Secondary School Athletic Coaches' Perceptions and Knowledge of the Athletic Training Profession

Procedures

A 2-pronged approach was used to recruit participants. Due to the many athletic coaches employed in the secondary school setting, we developed criteria to limit the number of contacts needed for questionnaire distribution while still recruiting a diverse sample. First, the primary researcher (A.P.L.) performed a cursory search of each state's high school athletic or activities association website and identified those with a public directory of school personnel (including coaches). This process resulted in the identification of 13 states (Alabama, Arizona, Illinois, Kentucky, Minnesota, Ohio, Rhode Island, South Carolina, South Dakota, Tennessee, Utah, Wisconsin, Wyoming). To reduce the population even further, contact information was obtained for the varsity head coach(es) of the 10 sports with the greatest number of participants nationally. To identify these sports, we used the 2017–2018 High School Athletics Participation Survey.¹⁰ Based on this survey, contact information was obtained for girls' and boys' team coaches (when applicable) for the following sports: baseball, basketball, cross-country, football, soccer, softball, swimming and diving, tennis, track and field, and volleyball. This was purposeful to promote consistency across the states included. Most schools offered some or all contact information for coaches of these sports.

The second recruitment strategy involved the use of pre-existing coach contacts that were gathered from a University of Connecticut Institutional Review Board–approved research initiative. Contacts obtained via this method represented 4 states (Arizona, Illinois, Oklahoma, Oregon). Duplicate contacts in Arizona and Illinois across both recruitment strategies were identified before distribution to eliminate multiple receipts of the questionnaire.

The primary researcher created and managed a database via Google Sheets in which contact information (first name, last name, email address) for coaches was stored. When pertinent information was missing from the directory, we cross-referenced the state association's website with individual school websites and transferred any missing information. After database completion, we obtained 36 319 email addresses from both recruitment strategies. An email invitation with the Qualtrics survey link was sent to all contacts in April 2019, with reminder emails on May 7, 2019, and May 21, 2019, to increase participation.

Questionnaire Development and Validity

Two members of the research team developed the questionnaire in conjunction with the National Athletic Trainers' Association (NATA) Marketing & PR Department. Questionnaire content was derived from the researchers' experience working clinically as ATs in secondary schools, specifically the interactions they had with members of the coaching staff. The questionnaire was composed of 3 sections: (1) demographics, (2) quantitative measures assessing the coaches' perceived value of athletic training and knowledge of the roles and responsibilities of ATs, and (3) open-ended questions allowing the coaches to expand on their perceptions and understanding.

Although we had experience in and were familiar with the secondary school athletic training setting, none of the research team members had experience coaching at this level. As a result, to improve the quality of the questionnaire, we shared a content validity tool with 2 high school coaches and asked them to review the questionnaire for clarity, relevance, and importance with respect to the predetermined purpose and research aims.¹¹ This process required the reviewers to grade each questionnaire item on a 4-point Likert scale from 1 (not clear, not relevant, and not important) to 4 (very clear, very relevant, and very important). All suggestions to improve item clarity were incorporated, and any items that were scored as a 1 or 2 by both reviewers in the relevance or importance category or both were removed from the questionnaire.

Item-level and scale-level content validity indices (CVIs) were calculated using the relevancy scores provided by the reviewers.¹² Item-level CVI scores were computed by dividing the number of reviewers who rated the item as highly relevant or quite relevant by the total number of reviewers.¹² We then determined the scale-level CVI score by adding the item-level CVI scores and dividing that number by the total number of items in the questionnaire.¹² After the review process, an electronic version of the finalized questionnaire was created through Qualtrics. As a final step before sending the questionnaire to all contacts in our database, a member of the research team completed the survey to ensure correct survey logic.

Data Analysis

Descriptive statistics for demographic data were calculated using Excel (version 16.29; Microsoft Corp). Counts and percentage responses for quantitative measures were obtained through the “Report” feature on the Qualtrics platform. To compare responses between coaches who were currently working with an AT and those who were not, we performed cross-tabulation analyses in SPSS (version 26; IBM Corp) for perception- and knowledge-related items. In addition to the perceptions of our sample as a whole, we also assessed differences in perceptions and knowledge based on various independent variables, including whether or not (1) the respondent personally knew an AT, (2) the school the respondent coached at employed an AT, and (3) the respondent participated in athletics at the high school or collegiate level through Mann-Whitney U tests (Kolmogorov-Smirnov values were <.001 for all variables). Effect sizes were calculated by dividing the Z-score by the square root of the sample size (n = 1097). The interpretation of effect sizes was as follows: r = 0.1 (small effect), r = 0.3 (medium effect), or r = 0.5 (large effect). The α level of significance for all comparisons was set at P < .05.

We used a general inductive approach¹³ to analyze open-ended responses. This approach allowed us to condense large amounts of data into more meaningful and consumable themes. Before we began the qualitative data analysis, the lead author reviewed and cleaned the data. This process involved reviewing responses and deleting any that were obviously pulled from the NATA website or other public definitions of athletic training or ATs. Minor grammatical errors were also corrected in the data-cleaning process. The analysis consisted of 4 major steps: (1) an immersive period that involved reading the open-ended responses to gain a better understanding of the data, (2) using the study's aims to identify words or phrases in participants' responses that could provide answers to the research questions, (3) combining similar words or phrases into overarching categories, and (4) finding meaning in and defining categories to identify the emerging themes in the data. During the qualitative data analysis, quantitative data (counts, percentages, and descriptive statistics) were reviewed and integrated into the qualitative data to further support emerging themes regarding coaches' perceptions and knowledge of the athletic training profession—a process in line with concurrent mixed methods.¹⁴

To reduce bias in the analysis process, we used multiple-analyst triangulation.¹⁵ Steps 1 through 3 were conducted individually by 2 members of the research team; 1 member had 5 years and the other had 8 years of experience conducting qualitative research. Then the 2 researchers discussed their overall impressions of the data via phone until an agreement was reached on the organization and presentation of participants' perceptions. Open-ended responses that warranted clarification were not included in the analysis because we were unable to follow up with participants due to the study design. Notably, in these cases, the participant's complete responses were not removed from the analysis; instead, only the single response lacking clarity was removed. Triangulation of the quantitative and qualitative data served as a second credibility strategy. A mixed-methods approach and method triangulation¹⁶ allowed us to confirm the key findings through multiple data sources to strengthen our understanding of the coaches' perceptions and knowledge of athletic training.

The CVI Results

Individual-item CVI scores ranged from 0.50 to 1.00. The overall content validity of the questionnaire was 0.82, which indicates acceptable content validity according to scale developers.¹²

Participant Demographics

Of 36 319 survey invitations sent via email, 704 were invalid (failed email addresses or bounce backs). Of the 35 615 coaches who received the questionnaire, 1422 started it and 1097 completed it, yielding a 3% (1097/35 615) response rate and 77% (1097/1422) completion rate. Although the response rate was lower than anticipated, we obtained representation from all targeted states (Table 1) and a representative sample based on geographic region (Northeast, Southeast, Midwest, Southwest, and West). Most respondents were male (n = 795, 72.4%). The average age of respondents was 44.7 ± 11.4 years (n = 1093, median = 45 years, range = 21–78 years), and they had served an average of 13.3 ± 10.1 years in their role at the time of the survey. We intended to collect data on years of experience in their coaching role, yet respondents may have referenced years in their position of employment outside coaching, as many coaches in this setting have an additional job as their primary source of income. A more detailed summary of demographics is in Table 2.

Table 1 Respondents by State

View Fullscreen

Table 2 Respondent Demographics (N = 1097)

View Fullscreen

Perceived Value and Effect of ATs

Coaches specifically described how they believed student-athletes trusted the ATs, how the ATs were valued as a member of the “athletic team,” and how coaches trusted that the ATs would refer student-athletes to appropriate health care professionals when warranted. Coaches described the trust they perceived student-athletes had in their ATs and explained that student-athletes felt comfortable talking to ATs about injuries because they trusted them. Quantitative measures that were used to assess coaches' perceived value of athletic training and support this idea of trust are outlined in Table 3. When coaches were asked directly about the value of an AT, approximately 94% responded that ATs were very to extremely valuable to student-athlete health and safety. More than 90% selected athletic trainer as a trusted source of medical information.

Table 3 Cross-Tabulation of Survey Responses for Select Questions

View Fullscreen

Coaches also indicated that ATs were a trusted member of the athletic team. When requested to explain the role of an AT, 1 coach responded, “[An AT is] a member of the athletic team who assists in keeping our athletes healthy through education, injury prevention, and injury treatment.” Notably, many coaches described the AT as a valuable member of the coaching staff or as a coach. Most coaches (93.2%) indicated that an AT was a key member of the sports medicine team, followed closely by the coach (87.1%) and team physician (61.6%). Coaches in our sample indicated that they trusted the AT would refer student-athletes to appropriate medical professionals when warranted, suggesting the role of the AT was that of a gatekeeper. The timely medical attention provided by ATs was valued by our sample, as most participants indicated that employing an AT at a high school definitely (55.5%) or probably (27.3%) reduced liability. Quotes from participants highlighting the perceived value and effect of an AT can be found in Table 4.

Table 4 Participant Quotes in Support of the Perceived Value and Effect of an Athletic Trainer (AT)

View Fullscreen

Perceived Roles and Responsibilities of ATs

The employment of ATs in secondary schools was identified as a top sports safety measure by 52.3% of responding coaches. When describing the role of the AT, they specifically discussed how ATs were available to provide care immediately when needed. Among the comments from coaches were “[An AT] help[s] get players immediate care, gives parents and coaches resources to use,” “It allows me, the coach, immediate access to a professional to care for an injury,” and “They attend to the athlete's immediate needs, which I believe prevents further injury and/or permanent injury.” Coaches in our sample clearly recognized that an AT was available to provide immediate care to student-athletes, and this finding was supported by our quantitative results. When asked to select the tasks ATs were qualified to perform, those that required or included an immediate presence or response ranked highest: first aid and wound care (97%), emergency care (85.8%), and make return-to-play decisions (71.7%).

Coaches also mentioned they could focus on their role knowing that another person was available to handle injuries. As 1 coach stated, “If a situation arises, the athletic trainer is there quickly and provides care to the athlete immediately. If she was not there, a coach would have to provide that care and that could be questionable.” The perception that ATs were available to provide immediate care, which frees coaches to focus on their role, is supported by our quantitative results that showed only 16.3% identified a coach as a trusted source of medical information.

Responding coaches consistently referred to an AT's ability to treat minor injuries. When asked about the role of an AT, 1 coach wrote, “[An AT] keeps them [student-athletes] ready and prepared to compete. Treats minor injuries before they become a major injury.” Although the coaches expressed the value of an AT in providing immediate care to athletes with minor injuries, they also discussed their belief that it was the AT's responsibility to be physically present at games and practices, emphasizing the “coverage” component of the AT role. One coach noted, “The job responsibilities of an athletic trainer [are] to be at all sports contests as [much as] possible; be available during school hours; to do immediate ‘evaluation and first aid' when an athlete has an accident.” Additional quotes highlighting the perceived roles and responsibilities of ATs are provided in Table 5.

Table 5 Participant Quotes in Support of the Perceived Role and Responsibility of an Athletic Trainer (AT)

View Fullscreen

The Role of Coaches' Individual Histories and Experiences

Coaches' perceptions of ATs were influenced by their individual experiences, including whether they worked with an AT, whether they personally knew an AT other than as a colleague, and whether they participated in high school or collegiate athletics.

Responses from coaches working with or without an AT at the time of survey completion are compared in Table 6. Most replies were similar for the 2 groups. For example, 91.4% of coaches working without an AT believed that ATs were trusted sources of medical information, compared with 93.6% of coaches working with an AT. Coaches working with an AT had slightly higher perceptions of the value of an AT pertaining to student-athlete health and safety (group 1 [high school employed AT] mean rank = 537.36, group 2 [high school did not employ AT] mean rank = 610.30; U = 69 947.5, P = .001, r = .106), but the largest discrepancy was in participants' willingness to coach at a school that did not employ an AT. Overall, 38.9% (n = 359) of coaches currently working with an AT were willing, to some extent, to work at a school that did not employ an AT versus 81.7% of coaches who were working without an AT. This difference was statistically significant (group 1 mean rank = 601.65, group 2 mean rank = 271.60; U = 32 129.5, P < .001, r = .386): respondents who worked with ATs demonstrated a greater level of disagreement with “I am willing to coach at a school that does not employ an athletic trainer.”

Table 6 Response Comparison for Coaches Working With or Without an Athletic Trainer (AT)

View Fullscreen

Coaches' pre-existing relationships with ATs also had a small effect on their overall perceptions of the athletic training profession. Individuals who personally knew an AT disagreed more with “I am willing to coach at a school that does not employ an athletic trainer” than respondents who did not personally know an AT (group 1 [coach knew AT] mean rank = 564.7, group 2 [coach did not know AT] mean rank = 489.5; U = 85 759.5, P = .001, r = .098). Additionally, coaches who personally knew an AT valued the role of the AT in enhancing student-athlete health and safety more than coaches who did not personally know an AT (group 1 mean rank = 520.16, group 2 mean rank = 658.30; U = 74 357, P < .001, r = .224).

Lastly, coaches' experience participating in athletics at the high school or collegiate levels had a small effect on their overall perceptions. Individuals who participated in high school or collegiate athletics perceived the value of the AT on student-athlete health and safety to be higher than respondents who did not participate in athletics at either level (group 1 [participated in high school or collegiate athletics] mean rank = 545.45, group 2 [did not participate in high school or collegiate athletics] mean rank = 675.42; U = 12 212.5, P = .005, r = .084).

Value

Most coaches considered an AT extremely valuable or very valuable to the health and safety of student-athletes. Interestingly, perceived value was slightly influenced by whether the respondent personally knew an AT, worked alongside an AT, or participated in high school or collegiate athletics. Having a pre-existing relationship with an AT, regardless of capacity (personal, professional, early years), brought first-hand exposure to the coaches in our sample and influenced their perceptions of the athletic training profession in a positive way. Coaches also indicated they trusted the ATs they worked with as valuable sources of medical information and viewed the role of an AT as a top sport safety measure. Interestingly, aside from athletic directors,¹⁷ secondary school coaches had the highest percentage of respondents indicating that ATs were a trusted source of medical information and a top sport safety measure compared with state legislators¹⁸ and principals.¹⁹ The higher numbers from coach and athletic director groups may reflect the level of interaction these individuals have with ATs. Coaches, in particular, frequently interact with ATs and can improve their knowledge base by witnessing firsthand what ATs do. This idea of trusting the AT was also apparent in our qualitative data. Coaches noted that it was clear to them that student-athletes trusted the ATs. Previous researchers²⁰ illustrated that ATs also believed trust was an important characteristic of the profession. Specifically, head ATs in the Division III setting discussed the importance of being trustworthy when handling confidential information and when developing relationships with student-athletes.²⁰ The Board of Certification Code of Professional Responsibility²¹ also highlighted the establishment of trust as a patient care responsibility. Given their discussion of the level of trust student-athletes have for ATs, this appears to be a value shared by coaches and ATs.

We also focus on the coaches' acknowledgment of the importance of trust between student-athletes and ATs. In a 2014 editorial published by the National Federation of State High School Associations, the author commented that the relationship between ATs and coaches should be based on trust and an understanding that each is working toward the same outcome.³ Overall, the importance of trust as a foundational component of the AT-coach and AT-athlete relationships was evident. It is likely because of this trust that coaches viewed ATs as key sources of medical information and a part of the team. Based on our results, coaches do trust ATs and therefore may advocate for their employment in the secondary school setting, which could lead to beneficial health-related outcomes for student-athletes.

Most of our participants indicated they considered the AT a key member of the sports medicine team. This finding was evident in our qualitative data as well, as many coaches described the AT as being part of their team. The idea of an AT being viewed as a member of the sports team could be positive and suggest the trust coaches have in ATs, yet this topic should be further explored. The NATA has consistently advocated for a medical model of health care delivery, in which ATs make decisions for patient health, first and foremost, without fear of repercussions from the athletic department.²² According to Garland,²³ data shared at the 2019 NATA Symposium in Las Vegas, Nevada,²³ showed that 30% of college and university ATs felt pressure from nonmedical personnel on medical decisions, and more than half (or 17.4% of total population) reported pressure from an administrator or coach to make medical decisions that were not in the student-athlete's best interest. Although these data were specific to the collegiate setting, they highlight the possibility that coaches may feel they can persuade ATs to make medical decisions. Given that secondary school coaches indicated they saw ATs as part of their team, questions about reporting structure and hierarchy within an athletic department arise.

Notably, coaches in our sample viewed an AT employed at a secondary school as a top sports safety measure, second only to injury-prevention programs. Coaches seemed to value the presence of an AT, although they described the importance of having an AT on site and available rather than the value of the medical care provided. Despite these relatively positive findings, about 46% of all respondents indicated that they would be willing, to some extent, to coach at a school that did not employ an AT. This willingness was greater for coaches who did not personally know an AT (small effect) and for coaches who worked at a school that did not employ an AT (medium effect). Pre-existing relationships with an AT, either through one's personal or professional life, exposed coaches to the role, value, and responsibility of the AT position, which may make it difficult for these coaches to imagine working without one. Regardless, coaches' willingness to work at schools without an AT is worrisome for multiple reasons. Because state athletic associations are allowed to dictate policies at the secondary school level,²⁴ required coaching education and training are inconsistent. Without a national mandate or standard, not all coaches are trained or certified in life-saving measures such as cardiopulmonary resuscitation (CPR) and automated external defibrillator (AED) use. Researchers²⁵ showed that the number of Chicago schools with a CPR-certified coach available at practice decreased by 23.8% from 2003 to 2017. This decreased availability potentially puts athletes at greater risk for injury or death, as prompt and appropriate responses to sudden cardiac arrest are known to improve outcomes.²⁶ Specifically, 89% of student-athletes who suffered an exercise-related sudden cardiac arrest survived when the event was witnessed and CPR and AED application occurred quickly.²⁶ Without proper training for coaches, negative outcomes from sudden cardiac arrest may result due to inappropriate responses, especially if a medical professional is not present.

Furthermore, previous investigators observed that coaches lacked the necessary knowledge, skills, and training to adequately perform the role of a health care provider, particularly as it pertains to the signs and symptoms of exertional heat stroke² and first aid,⁹ as well as the use of CPR and AEDs.⁷ Researchers have also demonstrated that coaches were not aware of current best practice guidelines. In 2015, youth sport coaches lacked knowledge of and appropriate behaviors with respect to the guidelines set forth by the NATA and National Weather Service regarding lightning safety.²⁷ Authors²⁸ also found that high school coaches were unfamiliar with the signs and symptoms of concussion. Interestingly, coaches who had access to ATs managed athletes with concussions more consistently.²⁸ Nonetheless, medical care for athletes, beyond basic wound care skills obtained from qualified first aid courses, should not be expected of coaches. Medical care should be provided by recognized health care professionals, and coaches cannot fill that role. For these reasons, among others, a coach should never be solely responsible for the health and safety of student-athletes²⁹ but rather should work collaboratively with members of the athletic health care team to deliver quality care.³⁰ In the future, we should work to better understand the motivating factors behind coaches' willingness to coach at schools that do not employ an AT.

When dichotomizing these results based on whether a coach worked at a school where an AT was currently employed, we determined that both groups believed an AT was valuable to the health and safety of student-athletes and a trusted source of medical information. However, coaches working at schools with ATs demonstrated greater perceived value of ATs than coaches who did not work alongside an AT at the time of survey completion. Firsthand exposure to the roles, responsibilities, and value of the AT is a plausible explanation for this result. The overall perceived value of ATs across our sample is noteworthy, however. Despite not working at a school where an AT is employed, coaches recognized the AT's value in promoting student-athlete well-being. This finding may indicate that coaches employed in schools not using the medical services of an AT could be potential advocates for their hiring. Unfortunately, many of those coaches also indicated they would be willing to work at schools that do not employ an AT. We suggest that these coaches and school districts could benefit from education on the importance of having an AT present on their campuses to enhance their ability to advocate for our profession.

Knowledge

The coaches in our sample did appear to be knowledgeable about the various roles and responsibilities of ATs. This finding is inconsistent with earlier literature¹ in which investigators reported that coaches had a limited understanding of ATs' qualifications, professional preparation, and experience. Those authors studied a smaller sample restricted to basketball coaches, whereas we examined a larger, more diverse sample. Additionally, these data were published more than a decade ago, and it is possible coaches have since had more exposure to ATs, which could explain improvements in their knowledge. Most of our participants stated that they worked in a school that employed an AT and personally knew an AT. Our results might have been different if our sample included more coaches employed at schools without an AT present.

Our respondents recognized many of the roles and responsibilities of ATs, including injury prevention, first aid and wound care, therapeutic interventions, emergency care, and clinical diagnosis. However, they were less knowledgeable regarding ATs' administrative tasks. Notably, the administrative tasks accompanying the AT role often go unseen by coaches, which may explain the lower percentage of coaches identifying the administrative component of the AT role compared with other responsibilities.

In the open-ended responses, ATs were often described as gatekeepers, which emphasizes an understanding that ATs are part of a larger sports medicine team. Referral is a key aspect of the AT role, particularly when appropriate care cannot be provided on-site, as it streamlines medical care and serves as the foundation for effective operation of the sports medicine team. Most of the referrals ATs coordinate for athletes likely result from orthopaedic injuries and general medical conditions. Furthermore, referrals for such purposes probably occur more frequently at the secondary school versus collegiate level; availability of and access to appropriate resources is more challenging in the former. In our sample, coaches' perceptions and knowledge of ATs as gatekeepers may stem from their experiences with athletes being referred to health care professionals for follow-up care. Ultimately, coaches viewed the ATs' role in the referral process as important because it prevented athletes' minor injuries from becoming major ones, thereby reducing time loss from injury.

Limitations and Future Research

We acknowledge that our response rate was low and represents a limitation of the results. However, the sample size, completion rate, and diversity of the sample help mitigate concerns related to the low response rate. Our sample may have been unintentionally skewed due to coaches' interest in or positive perceptions of the profession because most respondents worked at schools that employed an AT and were moderately to extremely satisfied with the medical services provided. Given our results, it is important to consider how positive experiences could shape perceptions. These data are valuable and highlight that perceptions of the profession could be positively shaped by exposure to and positive experiences working with ATs. Additionally, many respondents (approximately 42%) resided in Illinois and Ohio, which limited our ability to generalize the results to secondary school athletic coaches across all states. Two additional limitations of online data collection are the possibility of coaches looking up what was perceived to be the “correct” or “most appropriate” responses and the inability to follow up with coaches on any open-ended responses warranting clarification. We removed responses that were obviously copied from the NATA website or other public definitions of ATs from the data analysis to minimize the effect of outside influences and “copying.” Although we purposefully sought out coaches in specific sports, we did not collect survey data on the sport(s) the respondents were coaching at the time of the survey because our research aims did not depend on the sport(s) coached. Therefore, it is possible that most respondents coached a specific sport or more high-profile sports in which ATs' involvement was greater, but we cannot draw any conclusions regarding this demographic. Lastly, based on the nature of the survey, we were unable to determine if coaches from the same secondary school participated in the study. Our findings may have been skewed positively or negatively depending on the culture of the athletic program and the number of coaches who participated.

Future researchers should explicitly document the specific sports coaches are overseeing to determine if the sport coached affects their perceptions of ATs. Similar investigations of states not represented in this study should be conducted, and it will be important to target coaches who have limited to no previous experience working with ATs to directly compare the effect of exposure on their perceptions and knowledge. Furthermore, the idea of ATs being part of the athletic team warrants additional research. Specifically, it is important to understand coaches' intentions and determine if viewing ATs as part of the athletic team suggests the ability to overrule ATs' decisions or is the product of a successful AT-coach relationship. Approaching this topic from a qualitative perspective may provide a richer understanding of coaches' perceived value of the athletic training profession.