The athletic training profession has grown considerably since the 1970s. Now regulated in 48 of 50 states, athletic training is a profession that includes members sought after for their expertise and wisdom about the management of athletic injuries, and it is a profession that continually seeks to improve the educational competency of its members.
However, these advancements to the profession have created the possibility that we have become our own worst enemy.
Know Your Authority
At the 2011 annual convention of the National Athletic Trainers’ Association, I attended a roundtable discussion about laws and regulations. I was surprised by the conversations that ensued and by how many of the athletic trainers who attended are afraid of doing something to upset a coach.
As health care practitioners, athletic trainers must overcome this notion that we have less authority than a coach or, in some cases, must report to a coach.
Many legal cases demonstrate this point. For example, during the recent Ereck Plancher civil case1, involving the death of an athlete at the University of Central Florida due to sickle cell trait, it was reported that the coach may have ordered that the athletic trainers and water be removed from the field. I am amazed that the coach would be able to demand such a thing.
A portion of our profession seems to not know how to say “no.” Therefore, athletic trainers must do a better job in supporting and educating our colleagues during challenging situations—doing so involves the protection of our livelihood.
In December 2011, the Joint Commission, which accredits and certifies more than 19,000 health care organizations and programs in the United States, published an article about health care worker fatigue and patient safety.2 The article referenced many studies about the adverse effects of fatigue, such as decreased productivity and increased risk of making mistakes while assuming responsibility for the lives of others.
To highlight why we need to advocate for ourselves and for our profession, I want to point out two articles—one that was published last year in the November 2011 NATA News3 about a high school athletic trainer’s timeline of work starting at 7:00 AM and finishing at 1:00 AM, and one published more recently in the March 2012 NATA News4 about a professional athletic trainer’s work timeline of 8:00 AM to 11:30 PM. I’m not sure whether these articles aimed to point out how hard working we are or to point out how crazy we are for working such long hours. I am not berating these hardworking colleagues—I, too, sometimes work long hours—but given that other health care professionals5–7 recognize that this is a concerning issue, it is time for athletic trainers to focus on it as well.
The athletic training profession will never be a 9-to-5 job. However, to quote the 1976 movie Network,8 there comes a time when we have to open the window of discontent and say “I’m mad as hell, and I’m not gonna take it anymore!” I am not implying that we stop doing the job we’re most capable of doing, nor am I implying we shouldn’t get the job done. But 7-day weeks and 12-hour days comprise an issue we must confront and change.
As indicated in the recent NATA salary survey,9 it seems our salaries are improving in general, but it is not always the case. Athletic trainers must support each other. Don’t take the jobs that pay low wages. Don’t work excessive hours. Make it clear to potential employers that those “bad” work conditions will not receive our resumes. We need to protect our livelihood, and we need to protect ourselves from burnout. We must protect our certification and, for most of us, our license.
The influence of athletic trainers on collegiate and high school regulatory boards is outstanding, but much more needs to be done. Those organizations must be more aggressive in their support for our profession.
I am a firm believer that most, if not all, high schools should have more than one athletic trainer. It is possible that all the positive press lately may help that cause!
In August 2003, the National Collegiate Athletic Association (NCAA) issued a memo (Matt Mitten, e-mail communication, August 14, 2003) about the support of certified athletic trainers, stating:
The latest trends imply that certified athletic trainers are leaving the college setting or the profession as a whole due to the stress of the job from long hours, low pay, consecutive days without time off and high travel demands. Stress within the job setting can lead to fatigue, short tempers, impatience, and is linked to depression, anxiety, weight gain, and cardiovascular disease; all of which can adversely affect the adequacy and quality of sports medicine care provided to NCAA student-athletes.
It is now 2012. Have there really been any significant changes in NCAA schools?
Know the Legal Implications
Which of the following statements are true?
Athletic trainers have a strong sense of autonomy.
Certified athletic trainers render services or treatment under the direction of a physician.
Many athletic trainers don’t know as much as they should about the rules and regulations that govern our practice.
Many athletic trainers do a poor job with documentation.
In my opinion, all 4 of the statements are true.
We are regulated by government, not by what we know. Our state laws define our scope of practice. These laws legally define our profession and protect the public. Many of the cases of nonlicensed athletic training practice complaints in New Jersey (where I work) come from the public—certainly an interesting paradox there! First, why are athletic trainers practicing without a license? Second, certainly this is not the public recognition athletic trainers want! How many other states have this same issue? Do you know someone who is not compliant?
Many of the new state concussion laws certainly have helped the athletic trainer brand. Further, the National Football League’s new rule10 about athletic trainers in the press box (to monitor play of both teams and provide medical staffs with relevant information to assist in the evaluation and treatment of players) raises awareness of our expertise. However, once again this public recognition has not gone unnoticed, as more and more sports injury lawsuits name athletic trainers as defendants.
In 2009, part of a case involving athletic trainers from Eastern Illinois University centered on whether they could use the “sovereign immunity” defense.11 Many athletic trainers could claim that defense because we work for public institutions. In this case, it was determined that the athletic trainers could not use this defense because they were subject to a “duty of care” established by the Illinois Athletic Training Practice Act. In this case, it meant that the athletic trainers themselves—not the State—were responsible for defending the suit. Is this example a vision of the future or just an isolated case?
Communicate More Effectively
Another point here is the possibility of a lack of communication.
Lisa Kuiper, RN, of The Medical Detective, stated:
“Failure to communicate.” That charge is at the heart of a growing number of nursing malpractice cases these days. It’s not that nurses don’t talk enough; indeed, communication drives the entire nursing process. But RNs have been found negligent for endangering their patients by failing to communicate with the right person, at the right time and in the right way.12
In my opinion, lack of communication also refers to lack of documentation.
Athletic trainers must embrace and value the importance of good documentation to protect ourselves and to provide proof that proper care was rendered to athletes. In New Jersey, many cases brought before the Athletic Training Advisory Committee to the New Jersey Board of Medical Examiners reflect the inadequacy of proper documentation during athletic injury management. Those who have been involved in a malpractice case or tort claims case will understand what I’m talking about. Athletic trainers who think a simple sign-in sheet for athletes is adequate documentation of their care are sadly mistaken. Again, we can be our own worst enemy.
To tie together those 4 true statements mentioned previously in this editorial, we cannot be arrogant and pretend we work autonomously; certainly, we work as health care providers because of our skill set and the scope of practice laws in our respective states. However, we must understand our state laws and our duty of care, as we will be held liable for failure to communicate with our physician colleagues.
One personal example may further impress on you the importance of those comments. An athlete came into camp and, during his physical examination, admitted to having experienced numerous concussions. When we asked for information about the concussions, we came to realize he had never seen a physician, and the only person who he had ever seen was his high school athletic trainer. This is a violation of our state concussion law!
Besides me, does anyone else see a problem with this example? Did the athletic trainer feel he was autonomous? Did the athletic trainer not understand the state law regarding association with a supervising physician? Or was he concerned about upsetting the coach instead of acting in the role of the medical professional responsible for the safety of the athlete?
Athletic trainers are being watched now more than ever. Those who are involved with state regulations and governmental affairs can attest to that. Some groups and legislators behind the scenes would love for us to back down or disappear. It is a constant battle, and we cannot become complacent after a law has been passed or a legislative battle won. Newer athletic trainers have no choice but to get involved and stay involved in legislative action.
Develop Clinical Expertise
As I alluded to before, our clinical skills and educational competencies have been developed over time and look great on paper. I applaud that we are finally moving toward evidence-based practice; however, experience can be developed only over time. Did that athletic trainer I mentioned above have enough hands-on experience?
It seems we have started to sacrifice our hands-on skills for didactic skills. The more I speak with some of my colleagues, the more obvious it is that current students do not have the same opportunity to develop hands-on skills that former students from 3 or more years ago did; therefore, I feel that the critical thinking skills of our students have begun to suffer. There is a multitude of reasons for this, but they will not be debated in this editorial.
Our educational programs in their current form do not allow students enough clinical experience to develop this critical thinking component. Sure, we have laboratory classes and students complete their proficiencies, but that does not provide enough hands-on experience. Unlike other health professionals, athletic trainers do not often have the opportunity to work with preceptors or mentors in professional practice after graduation. Athletic training graduates are basically on their own if they go right into the workforce. This needs to change.
In 2008, a reprint appeared in the Athletic Trainer Education Journal of an excellent speech given in 2005 by Herbert L. Fred, MD.13 In that speech, Dr. Fred referred to “hyposkillia—deficiency of clinical skills”—a problem faced by the medical profession. Athletic trainers have always been proud of their clinical expertise, but our current educational models are not conducive to this history. Are we headed down the path of hyposkillia?
The field of athletic training needs a 5-year model that allows for a master’s degree, but with additional clinical experience that is built into the program in the fifth year. We must do something to improve our clinical competence as health care professionals.
This effort is even more important if we realize there are a growing number of state boards that are considering or at least are talking about how to determine whether health care professionals actually maintain their skill set or competencies and whether they need to be evaluated on a more regular basis. I bring up this issue with the following thought in mind: In New Jersey, there is a movement to change our concussion law to allow any “licensed health care provider” the ability to clear an athlete who experienced a concussion for return to play. Athletic trainers are well educated in concussion management, but new graduates are not well experienced in making a return-to-play determination. I have been practicing for more than 30 years, yet I still do not feel comfortable having the final say on the return-to-play decision. I make those decisions with our physicians as a group, as I hope all athletic trainers do. Yet here is the possibility that a new graduate can make an independent decision about return to play. I already gave an example of an athletic trainer making decisions that are in violation of our law as it stands right now. Would you want to assume that risk?
Athletic training is a great profession with an abundant history and a future that is yet unwritten. We can no longer afford to allow ourselves to be our own worst enemy. All of us must be vigilant in our efforts to maintain and improve our practice. So, I challenge you to help athletic training remain a great profession—don’t let yourself become complacent. You are in charge of your own destiny, but only if you take the time to understand what is needed to become better. Make comments about our education, stay vigilant about your state regulations, and maintain your clinical expertise. The only one who can make you better is you.
Athletic trainers have an important talent—protect it.
- Enock Plancher, as Personal Representative of the estate of Ereck Michael Plancher, II, Deceased vs. University of Central Florida board of trustees and UCF Athletics Association, Inc., a Florida Corporation, Defendants, (9th Cir 2009) (2012).
- The Joint Commission. Health care worker fatigue and patient safety. Sentinel Event Alert. 2011;(48):1–4.
- Grantham J. Day in the life: Flower Mound High School. NATA News. November2011:18, 20–21.
- Grantham J. Day in the life: Allen Americans. NATA News. March2012:20–22.
- Kelsall D. Must we keep depriving residents of sleep?CMAJ. 2009;180(11):1087. doi:10.1503/cmaj.090764 [CrossRef]
- Owens JA. Sleep loss and fatigue in healthcare professionals. J Perinat Neonat Nurs. 2007;21(2):92–100.
- Scott LD, Rogers AE, Hwang WT, Zhang Y. Effects of critical care nurses’ work hours on vigilance and patients’ safety. Am J Crit Care. 2006;15(1):30–37.
- Network [DVD]. Beverly Hills, CA: Metro-Goldwyn-Mayer and United Artists; 1976.
- Lowe R. Athletic training salaries on the rise according to latest survey. NATA News. November2011:12–14.
- National Football League. Memo explains policy to have trainers monitor for concussions. http://www.nfl.com/news/story/09000d5d82547e65/article/memo-explains-policy-to-have-trainers-monitor-for-concussions. Updated December 21, 2011. Accessed June 4, 2012.
- Sellers v. Rudert, 918 NE 2d 586 (Ill App Ct 2009).
- Nurses Service Organization. Beware of these communication pitfalls. http://www.nso.com/nursing-resources/article/38.jsp. Accessed June 4, 2012.
- Fred HL. Hyposkillia—deficiency of clinical skills. Athletic Training Education Journal. 2008;3(Jul–Sep):82–83.