Social media has evolved and is a prominent outlet for information and communication1 that allows technology to transform communication into interactive dialogue.2 Millions of people are engaged in social media and it is continuing to grow2; adult users have increased from 8% to 72% worldwide since 2005.1 Social media has become a way of life for Millennials and Generation Z, who look at the internet as a means of authority and are empowered through platforms like Facebook and Twitter.4 Health care must keep up with and develop an understanding of the rapid growth within these social media platforms.4
Social media can provide opportunities to strengthen and stabilize the health care profession and to establish more effective relationships with patients.5 Social media in health care has been used to maintain or improve peer-to-peer and clinician-to-patient communication, promote institutional branding, and improve the speed of interaction between and across different health care stake-holders.1,6,7 Health care professionals are using social media by providing health information, answering medical questions, facilitating dialogue between patients, collecting data, providing health interventions and education, and providing online consultations.6 There are also several risks associated with increased dependence on social media in professional settings, such as damage to an individual's professional image, breaches of patient confidentiality, violation of patient/health care provider boundaries, and licensing issues.1,4 Previous studies observed how health care professionals have misused social media in terms of Health Insurance Portability and Accountability Act (HIPAA) violations; however, little research has been conducted to observe positive social media use.4
Despite the drawbacks, social media has the potential to positively impact the athletic training profession. The purpose of this study was to determine how athletic trainers are currently using social media and what methods they are using to do so to allow for a better understanding of the effects of this use by athletic trainers. Our research was guided by the following questions: are athletic trainers currently using social media, how are athletic trainers currently using social media, and to what extent are athletic trainers using social media for advocacy purposes?
A qualitative, phenomenological research design was used to observe whether athletic trainers are currently using social media and to gain a better understanding of how and why athletic trainers are using these platforms. Focus groups were conducted, which resulted in rich data through the interactions of group members.8 Individual responses further stimulate authentic discussion among the group.8 Before focus group sessions, each participant completed a questionnaire (Qualtrics) to document demographic information and current social media use. The Indiana State University institutional review board approved this study.
All participants were recruited via direct message on Twitter through the Indiana State University NICER Lab Twitter account (@NICER_Lab). We searched for practicing athletic trainers in any clinical or educational practice setting who were active users on Twitter with at least 200 followers. Twitter was selected for the recruitment process based on the brevity and convenience of the platform. We looked for participants who were active on social media with 200 or more followers to ensure participants established themselves within the platform and used the platform to disseminate information regarding the athletic training profession. Participants received a direct message soliciting their participation in a focus group. Participants completed an initial questionnaire to determine eligibility, provide written informed consent, and select a time to complete the focus group. The individuals were selected to attend the particular focus group sessions based on availability. The study included five focus group sessions comprising 4 to 8 participants per session for a total of 30 participants. All participants provided written and verbal informed consent.
The research team developed the focus group script guided by the research questions about the social media platforms athletic trainers were using, the motivations for using or avoiding certain platforms, the differences in social media use for professional versus personal use, and the risks associated with social media use. The script consisted of eight primary questions and follow-up questions (Table A, available in the online version of this article). We used a panel of experts (n = 4) for content validation of the script. All of the experts were athletic trainers who have an active presence on social media. The initial script was sent to the panel and the experts provided feedback/suggestions to improve the script. We synthesized the feedback and made changes to the script where appropriate, and experts affirmed agreement with the script.
After institutional review board approval, pilot testing was conducted with two focus groups (18 total participants) from a convenience sample to help with focus group facilitation and clarity of the focus group script. The results from the pilot testing were not included in the final results. We made minor modifications to the order of questions following the pilot testing and also eliminated some of the follow-up questions to decrease redundancy. The primary investigator (SH) sent direct messages via Twitter to 174 potential participants who fit the criteria for the study. In total, 30 participants provided consent and were available for the study. Five focus group sessions were conducted via Zoom (Zoom Video Communications, Inc), a web-based video communication platform, which allowed the participants to engage in the focus group regardless of their location. Each focus group session included a moderator, who was the primary investigator using a semi-structured script. The audio components of all focus groups were recorded via Zoom and saved to a secured server to ensure accuracy in transcription. All five focus group sessions were transcribed verbatim. The transcriptions were completed through a commercially available transcript service (Temi).
Focus group transcripts were analyzed using open coding from the phenomenological tradition in data analysis.8 The analysis was guided by the overall purpose and research questions. Following data collection, the research team determined data saturation had occurred because no new data were being discussed during the focus groups. Two of the investigators used three randomly selected focus group transcriptions and segmented the transcriptions into themes. The team determined three transcripts would be used because this was representative of more than half (3 of 5) of the total focus groups conducted to ensure the sample was well represented. The investigators collaborated to develop a codebook of themes/subthemes. Then the investigators determined the consensus of themes and placed the participants' responses into a clear and concise format to be compared across the five focus group sessions. When the research team developed the themes, the principal investigator applied the codebook to the remaining transcripts and sent coded transcripts to the other team member (ERN) to internally audit. If there was a disagreement on the coding, it was discussed and consensus for the most appropriate code was used. When the data analysis team concluded the coding, the focus group script, consensus codebook, and coded response document were shared with the auditor. The auditor confirmed the themes were appropriate. Trustworthiness was established by the use of multiple team members and external auditing.
A total of 30 athletic trainers (age = 32 ± 8 years, clinical experience = 10 ± 8 years) who were predominately female (n = 18, 60%) participated in the focus groups. On average, participants had 8 active social media platforms that they accessed approximately 13 times per day. The demographic information is presented in Table 1. Three major themes emerged from data analysis following the focus group sessions to explain athletic trainers' social media use: (1) mechanisms for social media use, (2) motives for social media use, and (3) considerations for social media use (Figure 1).
Themes and subthemes derived from data analysis.
One of the major themes that developed from the focus group discussions was the mechanisms of athletic trainers' social media use. Supporting quotations from subthemes are listed in Table 2. Mechanisms included the various platforms as having two different accounts: one for personal use and one for professional use. The participants discussed differentiating between the accounts to keep personal and professional lives separate. The participants also discussed using different platforms for different purposes, some for more professional uses and others for more personal uses.
Quotations for Mechanism Theme
The other subtheme that fell under the mechanism theme was the various platforms that athletic trainers used for social media. On average, participants had eight active social media accounts they accessed approximately 13 times per day. The most commonly used platforms for social media use included Twitter, Facebook, Instagram, Snapchat, and LinkedIn.
The second theme that arose from our analysis was the participants' motives for why and how they use social media. The participants identified several sub-themes for the reasons why they were motivated to use social media (Table 3). Information gathering involved participants actively finding information related to athletic training including research, rehabilitation ideas, and relevant articles. Information sharing involved participants retweeting or forwarding relevant information or sharing educational resources in teaching.
Quotations for Motives Theme
Participants also identified that they used social media to advocate or educate by correcting behaviors, teaching about the profession, showing value for the profession, socializing with students, voting in Board of Certification elections, and obtaining educational information from professional organizations. Several participants discussed using social media for promoting accomplishments of students, peers, classmates, and organizations. Networking was an additional prevalent subtheme that athletic trainers identified as a motive for using social media.
Organizational practices such as marketing, branding, recruiting, hiring, and screening were also discussed as reasons why athletic trainers chose to interact on social media. Finally, social media was frequently used in a positive way for peer-to-peer collaboration to practice interprofessional engagement with other health care providers.
The final theme that the authors gathered from the data was the participants' considerations, or reasons to avoid social media use. The subthemes that participants discussed as considerations for social media use included e-professionalism, legal and regulatory implications, self-regulation, and listening instead of acting. The supporting quotations for subthemes are listed in Table 4. E-professionalism was a recurring subtheme where athletic trainers talked about selecting or deselecting certain accounts, avoiding trolling within social media, and not engaging in professional negativity on social media.
Quotations for Consideration Theme
Additionally, considerations for participants interacting with social media were legal and regulatory implications. This subtheme involved HIPAA violations and the implications for interacting with minors on social media. Participants discussed practicing impulse control while interacting on social media and thoughtful posting (thinking before they post). In some cases, athletic trainers also noted that they practiced listening instead of acting. This subtheme appeared when athletic trainers chose to follow certain social media accounts to be aware of the information being spread, but refrained from responding or interacting with these accounts. Listening instead of acting was described as following certain pages or sources to be connected, seeing what is going on, and staying up to date, but avoiding interacting with them.
Social media use is continuing to expand in health care. In 2005, only 5% of Americans used social media, but this increased to 70% in 2017.9 To keep up with social media expansion, it is important for athletic trainers to understand how to use information from social media.10 Social media has been described as both the most innovative and the most destructive emerging market forces.9 It has the potential to positively impact the athletic training profession if users consider the effect of their social media interactions.
Community engagement, promotion of health, out-reach, and patient education social media interactions increase daily.9 Based on our results, it is apparent that athletic trainers are currently using social media to influence their practice(s), but some athletic trainers may not be aware of the considerations needed to effectively and legally interact on these platforms.11
Mechanisms and Motives
Participants indicated that Facebook, Twitter, LinkedIn, Instagram, and Snapchat were their most frequently accessed social media platforms. They identified different motives for using each of the platforms and described that some of the platforms were used for their professional persona, whereas others were primarily for personal use. Current literature supports that the platforms accessed by our participants align with the most popular and growing platforms among users in general.12–18 Additionally, athletic trainers are using social media platforms to educate the public and empower patients, like other health care providers.1,3 The participants in our study indicated their social media activity was driven by professional motives versus personal ones (eg, pastime, meeting new friends). Having a better understanding of the most common uses of social media will allow athletic trainers to more effectively use these platforms for advocacy.
Facebook is currently considered the most popular platform of social media, growing from 500 million users in 2010 to more than 1 billion in 2012.5 According to previous studies, people are typically motivated to use Facebook as a pastime, to stay up-to-date, to share problems, to connect with or meet new friends, and to feel involved with what's going on with other people.12 Our participants identified using Facebook as a means of advocacy through promotion of the profession, especially during National Athletic Training Month, and through some of the athletic training Facebook group pages.
After Facebook, Twitter is the most commonly used platform, having grown from 100 million users in 2011 to more than 200 million active users in 2012.5 The majority of the focus group participants spoke about using Twitter for more of a professional outlet than some other social media platforms described, likely a result of our recruitment strategy. Many Twitter users have adapted the platform to fit their own purposes, rather than answering the original prompt from the site, “What are you doing?”13 Twitter does not necessarily replace other forms of media, but complements them, allowing users to actively contribute to the wider media sphere.14 Our participants identified that this easily accessible platform has provided a convenient outlet to educate the general public and advocate for the profession. The brevity, immediacy, and openness of Twitter is shown to empower educators and students to interact with various people in non-traditional ways.13 Our participants frequently discussed using this platform to retweet information and stay up-to-date on current practices and important news in the profession. Professional organizations may consider the concept of posting on sites like Twitter to increase information dissemination such as elections or continuing education opportunities to increase engagement.
Instagram is currently the fastest growing social network site globally, but there is not a lot of research to support why people are using it.16 According to the company's website, there are more than 400 million active monthly users, sharing more than 40 billion photographs.17 The top four motives for Instagram among users were surveillance/knowledge about others, documentation, coolness, and creativity.16 Many participants in our study identified Instagram as a resource for peer-to-peer collaboration and to gather information from other health care professionals. They also discussed the platform growing in its use for professional advocacy, primarily to educate followers on the roles of athletic trainers and to promote the profession to a larger reach. Many of the participants reported having separate personal and professional accounts with different motives for using each of the accounts.
Snapchat is another commonly identified platform that allows users to send and receive time-sensitive photographs and videos.18 It has been estimated there are currently more than 100 million Snapchat users worldwide, making it one of the most popular social media platforms.17 Many Snapchat users report that they access this platform for both entertainment and functional needs (users think the platform is fun and practical).18 Our participants spoke about using Snap-chat more frequently for personal use and avoiding this platform professionally or for professional advocacy.
Although our participants discussed using social media for several positive motives and advocacy purposes, they also identified major risks and considerations. The most prevalent considerations were the issues of e-professionalism, legal and regulatory implications, self-regulation, and listening instead of acting. E-professionalism is the attitudes and behaviors that reflect traditional professionalisms in digital media.19 The participants found themselves being selective in accounts they followed or interacted with and avoided engaging in professional negativity due to issues with e-professionalism. Social media is an influential communication tool, but short lapses of judgment where unprofessional content is posted can create a negative image for the person involved, the profession, and the employer.20–21 With the growth of social media, it seems necessary to introduce more educational intervention opportunities to teach concepts of e-professionalism, even within professional education.
One of the most consistently discussed risks was the legal and regulatory implications of social media, specifically HIPAA violations. The HIPAA legislation (1996), created standards to protect a patient's protected health information.11,22 An amendment to HIPAA, the Health Information Technology for Economic and Clinical Health (HITECH) Act, was created specifically for the protection of electronically protected health information of patients (medical records and photographs).11 Our participants discussed the importance of being well-educated on these policies and having clearly defined social media policies. A previous study examined athletic trainers' knowledge of legal practice within information technology and social media and showed that respondents lack the appropriate knowledge regarding HIPAA and HITECH regulations and application of this knowledge within social media.11 Our participants believed that with the rapid growth of social media, it is essential to better incorporate teaching these concepts within athletic training educational curricula to protect both patients and clinicians. They noted that athletic trainers may avoid social media use due to legal risks but, if better educated, they would be able to properly use these platforms for professional advocacy purposes.
Self-regulation is the way people motivate and control their behavior to achieve desired outcomes.23 Self-regulation, or lack thereof, is controlled by emotions, automatic behavior, and impulses.23 The participants discussed impulse control, stating they would see things on social media that triggered them to want to respond, but practiced self-regulation to maintain professionalism and refrain. They also referred to this consideration when determining whether to post or engage on social media. Although our participants discussed the risks and considerations of social media use, they also noted considerations provided many opportunities for growth and education to positively use social media.
Implications for Clinical Practice
A limitation of the study is the use of criterion sampling (Twitter) rather than a broader recruitment method with other platforms. The findings of this study provide insight on the social media platforms that athletic trainers are using and the motives that attract athletic trainers to use these platforms. The results also allow us to observe participants' self-perceived considerations and risks involved with social media. Social media is continuing to grow and, with proper education and avoidance of legal risks, we can continue to use these sources to advocate for athletic training and advance the profession.
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- Wagner R. Social media tools for teaching and learning. Athl Train Ed Jour. 2011;6(1):51–52.
- Househ M, Borycki E, Kushniruk A. Empowering patients through social media: the benefits and challenges. Health Informatics J. 2014;20(1):50–58. doi:10.1177/1460458213476969 [CrossRef]
- Neil ER, Winkelmann ZK, Eberman LE. Athletic trainers' knowledge of legal practice within information technology and social media. JSMAHS. 2017;3(2). doi:10.25035/jsmahs.03.02.01 [CrossRef]
- Antheunis ML, Tates K, Nieboer TE. Patients' and health professionals' use of social media in health care: motives, barriers and expectations. Patient Educ Couns. 2013;92(3):426–431. doi:10.1016/j.pec.2013.06.020 [CrossRef]
- Moorhead SA, Hazlett DE, Harrison L, Carroll JK, Irwin A, Hoving C. A new dimension of health care: systematic review of the uses, benefits, and limitations of social media for health communication. J Med Internet Res. 2013;15(4):e85. doi:10.2196/jmir.1933 [CrossRef]
- Ventola CL. Social media and health care professionals: benefits, risks, and best practices. P T. 2014;39(7):491–520.
- Maxwell JA. Qualitative Research Design: An Interactive Approach. Sage Publications; 1996:62–63.
- Surani Z, Hirani R, Elias A, et al. Social media usage among health care providers. BMC Res Notes. 2017;10(1):654. doi:10.1186/s13104-017-2993-y [CrossRef]
- Rosen AB. Using social media to enhance sports medicine research connectivity and patient care. Athletic Training & Sports Health Care. 2018;10(4):147–148. doi:10.3928/19425864-20180530-01 [CrossRef]
- Winkelmann ZK, Neil ER, Eberman LE. Athletic training students' knowledge of ethical and legal practice with technology and social media. Athl Train Educ J. 2018;13(1):3–11. doi:10.4085/13013 [CrossRef]
- Quan-Haase A, Young AL. Uses and gratifications of social media: a comparison of Facebook and instant messaging. Bull Sci Technol Soc. 2010;30(5):350–361. doi:10.1177/0270467610380009 [CrossRef]
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|Age (years), mean ± SD||32 ± 8|
| Asian/Pacific Islander||2|
| Black or African American||2|
|Route to certification|
| Accredited professional bachelor's program||20|
| Accredited professional master's program||5|
|Highest degree earned|
| Clinical doctorate||3|
| Research/academic doctorate||2|
|Years of experience, mean ± SD||10 ± 8|
| Current setting|
| Secondary/intermediate school||4|
|Social media sites|
|Average no. of times per day to access social media||13|
Quotations for Mechanism Theme
|Personal vs professional use||“I guess when the profession started becoming more [social media] based, I used to use it from both a personal as well as a work standpoint. But now, to minimize the risk of unprofessionalism, my work has allowed us to start [social media] pages. . . so from that standpoint, we use the work accounts for [promoting] the profession and stuff we're doing in the office. And then, I keep my personal pages personal.”|
|“I use Instagram, Twitter, and Facebook. On Facebook I have one page, and on the other two platforms, I have two accounts. One [account is] a personal one and one is athletic training related and work related.”|
|“I pretty much use Twitter for most of my professional collaboration. . .or just to promote the professions. I have Snapchat, but it's only for personal use.”|
|Platforms||“So my primary [social media] use is on Twitter. I'm more for getting information about clinical practice as well as retweeting and sharing information.”|
|“I use Facebook purely for personal use. . .on occasion I'll post about athletic training advocacy on there. My Twitter is primarily athletic training related, but occasional personal posts. Instagram is just personal use, and LinkedInis professional networking and advocacy for athletic training.”|
Quotations for Motives Theme
|Information gathering||“I like getting different ideas from other athletic trainers. . .whether it's different rehabs or new ideas for exercises. Especially on a professional level for finding out different things that are going on. . .and seeing what other athletic trainers are dealing with on a daily basis.”|
|“Professionally, the things I see on [social media] allows me to dig a little deeper. So if someone posts something, I can do my own homework and background and get a little bit more information and knowledge about that.”|
|Information sharing||“My Twitter is where I repost or encourage professional articles or referrals from other professional organizations.”|
|“Most of the time[s] that I share things [are] just to try to share the news because that's how I capture most of my news. I tend to retweet it or I'll try to share it as well, just to capture a larger audience.”|
|Advocate/educate||“I do try to retweet or repost whenever National Athletic Trainers' Association (NATA) posts a new position statement or an article, or the Board of Certification with voting and things like that that I think are beneficial for other people to see. Just to promote our profession. . . .”|
|“It's almost like a news media source to some extent. . . . I think on a professional standpoint we can use that to our advantage to kind of promote certain things. Like if BOC voting is going on, or if an event is going on within our program, or an article is published, anything, then we can kind of use that as a platform to promote it and educate people.”|
|Promoting accomplishments||“I have a Doctor of Athletic Training (DAT) so I know I use [social media] a lot to promote the DAT because it's something I personally and professionally believe in. I use it to connect with classmates, especially from my DAT, which was an online program. I'm using it to keep up with what they're doing or maybe disseminate their research. . . . I hope to promote anything that they may have going on research or professional-wise.”|
|And then also the student accomplishments, I like to really put that [social media] praise out there for their accomplishments because again, that hard work that they put into those assignments or those projects, I view as really important to get that out there. Not only for their own personal recognition, but our program recognition.”|
|Networking||“I mean I follow all the NATA, [state] Athletic Trainers' Association, all of the main organizations. I even follow a lot of the Cramer, Henry Schein, or Medco, and then just a lot of people I've traveled and seen or covered some of their events and stuff; I've been able to connect with them nationwide.”|
|“I follow a lot of people I've met when traveling or covering their events, so social media is a great way to be able to connect and network nationwide.”|
|Organizational practices||“Well, we try to post a lot regarding what we do as a department, not only to advocate for the club sports medicine program because we're such a small department so the university doesn't really know about us. It started off as, let's market ourselves to the university and to the student body so that they understand that we are here and sports medicine is not just accessible to scholarship athletes.”|
|“Sticking with the athletic training education, as somebody who is in the process of transitioning into the professional master's program from our undergraduate program, we're relying heavily on the use of [social media] to eventually get the word out about our professional program. We plan on using [social media] as a recruiting platform as well to find those students who may be interested and directing them specifically toward our institution. And I think it's a great way to plug marketing campaigns for your program. . . . So whether we want to be a part of it or not, we have to be a part of it if we are going to be a sustainable program.”|
|Peer-to-peer collaboration||“I think it is only going to get better and I think that it has. I like to think that it will increase and more athletic trainers will start using it and we'll start educating other professionals like strength coaches, chiropractors, medical doctors, and doctors of osteopathic medicine. I think everybody's watching, and this is our time to just really show out.”|
|“I follow a number of physical therapists, strength coaches, and athletic trainers. Everyone is posting content nowadays. It's there as a source of inspiration or creation of new ideas and what you can bring back to your own practice.”|
Quotations for Consideration Theme
|E-professionalism||“I try to stay away from almost all of the forums. I'll read them, but I don't think I've participated very much in contributing to those platforms. I don't want it to be something where we're complaining about our patients and sometimes I get really concerned about some of the groups that tend to want to have a spot to complain. Our patients can find those pages. And I think that we need to be very careful.”|
|“I think that a risk that people are taking that I don't even think they're thinking about is, I've seen some folks that [confuse] that crossover between the personal and professional [use]. . .to see some of the political things and some of the ostracizing comments that people branded as a health care professional make. It's unbelievable to me. And if I were that parent or that patient, I would probably be making different health care choices based purely [on] if this is what they think is appropriate to put out there to essentially brand themselves, then this is perhaps somebody that I don't need taking care of me.”|
|Legal and regulatory implications||“Most people don't think about those things when you give someone advice, you are assuming liability for it. . . . So definitely the liability issues I think people don't really take into consideration as much, especially if you post something like the mandatory reporting, if you know, you should report it, you should report it. Come on.”|
|Self-regulation||“So people typically know my political views by following me on [social media] and I don't overstep the bounds of what I think is socially acceptable, but I do understand that that could easily get someone in trouble by what they post and you see that right now in most of mainstream media, even athletes, political figures, people in entertainment. . . . We do try and avoid getting into situations that get us in trouble politically, but at the same time we avoid too many things and avoid conversations that we should be having. . . . I think that's a big challenge for younger athletic trainers in learning how to use [social media] but not being afraid of it at the same time.”|
|Listening instead of acting||“I do follow some of those larger group things Like athletic trainers anonymous, but I typically don't interact with them, they mainly frustrated me because I feel like they're the same post every day. They're cyclical. I feel like once a month we [got] the same post and it really, really, really frustrated me. So I stopped interacting with that.”|
|Focus Group Script|
We are going to start by asking for introductions from each of you. If you would all please start with your first name or pseudonym, the role you are currently in, what degree your currently possess, and the state in which you are from.
What social media platforms are you currently using and how are you using them?
How many hours a day would you estimate that you are using social media?
What motivates you to post or connect on social media with friends and family? What about with patients, co-workers, and other athletic trainers?
Describe some of the accounts you connect with to receive professional communication on social media.
What motivates you to communicate by that source? Which platforms have you found the most success with? What motivates you to avoid certain sources?
What are some of the risks in using social media while connecting with friends and family? What about with patients, co-workers, and other athletic trainers?
Do you find yourself avoiding connecting on social media because of these risks? If so, why?
Do you feel like you follow HIPAA/FERPA/Hi-Tech guidelines within your social media use? Explain.
Does your place of employment have a social media policy?
Do you feel like social media has a place in the future of athletic training?
How do you think social media can be used to advocate for the athletic training profession?
What campaigns have you found to be successful for the profession? Are there social media accounts or sources that could be made for the profession? Why do you think?
Do you feel like you currently use social media as a means of professional advocacy? If so, how?