement

When we consider factors that may facilitate moral disengagement, ATs' broad attitudes and orientations toward sport are particularly relevant. Although this subject has not yet been studied among ATs, we can turn to prior research^19,20,22 on moral disengagement among athletes and coaches. As highlighted by sport sociologists, one way of capturing sport attitudes that may be closely related to moral disengagement is the extent to which an individual subscribes to, or supports, a concept known as the sport ethic. The sport ethic is described as overconformity to the norms of sport (eg, athletes should play through pain to help the team) to achieve success and consists of 4 components: (a) willingness to sacrifice for the sport, (b) striving for distinction, (c) accepting risks and playing through pain, and (d) refusing to accept limitations.²³ Upholding this set of attitudes can lead to unsafe sport practices such as playing through injury or treating others poorly in pursuit of greatness.²⁴ This belief system is typically emphasized in competitive sport environments in which athletes are often viewed and treated as warriors striving for success with little regard for their safety.²³

Alongside attitudes toward the sport ethic, ATs' views of antisocial and hostile behaviors toward opponents are anticipated to emerge as key predictors of moral disengagement. Indeed, researchers^22,25 have found that, in athletes, moral disengagement is closely linked to antisocial behaviors such as hostility or aggression toward opponents. Contesting theory provides a relevant framework for capturing ATs' broad orientations toward these behaviors in sport competition.²⁶ This theory holds that individuals view sport competition along 2 dimensions: “warfare” and “partnership.”²⁶ A warfare orientation entails a belief that sport is war-like, such that athletes are warriors who should do anything it takes to win. Alternatively, a partnership orientation reflects beliefs that sport competition is a partnership among competitors that can bring out the best in both parties.²⁷ Investigators²⁶ have shown that athletes who are high in warfare orientation typically involve themselves in more risk-taking behaviors and morally disengage more often than those who are high in partnership orientation. Importantly, individuals can hold both types of beliefs toward opponents, though high warfare orientations typically override partnership attitudes.^26,27 Contesting theory has not yet been applied to ATs but is nevertheless an ideal framework for examining whether ATs' sport orientations relate to moral disengagement. In line with the literature on contesting theory in athletes, ATs who view sport with a warfare orientation would be expected to display more moral disengagement regarding student-athletes playing through an injury.

In addition to ATs' general attitudes and orientations toward sport, it is also important to consider ATs' relationships with and connections to the teams with whom they work. One salient indicator of ATs' connection to the team is their level of commitment. Whereas a strong commitment to the team may be expected to result in highly ethical attitudes toward athlete care,²⁸ contrasting evidence suggests that a strong commitment can have deleterious effects if an AT is committed to a goal other than providing medical care. Athletic trainers often view themselves as staff members (eg, coaches or assistants or even as fans, which can shift their focus away from the duty to provide ethical care and toward team-oriented goals (eg, winning).²⁹ A strong commitment to the team may also increase pressure to help the team win in ways that may facilitate moral disengagement regarding injury.

Notably, roughly 65% of collegiate ATs reported feeling pressured by both coaches and other medical care providers to rush student-athletes back to play.⁴ Nevertheless, these expectations should be considered alongside evidence that medical care providers (eg, nurses, doctors) who are more committed to their patients indeed provide higher-quality care.³⁰ However, many ATs are in charge of at least 3 athletic teams, creating an environment in which ATs are stretched thin and often unable to commit themselves to a single team, perhaps resulting in minor injuries being overlooked due to extreme workloads.³¹ In addition, ATs have indicated that this difficult work environment, as well as a lack of respect or pressures from the team to keep athletes in competition, makes committing professionally difficult.³² Thus, considering the commitment to one's duties is imperative,²⁸ but how ATs view themselves in relation to their team(s) may emerge as a key predictor of moral disengagement in the context of athletes playing through injuries.

A second key indicator of ATs' connections to the teams they care for is the extent to which they consider their role on the team an important aspect of their own self-concept. Social identity is defined as one's sense of belonging to a group, which is reflected in the development of close interpersonal ties with group members and positive attitudes toward being a member of the group.³³ Theoretically grounded in the social identity approach, the strength with which an individual identifies with a group plays a key role in his or her attitudes and behaviors toward the members of the group.³⁴ Given the link between social identification and attitudes and behaviors, interest in social identity is growing among sport researchers.³⁵ For example, youth athletes who identified strongly with their team typically engaged in more positive moral behaviors toward ingroup team members (those with whom they identified), whereas outgroup members (those with whom they did not identify) were more likely to morally disengage.³⁶ Although the topic is yet to be explored among ATs, tenets of social identity theory suggest that the strength with which an AT identifies with the team may have important implications for his or her attitudes and behaviors toward those team members. Developing close ties with team members may humanize athletes in the eyes of ATs, such that they view an athlete as a whole person rather than just an athlete. These attitudes may then influence ATs' attitudes toward athletes playing through injuries.

Participants

The participants were 187 ATs currently employed by NCAA athletics departments (Division I = 160 [85.7%], Division II = 23 [12.1%], Division III = 4 [2.2%]). They were recruited from 100 universities and ranged in age from 22 to 65 years (age = 31.79 ± 9.23 years; n = 101 [54%] female; white = 157 [84.1%], Hispanic = 11 [5.8%], Asian = 9 [4.8%], African American = 7 [3.7%], and other = 3 [1.6%]). On average, participants had been ATs for 8.7 ± 8.55 years. The sample consisted of ATs recruited from 17 NCAA men's and women's sports, and many of the ATs provided care for multiple teams (n = 138 [73.8%]).

Procedures

After obtaining approval from the institutional review board, we e-mailed ATs to invite them to participate in the study. Of the approximately 2000 individual ATs from randomly selected universities (equal numbers from Division I, II, and III institutions) invited to participate, 9.4% responded. The initial message consisted of a description of the study and a link to the consent form and online questionnaire. Participants were informed that the goal of the research was to determine how NCAA medical staff personnel could affect the physical health of student-athletes. The questionnaire took an average of 10 minutes to complete and contained demographic items (eg, athletic and AT history), as well as a battery of scaled measures, some of which were adapted for the current sample of ATs. Participants were compensated with a $10 digital gift certificate on survey submission.

Measures

Moral Disengagement

A modified version of the Moral Disengagement in Doping Scale (MDDS) was used to assess moral disengagement pertaining to the ATs' attitudes about athletes playing through injuries.³⁷ The MDDS is a 6-item scale that was originally designed to assess how athletes perceive the use of performance-enhancing drugs in sport, but we modified questions to represent how ATs accept the notion of student-athletes participating through injury. Each component of the scale reflects 1 component of moral disengagement: moral justification, euphemistic labeling, advantageous comparison, displacement of responsibility, distortion of consequences, and diffusion of responsibility (see Table 1 for examples).¹⁷ The items were (a) playing through injury is all right because it helps your team; (b) an athlete playing through injury is “maximizing hir or her potential” by not missing playing time; (c) compared with illegal activities people do in everyday life, allowing an athlete to play through an injury is not very serious; (d) ATs cannot be blamed for allowing an athlete to play through injury if the team pressures them to do so; (e) an AT should not be blamed for allowing an athlete to play through injury if other teams allow athletes to do it; and (f) playing through injury does not really hurt anyone. Participants rated their agreement with each statement on a 7-point Likert scale ranging from strongly disagree to strongly agree, and a composite score was calculated based on these responses (see Table 2).³⁷ The internal consistency for the sample was adequate (α = .87).

Table 2 Bivariate Correlations Among All Variables

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Data Analysis

Initial data analyses included reviewing the data and identifying outliers or cases in which survey responses were incomplete. Additional preliminary analyses included calculating descriptive statistics and computing bivariate correlations to examine zero-order associations between variables (Tables 2 and 3). Gender differences were examined using t tests. Finally, to accomplish the primary study aims of identifying the profiles of ATs who may be more likely to morally disengage when considering whether athletes should play though an injury, we performed a k-means cluster analysis.

Table 3 Cluster Groupings and Findings After Independent-Samples t Test

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Cluster analysis is a person-centered method that is used to identify subgroups of people based on similarities across a set of variables. Unlike a variable-centered approach, which examines relations among variables, a person-centered approach enables researchers to examine participants holistically to identify patterns across several theoretically relevant constructs.⁴¹ Given the complexity of factors that may influence moral disengagement in ATs, we conducted a cluster analysis to identify meaningful configurations of these factors. Specifically, clusters were identified based on measures of social identity, the sport ethic, contesting orientations, and commitment. Before conducting the cluster analyses, we standardized all questionnaires, so that each variable received equal weight in the cluster analyses.⁴² A set of k-means cluster analyses were performed, which maximized similarities within groups and differences between groups. We considered a range of cluster solutions and identified the optimal cluster solution on the basis of statistical fit (ie, silhouette coefficient), parsimony, and theoretical interpretability. A higher silhouette coefficient represents the similarity of individuals within clusters.⁴¹ After the clusters were identified, the next step was to determine whether group differences existed in moral disengagement between the resultant clusters. This was done using an independent-samples t test, and α was set at the .05 level.

Predicting Moral Disengagement

The purpose of our study was to explore individual characteristics and beliefs among NCAA ATs that may predict moral disengagement related to allowing athletes to play through injuries. A cluster analysis revealed 2 groups of ATs based on divergent beliefs in the areas of sport ethic, team commitment, contesting orientations, and social identity. The findings suggested that ATs who reported greater sport ethic and contesting orientations with lower commitment and social connection to student-athletes were more prone to moral disengagement (Figure). Cluster analysis is designed to maximize dissimilarities between profiles, which explains the relatively strong effect sizes (Table 3). However, further inspection of these effect sizes revealed that the most salient factor driving the difference between the AT profiles was attitudes toward the sport ethic, followed closely by warfare contesting orientation.

It is important to consider that, although moral disengagement regarding athletic injuries may have adverse effects on ATs' abilities to ethically evaluate an injury, the present findings are preliminary and only describe associations between variables that may predict moral disengagement. Nevertheless, these findings contribute to the literature as they begin to fill a critical knowledge gap regarding the psychological processes that may explain ATs' ethical (or unethical) attitudes toward athletes' injuries. Indeed, to our knowledge, we are the first to explore moral disengagement among ATs. Variability in moral disengagement may be explained by ATs' attitudes and orientations toward sport, as well by their connections to the teams they treat. Additional research is needed to better understand how moral disengagement may relate to an AT's ability to make ethical decisions regarding whether to allow an injured athlete to play.

Despite the lack of research on moral disengagement among ATs in sport, our findings are in line with those of researchers^18,19 who examined health-risk behaviors in athletes, such as doping and overly aggressive play. Using a person-centered approach via cluster analysis and subsequent t tests provides insight into the relationship between an individual's sport-ethic beliefs and moral disengagement. An investigation²⁶ of student-athletes and coaches showed that individuals were more likely to act unethically and justify these actions if they believed that the sport culture demanded such behavior. For example, if an injury is considered a weakness in a highly competitive environment, an athlete may not report it or may continue to play through pain. Similarly, clinicians were influenced by cultural and sport beliefs, often weighing their own subjective sport experiences and those of the culture surrounding them more heavily than ethical standards.^43,44 The manifestation of the sport ethic may subsequently cause morally unacceptable actions such as using euphemisms for injuries or providing harmful medical suggestions. For example, Saposnik et al⁴⁵ noted that ATs' behaviors were influenced by beliefs about what was expected of the athletes in a given context, such as believing that all players wanted to keep playing through injury because they were in a contact sport with an inherent “culture of risk.”

Additionally, the literature on moral disengagement has described the relationship between an individual's contesting orientation relative to sport and morally disengaging behaviors. Warfare orientations have been associated with decreased self-control, increased violence, and risk-taking behaviors.²⁴ Shields et al²⁶ determined that moral behaviors were strongly predicted by warfare orientations, regardless of the level of partnership orientation. Similarly, this pattern was observed in our sample of ATs: the high moral disengagement cluster had high warfare orientation, which entails viewing the sport environment as a battlefield.²⁶ Although ATs may not be currently active in competitive sport, entrenched views of sport as war may negatively affect their ethical views of allowing an athlete to play through injury. Cognitive biases and previous beliefs relating to a particular context influenced the care provided to athletes.^44,46 Therefore, ATs who embrace a war-like team culture may be at risk of moral disengagement when considering the return of an athlete to play after an injury.

Athletic trainers in cluster 1 (comparatively lower in commitment to the team and lower in social identification with the team) scored higher on moral disengagement. One possible explanation is that ATs who struggle to adequately understand or relate to student-athletes may more readily engage in moral disengagement when making a return-to-play decision.²⁸ Similarly, those who do not view themselves as a part of the team (eg, feel disconnected from athletes, view themselves as a coach or staff member) may not prioritize their athletes' health and wellbeing to the same extent as ATs who more closely identify with the athletes. Athletic trainers who feel more like a coaching figure with desires for victory may experience impaired judgment during medical treatment.²⁹ Other authors have explored the relationship between empathy based on social identity and moral disengagement. For example, Aquino et al⁴⁷ found that individuals who lacked social identity with a group might find it difficult to treat individuals humanely and have empathy for their pain; thus, they might be more likely to display moral disengagement. Moreover, low commitment levels predicting moral disengagement is in line with previous results in patient care settings, indicating that commitment levels were heavily influenced by one's social identity or feeling of belongingness to a group.³² Thus, the current findings provide an early indication that ATs who demonstrated lower levels of commitment may be more likely to justify unethical behaviors in the sport context.

Moral disengagement during medical treatment is influenced by a spectrum of factors that shape ethical behaviors. Previous investigators⁴⁸ cited gender differences in both athletes' and ATs' willingness to push ethical bounds and promote risky behavior (eg, play through injury or return to play prematurely). Moreover, Baugh et al⁴⁹ noted that female ATs were less willing to take risks in the sport context and that male ATs often framed injury as less of a concern than female ATs, thus encouraging continued participation despite injury.⁴⁹ Although a t test indicated that moral disengagement was higher among the men in our study, no gender differences were present between the clusters. Therefore, personal characteristics and views of sport may have influenced moral disengagement more than gender.

Understanding the psychological characteristics and mechanisms that predispose ATs to moral disengagement is an important step in ensuring ethical treatment of collegiate student-athletes. Regarding professional ethics, Peer and Schlabach⁶ observed that the most important values of ATs who were more likely to follow the NATA COE were truth and honesty, integrity, and accountability. The researchers⁷ stated that it was important for ATs to display these generalized characteristics but also imperative to understand the personal traits that foster adherence to the set code of ethics. Therefore, it may be wise to consider the breadth of scaled measures and personality characteristics to understand which traits predispose ATs to adhere to professional standards. Further study in this line of inquiry is needed to understand how moral disengagement relates to ATs' ability to follow the NATA COE.

Limitations and Future Directions

Alongside the strengths of our study, several limitations and future directions must also be considered. The 2 distinct profiles of ATs were based on several variables that are theoretically linked to moral disengagement, but they did not account for any possible effects of an AT's environment on his or her moral attitudes toward playing through sport injuries. For example, sport activity and the organization's competitive level (ie, NCAA Division I, II, or III) did not display enough variation to enable us to observe differences. Based on increased monetary spending for Division I sports such as football and basketball, an AT may perceive heightened pressures to keep star athletes playing.³ Moreover, nearly three-fourths of our ATs provided care to multiple sports, making it difficult to examine differences between sport types. In addition, given the inherent limitation of a cross-sectional design, we were unable to draw causal inferences and were not able to investigate the possibility that moral disengagement evolves or changes throughout a season based on team success or coach pressures. Also, men and women did not participate in equal numbers, resulting in slightly skewed clusters. Previous authors^45,49 indicated that females tended to report lower levels of moral disengagement. However, this was not the case in our clusters, which could have been due to the low response rate and relatively small sample. Given the exploratory nature of our study, the findings were based on adapted scales that were used in previous moral disengagement research in sport settings. Although we could argue that the adapted scales had strong face validity, future work in this domain would benefit from the development of psychometrically valid scales to measure moral disengagement in ATs specifically and even to potentially assess ethical evaluations of injuries.

Considering the limitations of the current examination, future investigators should attempt to longitudinally measure how moral disengagement may fluctuate based on social factors such as the winning percentage, NCAA division level, employment setting (eg, does the program work within a medical model?), sport type, and motivational climate of the team. For example, collecting responses at multiple time points throughout a season would provide insight into how continual exposure to the sport context may shift moral behaviors based on the team's unique environment. Another avenue for exploration could be the educational institutions that ATs attended: assessing the programs that ATs were trained in, the terminology they learned (eg, athlete versus patient), sport fandom in their formative years, and overall professional preparation. Practitioners, educators, and researchers should attempt to further promote ethical training in the athletic training curriculum with increased awareness that moral disengagement may influence ethical decision making. To ensure proper ethical attitudes, educational programs should emphasize commitment and identifying with student-athletes on a personal level while dismissing their past sport experiences (eg, biases they may have developed as former athletes or as allegiances to a group [ie, favorite team fandom]). Future directions could include taking a qualitative approach and probing the most salient social factors that influence ethical standards by contacting ATs at various levels (eg, Division I, II, and III) and with different success rates (eg, winning versus losing programs). Lastly, researchers should test the extent to which these findings generalize to other levels of sport, including the high school and professional levels.