Workplace Climate for Sexual and Gender Minorities in Athletic Training

Design and Setting

We used a sequential mixed-methods design via an anonymous cross-sectional survey and follow-up interviews with ATs portraying an inclusive or somewhat inclusive workplace climate. This project was deemed exempt research by the Indiana State University Institutional Review Board.

Participants and Recruitment

Using criterion sampling, we identified members of the LGBTQPIA+ community and recruited participants via both the National Athletic Trainers’ Association Research Survey Service and social media. The Research Survey Service distributed the survey to 8666 people, and although the recruitment materials clearly indicated that eligibility required being a member of the LGBTQPIA+ community, 462 individuals clicked in to participate (5.3% access rate); only 61 individuals of those were eligible, and 6 of those individuals did not consent. One person was excluded for defiling the survey with prejudicial speech. As such, 54 individuals completed the survey via the Research Survey Service sampling between September and November 2021. Only 4 individuals opted in to the follow-up interview, and as such, data saturation was not achieved. We then used social media recruitment through personal and professional Twitter accounts, yielding 107 more individuals clicking into the survey: 101 were eligible, 76 consented, and 63 provided the necessary sexual orientation or gender identity responses to be included. Social media recruitment occurred between February and March 2022. The final survey sample consisted of 117 participants (Table 1). Twelve individuals from the 2 recruitment methods opted in and consented to the follow-up interview (Table 2).

Table 1. Survey Participant Demographic Characteristics (n = 117)

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Table 2 Interview Participant Characteristics

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Instrumentation

We identified 2 tools used in common practice to develop the survey and interview script: the LGBTQ Inclusion Assessment from the Social Transformation Project¹¹ and the Organizational Self-Assessment from the Demonstrate LGBTQ Access organization (Appendix A).¹² Both tools are recommended for assessing workplace climate but neither has been validated or used in contemporary research. The LGBTQ Inclusion Assessment, which is no longer available on the Internet from the Social Transformation Project, has 5 constructs (program, power, policies, people, and culture), whereby the respondent indicates whether the organization has fully, partially, or not yet completed an inclusive action. The Workplace Climate subsection of the Organizational Self-Assessment includes items about organizational effectiveness in creating an inclusive workplace climate. We merged these instruments from both tools and slightly modified their terminology and sentence structure. In addition, we developed an interview script intended to deepen understanding relative to organizational behaviors that promote inclusion. The survey and script were distributed to our 4 content experts to establish content validity. In the first phase, the reviewers provided feedback using track changes and comments to the initial draft. The research team then merged the feedback to construct another draft to share with the content experts, repeating the same request for feedback. Once the language was refined, we used a content validity index to establish an item and scale content validity index score. The content experts rated each item on a 4-point scale (1 = not relevant, 2 = somewhat relevant, 3 = quite relevant, and 4 = highly relevant). Each item required an item content validity index score >0.49 to be included, and the scale content validity average was 0.82, which met the required threshold (>0.80).¹³ Overall, 4 items were excluded from the survey, and 1 item was excluded from the interview through this validation process. Results for item content validity and the survey items are detailed in Table 3. The interview script also met the threshold for scale content validity index (0.94) and is shown in Table 4.

Table 3 Survey Items^a

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Table 4. Interview Script^a

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Procedures

On clicking the recruitment link, recruits accessed the screening items (certified, licensed provider working clinically and a member of the LGBTQPIA+ community), reviewed the consent statement, and consented to participate. They completed the survey and then had the choice to opt in for the follow-up interview if they indicated they worked at an inclusive or somewhat inclusive workplace. We contacted the potential interview participants to schedule a meeting using Zoom video or phone conferencing software. On completion of the interview, the audio and transcription files were downloaded, and the transcription files were deidentified before being saved. Transcriptions were performed by artificial intelligence (Otter.ai) and then corrected by the primary investigator. We sent the deidentified transcript to each participant for member checking. Data saturation was achieved through consultation with all members of the research team, based on the primary investigator’s field notes.¹⁴

Data Analysis and Trustworthiness

We used a descriptive approach to analyze the survey data. Means ± SDs and frequencies (%) were calculated to characterize participant responses.

We used the consensual qualitative research tradition to analyze the qualitative interviews.¹⁵ Consensual qualitative research involves a multiphase process and multianalyst triangulation to strengthen thematic review of the data. In phase 1, a 3-member team reviewed 4 transcripts independently, met and compared notes, and developed an initial codebook. The initial codebook contained the overarching domains and the core ideas (categories) that constituted those domains. In phase 2, we applied the initial codebook to 2 transcripts from the first phase and 2 more transcripts to ensure that the codebook reflected the data. The team met again to confirm the consensus codebook. Phase 3 had 2 steps: first, the primary investigator coded each transcript individually. Then the coded transcripts were independently, internally audited by the other 2 members of the team. We met to discuss any diverging opinions. After the 3-phase coding process, we conducted a cross-analysis in which we organized all the coded data for each domain and category to verify that it was coded properly. We sent the consensus codebook, coded transcripts, and interview script to an external auditor to confirm the findings. Lastly, we assigned a frequency to each category based on the number of transcripts from which the category emerged. Data were characterized as general if represented in 11 or 12 cases, typical if represented in 6 to 10 cases, variant if represented in 3 to 5 cases, or rare if represented in 1 to 2 cases.¹⁵

Trustworthiness of the data was established through reflexivity (researchers acknowledging and checking bias through the research process), member checking, multianalyst triangulation, internal auditing, and external auditing.

Safety

Our participants commented on largely feeling safe in their workplace due to organizational initiatives that addressed inclusion. Many respondents noted initiatives sparked by the death of George Floyd and the civil unrest that followed in the United States. However, those initiatives primarily focused on racial and ethnic diversity. Although we agree these initiatives are essential, we advocate for organizations to consider how their initiatives can also address all protected classes, including SGMs. Previous researchers have suggested that inclusive decoupling may affect employees’ sense of safety in the workplace.¹⁶ Inclusive decoupling is defined as the gap between adopting inclusive policies for employees and involving those employees in organizational processes, such as decision-making and implementing the developed policies.¹⁶ Many participants revealed that initiatives were occurring at a high level within their organizations, but few were involved in the evolving organizational processes to promote inclusion. Organizations should consider how they might include various stakeholders in shared decision-making and policy implementation to mitigate the gap between policy and practice.¹⁶ We suggest high-level administrators support supervisors to enact inclusive policies as 1 effective strategy for improving the inclusive climate of the organization.

The ATs also portrayed a sense of safety in their workplace when organizations had policies for inclusive patient care. Inclusive patient policies are essential to protect patients, yet we advocate for organizations to develop and educate policies to protect employees. For example, participants indicated a sense of safety in their organization when they were aware of health care providers supplying gender-affirming care. However, few individuals knew whether employees within their organization could have gender-affirming care covered by the organization’s employer-sponsored health insurance policy. Developing and implementing this type of policy may decrease employees’ perceptions of inclusive decoupling and demonstrate the organization’s willingness to put policy into action for employees.

Our participants specified state, federal, or both types of laws that protect LGBTQPIA+ individuals as another reason they felt safe within their organization. Nonetheless, in recent years, anti-LGBTQPIA+ legislation has increased, which requires organizations to overtly signal and develop policies to protect their employees. Despite state or federal laws that may allow for discriminatory action, organizations can implement nondiscriminatory policies and create inclusive environments that value all employees. Appendix B has a list of resources for monitoring current discriminatory legislation.

Inclusion

Our findings suggest a direct correlation between including and welcoming diverse patients and a sense of belonging for the SGM provider in that same workplace. Participants felt that inclusive efforts from their employer that explicitly targeted patients would also translate to them as employees. Similarly, in nursing, previous authors have determined that workplace climate was directly influenced by facility policies and general interactions with those around them.⁸ Additional factors that created an inclusive workplace were the overall diversity of the employee community and the presence of LGBTQPIA+ individuals within the workplace,⁸ which was consistent with our results. Although the ATs indicated a sense of belonging themselves when patients at their workplace were included, employers should work to ensure a culture of belonging that specifically supports SGM ATs.

Respondents discussed the value of employers having inclusive policies and procedures and inclusion training. However, participants were largely unaware of the specific inclusive policies at their workplace. Workplace discrimination is historically evident in a lack of consistent formal policies and biased treatment during hiring, firing, job assignments, promotion opportunities, and benefit offerings.¹⁷ Similarly, among organizations, providing partner benefits, diversity statements, diversity training, and equity in health care coverage had a positive effect on the workplace experience for employees.⁸ For employers to best provide an equitable workplace, organizations should not only ensure that their policies and hiring practices are nondiscriminatory but that such policies are widely available and supplied to the employee.

Efforts toward LGBTQPIA+ inclusion do not end with inclusive policies and procedures. Rather, employers should work to magnify their inclusion efforts for SGM employees via benefits such as partner recognition and transgender-inclusive health care.¹⁸ The Human Rights Campaign’s Corporate Equality Index (https://www.hrc.org/resources/corporate-equality-index) has outlined a core set of criteria for employers to adopt to ensure they are meeting best-practice standards for equitable and inclusive workplace practices for LGBTQPIA+ employees. Among the criteria are a written employment nondiscrimination policy that addresses both sexual orientation and gender identity across all operations, inclusive benefits (Appendix C), internal education and training, and social responsibility targeted for LGBTQPIA+ advocacy. Employers who hire ATs should use these types of resources to guarantee they are not only including SGM ATs in the hiring process but also celebrating their identities once they become employees.

Limitations and Future Research

Criterion sampling was the appropriate choice for this investigation; however, the common recruitment mechanisms used in athletic training do not easily target SGM ATs. As such, we are unable to report traditional metrics, such as the response rate. Although we explored our biases at various points in the data-analysis and interpretation process, it is important to acknowledge that members of the team identify with the LGBTQPIA+ community, and these experiences inform the analyses, even with bias checking.

Future researchers should explore how supervisors are creating inclusive workplaces and how well informed all ATs are regarding workplace policies, procedures, and benefits.