Supervisor Authority and Its Impacts on Equity, Diversity, and Inclusion in National Collegiate Athletic Association Athletic Training Environments
The demographic landscape of the United States is changing daily, and the demand for representation in today’s workforce is both a moral and practical imperative for creating workplaces diverse in thought, expression, and people. The purpose of this study was to investigate workplace culture and the direct and indirect influence of supervisors on inclusion of minoritized communities, including those who have experienced marginalization for race, ethnicity, religion, national origin, age, marital status, ability, sexual orientation, sex, gender, gender identity and expression, socioeconomic status, spirituality, political affiliation, literacy, or the intersectionality of multiple identities. Consensual qualitative research study. Semistructured interview. Eighteen participants were recruited through direct contact via their public domain email addresses that are located on college/university websites. Demographic data were collected through a web-based recruitment survey, which was also used to schedule a semistructured interview. We used the multiphased consensual qualitative research tradition to identify domains and categories representative of the data. Three domains emerged. The environment domain spoke to the culture each supervisor created through relationship building and intention; intention was further characterized as active or passive behaviors whereby almost all participants described both. Only one-third of participants referenced diversity, equity, inclusion, and accessibility policies and procedures within their organization. The resources domain represented the existence and awareness of organizational diversity, equity, inclusion, and accessibility resources, or lack thereof. The perceptions domain characterized the beliefs of the supervisors relative to diversity, equity, inclusion, and accessibility. Structural efforts must include the creation and implementation of policies and procedures for employee inclusion, not just patient inclusion. The awareness and use of organizational resources is an important component to support supervisor efforts and should be leveraged from within the unit.Context
Objective
Design
Setting
Patients or Other Participants
Data Collection and Analysis
Results
Conclusion
Key Points
Participants confidently described their desire to create an inclusive culture, but few were able to provide examples, even with repeated follow-up questions, to create this space. A willingness to create an inclusive environment falls short of the actions necessary to employ structural and cultural change in health care.
Participants in this study indicated that some of the diversity, equity, inclusion, and accessibility resources failed to resonate for their specific job functions, and they had limited time and funds to use these best practices. Other barriers in organizations may include a lack of goals and metrics to measure success of diversity, equity, inclusion, and accessibility program/training, limited or no buy-in from leadership, or cultural resistance.
Participants struggled to differentiate the concepts of equality and equity. Offering the same access to opportunities and resources without acknowledging the circumstances and context to which staff engage in a space disadvantages under-resourced groups.
Inclusion can be defined as “involvement and empowerment, where the inherent worth and dignity of all people is recognized.”1 Inclusion of diverse individuals collaborating in a health care setting, who are also different thinkers because of their lived experiences, can increase the breadth and depth of biomedical and clinical thought to improve the scope and approach to problems that affect society.2 Inclusion and diversity have been shown to be an important factor when measuring profitability within organizations.3 Firms or organizations that are in the top 25% for gender diversity are 27% more likely to have superior value creation.3 Value creation, specifically in health care, refers to the integration of resources through activities and interactions with collaborators to realize the benefit of patients in the health care service delivery network.4 In addition to value creation, firms or organizations in the top 25% for ethnic and cultural diversity within executive teams are 33% more likely to be industry leaders.3 Diverse thinkers can impact the outer boundaries of health care inequity by allowing their practice and research to be informed by broader social contemporary issues.2 In addition, diverse health care teams that represent the community it serves can help eliminate disparities and are more proficient at meeting the needs of diverse individuals.5
Socially, diversity refers to a wide range of identities that broadly include race, ethnicity, gender, age, national origin, religion, disability, sexual orientation, socioeconomic status, education, marital status, language, veteran status, physical appearance, etc.6 In 2010, 72% of certified athletic trainers identified as “non-Hispanic White” and 63% as male, with 47% indicating they have been certified for 40 or more years.7 According to the Board of Certification’s athletic trainer demographics survey conducted in 2022, approximately 81% of athletic trainers identify as “non-Hispanic White,” 58% identify as “female,” and 52% have indicated that they have been certified for 0 to 9 years.8 In just 12 years, those who identify as female are now the predominant gender identity, the proportion of White athletic trainers has increased, and newly certified, younger athletic trainers are also predominant. As the demographic profile of the United States continues to change, the athletic training profession must have the capacity to adapt and strive to recruit, staff, and retain those who represent the various communities and patient populations that they serve.9 This can align with the quadruple aim that acknowledges practices to enhance patient experience, improve population health, reduce the costs of health care, and improve the work life of health care providers, including clinicians and staff.10
There is an urgent need to understand how diversity, equity, inclusion, and accessibility (DEIA) are seen in practice settings and how organizations can better promote DEIA initiatives in their respective organizations.9 Studies suggest that racial concordance is a consistent predictor of better patient-provider communication.11 A research team examined responses from Press Ganey surveys following adult outpatient visits and found that 88% of physicians from racially/ethnically concordant patient-physician pairs received the maximum score for questions regarding positive experiences from their visit.12 For those who identify within the LGBTQ+ community, it is seen that better patient outcomes will be achieved if providers learn terms and health care risks and maintain education on the care of patients who represent this community.13 Espousing diversity in health care is critical because it can lead to cultural competency and the ability of health care providers to offer services to meet the unique social, cultural, and linguistic needs of their patients.14
Diversity is not something that can be created overnight; it requires a leadership team that is dedicated to increasing cultural awareness and inclusion.14 Organizations, from small businesses to large corporations, are autonomous entities that afford leaders a high level of control over cultural norms and procedural rules, making these settings the ideal places to plan and develop policies and procedures that promote equity across their clinical practice settings.15 Managers and individuals in formal leadership positions are critical for creating inclusive environments because group members form perceptions of inclusion based on the treatment they receive at work.16 Current efforts around DEIA in the profession are focused on patient care for specific minoritized populations or based on recruitment for masters’ in athletic training programs.9,17 Both are incredibly important, but more work is necessary to address the Quadruple Aim and the wellness of health care providers.10 The purpose of this study is to investigate workplace culture and the direct and indirect influence of supervisors on inclusion of minoritized communities, including those who have experienced marginalization for race, ethnicity, religion, national origin, age, marital status, ability, sexual orientation, sex, gender, gender identity and expression, socioeconomic status, spirituality, political affiliation, literacy, or the intersectionality of multiple identities.
METHODS
Study Design
We used the consensual qualitative research tradition with a semistructured interview protocol to explore workplace culture and the direct and indirect influence of supervisors on inclusion of minoritized communities. We used the Standards for Reporting Qualitative Research guidelines to improve the quality of reporting of the qualitative research in this study (Figure 1).18 Before interviews, participants signed informed consent forms to participate in the research. This project was deemed exempt by the Indiana State University Institutional Review Board.
Citation: Journal of Athletic Training 60, 5; 10.4085/1062-6050-0137.24
Participants and Recruitment
We identified (n = 995) potential participants using publicly available information on athletic trainers in the college and university setting; 125 individuals clicked on the invitation, 118 completed the invitation, and 48 were contacted by the primary investigator. Eighteen participants met our inclusion criteria and chose to participate in the semistructured interview process. Participants were generally White (94%) and identified as male (61%), with an average of 18.7 years (SD = 12.1) of experience as an athletic trainer and an average of 12.5 years (SD = 10.7) as a supervisor of other athletic trainers. Participants mainly worked in urban (83%), National Collegiate Athletic Association Division I or II settings (39% each) in an athletics clinical model (83%; Table 1). Participants met the inclusion criteria if they self-identified as supervisors based on the definition that was provided to them by our research team. Our research team defined “supervisor” as “responsibilities for supervision of certified athletic training staff members.”
Instrumentation
To obtain demographic information for each participant, a survey tool was created. Demographic data that were collected included Division (I, II, or III), location (urban or rural), gender, race, clinical model (athletic, medical, or mixed), years of experience as an athletic trainer, and years of experience as a supervisor. To explore the experiences of supervisors and their exposure to DEIA, the primary investigator developed a semistructured interview script that consisted of 12 questions, with each question having 1 to 2 follow-up responses based on the participants’ answer to initial questioning (Table 2). The research team conducted multiple revisions of the semistructured interview protocol to better enhance quality of the questions asked to encompass DEIA as a whole while aligning more with a supervisor’s interpretation of their environment rather than questions regarding DEIA integration being patient focused. The interview protocol was then externally reviewed by 3 experts in qualitative research (Table 3). The interview questions were modified to better align with the research question and enhance interviewee comprehension through inclusion of subquestioning prompts based on the participants’ responses.
Procedures
We identified potential participants using publicly available information on athletic trainers in the college and university setting. We sent potential participants a web-based survey (Qualtrics, Inc) to collect demographic data and screen out individuals that did not meet our inclusion criteria. If the participant met the inclusion criteria, we contacted them to schedule a 1-time interview using audio Zoom conferencing software (Zoom Video Communications, Inc). Once the Zoom interview was completed, the audio and transcription files were downloaded into a cloud storage file with 2-factor authentication. The transcription files were deidentified before saving. Transcriptions were performed by artificial intelligence, Otter.ai., and then corrected by the primary investigator. The deidentified transcripts were then sent back to the participants to check for accuracy.
Data Analysis and Trustworthiness
We used descriptive statistics to analyze participant’s demographic data. Means, standard deviations, and frequencies were used to characterize participant responses for basic demographic information. Consistent with the consensual qualitative research tradition, we analyzed the interviews using a multianalyst approach with several phases of review to develop a consensus codebook.19 In phase 1, a 3-member data analysis team reviewed 5 transcripts and completed individual reviews (Table 3). We then met to develop an initial codebook. In phase 2, the initial codebook was applied to 5 transcripts from the initial coding process and then another 5 transcripts after creation to confirm the accuracy of the initial codebook. After initial codebook application, we met to confirm consensus of the codebook. In phase 3, the primary investigator coded each transcript individually, and then the coded transcripts were independently internally audited by other members of the research team. After the 3 phases of the coding process, a cross-analysis was conducted to organize the coded data and to verify that the coding was done accurately. The consensus codebook, coded transcripts, and the interview scripts were sent to an external auditor to confirm the findings. Finally, a frequency for each category was determined based on the number of transcripts from which the categories were present. Data were categorized as general if represented in 17 or 18 cases, typical if represented in 10 to 16 cases, variant if represented in 5 to 9 cases, and rare if represented in 2 to 4 cases.19 Trustworthiness of the data was established through the researchers acknowledging and checking biases throughout the research process, member-checking, and internal and external auditing.
RESULTS
Three domains and their respective categories emerged regarding the direct and indirect impacts of supervisors on DEIA (Table 4). The domains included (1) environment, (2) resources, and (3) perceptions (Figure 2). Supporting quotes for each domain and category can be found in Table 5.
Citation: Journal of Athletic Training 60, 5; 10.4085/1062-6050-0137.24
The environment domain spoke to the culture each supervisor created through relationship building and intention; intention was further characterized as active or passive behaviors whereby almost all participants described both. Relationship building was defined as the supervisor’s effort to connect with others and improve their and the staff’s cultural knowledge surrounding DEIA. Participants noted that relationship building often looked like behavior mirroring, in which, the supervisor would perform an action that was expected to be followed by the rest of the staff. Active intentionality spoke to the actions made that are tangible or can be attributed to a specific action that was performed. For instance, Tom states, “I think it comes down to education and conversation.” Passive intentionality included the good intention for promoting DEIA, without tangible evidence of those actions; Jenn talked about her “open door” policy where she described a situation where she waited for her staff to bring issues to her versus intentionally inserting inclusive practices into the system. The environment was also supported through structural efforts, specifically the existence and implementation of DEIA policies and procedures and training. When coding, we gathered whether participants developed policies and procedures, and only one-third of participants referenced DEIA policies and procedures to support their efforts of workplace inclusion. One participant noted, “I feel like DEIA is more of an expectation. Word of mouth is how we do it here.” We coded DEIA training when participants characterized active efforts to promote or initiate DEIA activities during onboarding of new employees or regularly throughout the year as professional development. Hiring and retention was discussed in over half of the interviews as a valuable tool to be used to promote DEIA in the workplace to actively increase and sustain retention. Additional supportive quotes for the environment domain are provided in Table 5.
The resources domain represented the existence and awareness of organizational DEIA education, hiring, or cultural resources whether that be physical (eg, pamphlet, guest speakers, online seminars) or social (university-affiliated DEIA committees, continuing education units, National Athletic Trainers’ Association DEIA council) or lack thereof. Two-thirds of participants indicated, even when resources were available, that there was a lack of use. When participants went to their organization’s DEIA groups, many were unsatisfied. Ron said, “we have a [DEIA] committee on campus, but they haven’t really done much with it … It hasn’t been advertised well enough on a big enough platform to hit everyone on campus.” Some participants indicated a lack of time, whereas others spoke about a lack of funding to access outside resources as a primary barrier. Kyle noted, “We want to engage in DEIA meetings, but they meet at 3:30 pm and say, well that works for everyone else [within that athletics department],” indicating that this was not convenient for the athletic training staff. Some participants noted many of their DEIA policies, as well as staff activities, came from the university’s DEIA committees, and the lack of specificity to athletic training services limited their usefulness as seen by Kaylee: “It’s like some things that institutions do are so generic; it’s unhelpful.” However, several participants stated that their student-led committees for DEIA have been extremely effective. One supervisor highlighted that “the student-led DEIA committee led training for the coaches, students, and staff. Coming from a student perspective, it really opens some people’s eyes to what our students are actually going through.” Using student and organizational resources can help bridge the gap that exists between patient and provider education surrounding DEIA, but those resources must be accessed.
The perceptions domain characterized the beliefs of the supervisors relative to DEIA, where about half of participants indicated that an equality-based approach, where things are equal for everyone, is sufficient to create an inclusive workplace. This is shown by Drew who stated, “I try to make sure that all my employees or assistants are listened to and treated as professionals … I am looking for the athletic trainer not so much the protected group.” When asked directly, and then again during follow-up questioning, about workplace inclusion and efforts to make employees feel included, two-thirds of participants described efforts to create inclusive environments for patient care. This suggested a potential perceived equivalency between inclusive environments for patients and employees. Interestingly, many of the participants highlighted substantial inclusion efforts targeted for the patients that they served but were unable to specify inclusion initiatives for the athletic training staff. This is exemplified through Naomi’s quote,
Again we work in a customer service field. If the student-athletes stop coming in, then something’s going on. We have got to address that issue and figure out why and take those next steps and try to create an environment where they want to come into and be a part of.
A little over half of participants responded to the interview questions, limiting their responses to populations of differing race, ethnicity, and sexual orientation, and were not reflective of other minoritized communities even upon follow-up questioning.
DISCUSSION
Cultural inclusion addresses and supports the needs of people from diverse cultures and values their unique contribution to the organization.20 Structural inclusion involves addressing long-standing oppression perpetuated by political, economic, and social systems.21 Practically, the differences between these 2 concepts is important, as one can make a subsystem inclusive of minoritized communities, but if the systems of the larger organization fail to change, those efforts can lead to continued oppression. Cultural inclusion can address individual biases where structural inclusion is about putting equitable systems in place that prevent those biases from occurring in the first place then corrects the biases when they occur.22 The existence of cultural and structural inclusion events are pervasive throughout our data, where the resources domain characterizes structural inclusion, the perceptions domain directly speaks to cultural inclusion, and the environment domain speaks to both.
Environment
An inclusive workplace environment has been shown to improve the quality of health care in athletic training community relations and positively affect the health and wellness of our communities.23 Those who assume leadership roles define what the cultural and workplace standards are regarding peer-to-peer interactions as well as health care delivery. Many of the participants confidently described their desire to create an inclusive culture, but few were able to provide examples, even with repeated follow-up questions, to create this space. Intentional leaders are clear about their goals, what they want to accomplish, and how this aligns with their organizations values.24 Leaders who take a more passive approach and lack tangible examples of allyship for minoritized communities may not be able to fully communicate the organization’s mission, vision, values, and expectations around inclusion to their employees. Overall, the idea of role modeling desired behaviors by the participants was seen as a way to effectively promote inclusion efforts. This may be explained by the behavioral leadership theory, where the focus on role modeling assumes that these traits will be copied by others.25 This role modeling is consistent with those participants that spoke to actively behaving in a way they wanted their staff to behave, but this also has the potential to leave a gap for interpretation and implicit bias from staff.
Belongingness is defined as a feeling of being accepted as a part of a community where inclusion involves creating a welcoming and respective environment. Inclusion requires active effort from the system, where the sense of belonging is the potential result, and an individual feels included. Inclusion initiatives have the potential to increase an employee’s sense of belongingness and trust, yielding a healthy workplace culture.26 This can start at the beginning during the hiring process. When an employee gets hired into an organization, they are exposed to that organization’s mission, vision, values, policies, and procedures. Over half of the participants indicated that hiring and retention practices were a way that they introduced DEIA inclusion efforts to staff. By introducing new employees to a workplace culture structured around inclusion and belongingness, there is an opportunity to speak directly to staff at the onset. Belonging is linked to a 56% increase in job performance, a 50% drop in turnover risk, and a 75% reduction in sick days.27 If an individual can gain a sense of belongingness in their athletic training community, it may have the potential to increase the vitality of their athletic training career.28 When leaders are committed to DEIA, employees’ sense of belongingness nearly doubles.29 Through their attitudes and actions, leaders can build a sense of community and social responsibility in which each staff member feels included, valued, respected, and heard, resulting in greater retention.27
Many supervisors were unaware of or did not implement DEIA initiatives directly in their organizational structures. Part of the role of policies is to set an expectation and aspiration for employee conduct and engagement at work.30 Implementing DEIA initiatives, specifically clear policy around inclusion, can help bridge the gap between a policy and culture by providing both the employee, and supervisor, with clear expectations.30 Efforts to advance DEIA in health services has been hit or miss, in that the health care workforce has indicated that initiatives are often planning focused and not implementation focused, leaving workers, particularly minoritized workers, feeling that there is far more work left to be done.31 Similarly, in athletic training, participants in a recent qualitative study indicated that committees were convened, but little action had been implemented after the uprising of discontent in 2020.32 That study went on to further state that most athletic trainers were unsure of the stages of change their health care organizations were in relative to creating a more inclusive workplace, either structurally or culturally.32
The growing body of evidence around positive patient outcomes in a more diverse work environment should continue to serve as the guidepost for hiring practices in health care. Race concordant relationships are important for the patient experience and improve things like patient education and shared decision-making.11 Health care systems should be actively engaged in assessing and benchmarking their equity efforts, but with that, a full picture of diversity must be captured.33 Historically, institutions have used race and ethnicity to quantify representation, but these metrics fail to assess the experiences and intersectionality of the workforce today. In this study, the supervisors struggled to describe diversity among their employees beyond race, ethnicity, and sexual orientation. Systems should engage in more holistic assessment and ensure they are capturing the experiences of their workers, not just calculating the groups they may or may not represent.33
Resources
Failure to be up to date on best workplace practices for inclusion can lead to discrimination among patients and employees, social isolation, increased injury, and increased overall costs of health care needs to the organization.34,35 Participants in this study indicated that some of the DEIA resources failed to resonate for their specific job functions, and they had limited time and funds to use these best practices. Other barriers in organizations may include a lack of goals and metrics to measure success of DEIA program/training, limited or no buy-in from leadership, or cultural resistance.36 One way to combat these barriers is to have awareness of university-specific, athletic training-specific, and general health care-specific DEIA best practices. All participants indicated that there was opportunity for growth for expanding their knowledge on DEIA awareness and education. Much of this awareness should arise from gaining an understanding of what various types of diversity exist within their community. Supervisors have the opportunity to support their employees’ global awareness of DEIA through using continuing education units and university-specific DEIA committees as well as sharing or reflecting on their own experiences as a way to increase overall awareness that diversity exists in our communities, when we welcome it. There is an urgent need for organizations to reframe their mission and values to align with the core principles of DEIA. By 2050, it is estimated that 50% of the US population will consist of minoritized populations, and, unfortunately, today’s model of health care fails to represent these minoritized communities.34
Perceptions
The Quadruple Aim is focused on improving population health through improving work life integration for those who deliver care.10 The 4 wings of the aim are improving the health of populations, enhancing the patient experience of care, reducing per capita costs of health care, and improving the work life of clinicians and staff.10 These health care aims have evolved from the first 3 aims, adding this fourth aim focusing on health care workers10 and most recently a fifth aim on health equity.37 Health care is a relationship between those who provide care and those who seek care, a relationship that can only thrive if it is symbiotic, benefiting patients without harming health care workers.10 As part of the health care team, services provided by athletic trainers may include, but are not limited to, primary care, injury illness and prevention, wellness promotion and education, emergent care, examination and diagnosis, therapeutic intervention, and rehabilitation of injuries and medical conditions.38 Efforts to help make patients feel included in the athletic training clinic, although an important part of the overall Quadruple Aim, fall short of ensuring an inclusive workplace. With athletic trainers in college and university settings having the possibility of working in multiple workspaces, it is crucial that supervisors make attempts to ensure that all work areas are following inclusive practices to increase an employee’s sense of belongingness. This may include signage, working with other University or national committees on inclusive practices that should be encouraged, or general education to entire athletics departments.
Participants in this study, and in other studies in athletic training, struggled to differentiate the concepts of equality and equity.32,39 Half of the participants expressed a desire to treat everyone equally as their central tenant of inclusion and indicated its use as an effective strategy to promote DEIA. Equality requires that everyone receive the same resources and opportunities, regardless of circumstances and despite any inherent advantages or disadvantages that may apply to marginalized communities.40 Equity accounts for the different challenges that historically marginalized communities may face and acknowledges that different levels of support must be provided to achieve fairness in outcomes.40 Offering the same access to opportunities and resources without acknowledging the circumstances and context into which individuals engage in a space disadvantages under-resourced groups. Many workplaces are trying to promote “fairness” across their organizations when, in actuality, there should be efforts to ensure equity.41 If equality is the main focus for DEIA efforts, it can lead to a counterbalance where the work being put in to eliminate bias is instead increasing implicit biases and furthering the inability for an inclusive workplace culture to be built.41 Ensuring that athletic training workplaces acknowledge these concepts of equity versus equality is imperative when delivering DEIA education, providing actionable changes to promote a safe workplace environment, and when making efforts to increase an employee’s sense of belongingness.
Historically marginalized communities were defined in this study as
those who have experienced marginalization based upon race, ethnicity, religion, national origin, marital status, ability, sexual orientation, sex, gender, gender identity and expression, socioeconomic status, spirituality, political affiliation, literacy, or the intersectionality of multiple identities.
Many of the participants limited their responses when answering interview questions to only discussing marginalized communities based on race, ethnicity, or sexual orientation. Acknowledging all forms of diversity will enable any organization to foster a more collaborative workplace positioned to grow to its fullest.42 If supervisors are not able to define what DEIA is and integrate it into their culture, they may promote an environment of unintentional hostility and see an increase in turnover.43
Limitations and Future Research
Most of the participants in our study identified as White, non-Hispanic males working in urban settings, which is generally representative of supervisors in athletic training.44 The scope of this investigation is limited to those in college and university clinical practice settings, and thus our findings may not be wholly generalizable to other practice settings. Other leadership structures, system expectations, and available resources may offer different findings. Assessing the various challenges and successes in settings other than colleges and universities could provide insight into additional barriers and solutions for implementation of DEIA practices in athletic training. It is also important to acknowledge that participants may be facing pressures organizationally and politically that impact their ability to create an inclusive work environment. In this study, we did not explore the participants’ lived experience in the sociopolitical context. Future research is needed for DEIA efforts in athletic training, as well as other health care professions, to determine what direct and indirect actions can be taken to create desirable workplace environments. This study was exploratory in nature, but future research that evaluates a supervisor’s years of experience, education, and preparation as a leader may also inform questions around workplace inclusion in athletic training.
CONCLUSIONS
This study has shown that supervisors see themselves as leaders within their clinical environment who have direct and indirect influence on their organizational culture. The respondents discussed the importance of DEIA in their organization but often were unable to identify resources or have structure around their inclusion policies. Organizations should work to implement consistent DEIA training, cultivate a sense of belongingness, and acknowledge the broad range of diversity to better include and represent minoritized employees.
Methods flow chart.
Codebook diagram.
Contributor Notes