Portal de Periódicos da CAPES

Organizational Socialization Experiences of Athletic Trainers Working in the Clinical Context

2012; Volume: 4; Issue: 6 Linguagem: Inglês

10.3928/19425864-20120622-02

1942-5872

William A. Pitney, Stephanie M. Mazerolle,

Innovations in Medical Education

Original Research freeOrganizational Socialization Experiences of Athletic Trainers Working in the Clinical Context William A. Pitney, EdD, ATC, FNATA, , and , EdD, ATC, FNATA Stephanie M. Mazerolle, PhD, ATC, , PhD, ATC William A. Pitney, EdD, ATC, FNATA and Stephanie M. Mazerolle, PhD, ATC Athletic Training & Sports Health Care, 2012;4(6):265–274Published Online:June 22, 2012https://doi.org/10.3928/19425864-20120622-02Cited by:5PDFAbstract ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinkedInRedditEmail SectionsMoreAbstractAccording to the National Athletic Trainers' Association (NATA), the clinical setting is where the highest percentage of certified athletic trainers who are also NATA members is employed (21.5%). However, little data exist related to their organizational socialization in this setting. The purpose of this qualitative study was to gain insight and understanding about the organizational socialization of athletic trainers working in multidisciplinary clinical rehabilitation settings. Fifty-two (27 women; 24 men; 1 undisclosed) athletic trainers participated in this study. In some instances, an athletic trainer's role was relegated to assist or support other health care providers. Most participants' socialization experiences were informal and unstructured, which may allow athletic trainers entering the multidisciplinary clinical setting to negotiate their roles to more fully use their professional capabilities. Study participants perceived that settings that encourage professional collaboration lead to improved patient care outcomes.IntroductionThe way in which a health care provider engages in his or her professional practice is dependent on the interactions he or she has with others as they are socialized into the organizational setting.1 The organizational aspect of professional socialization is a developmental process whereby an individual learns through social interactions and acquires the cognitive, behavioral, and affective aspects of a particular role.1–3 Organizational socialization can influence the expectations, attitudes, perceptions, and execution of a professional's role.4,5The organizational socialization process may have varied influential outcomes. The negative outcomes of organizational socialization include burn-out,5 role stress and strain,6 work dissatisfaction,7 low self-esteem,8 and a propensity to leave an organization.6 Many of these negative outcomes are the result of a socialization process that results in ambiguity about one's role or creates role overload.9 The positive outcomes include personal enrichment,5 job satisfaction, and professional commitment.10 The positive outcomes emerge from a socialization experience whereby one's role is congruent to the values of the organization, thus resulting in a well-defined role.9 Of particular importance for health professionals is the effect the socialization process has on patient care. Indeed, if the social interactions within an organization lead to negative outcomes, the delivery of health care to patients can be compromised.11,12Some aspects of the organizational socialization of athletic trainers have been investigated in a variety of settings, including college and secondary schools.12–15 Key findings from these studies reveal that socialization processes are unstructured,13,14 which leads to concerns relating to one's quality of life13 and role overload.15 Moreover, others (eg, coaches) do not fully understand the role of an athletic trainer,12 which can create an environment where one's ability to fully use his or her professional skill set is challenged. However, to date, the socialization process in the clinical setting has not been fully investigated. The clinical setting is an organizational environment in which athletic trainers have gained entry over the past 20 years. In fact, according to the April 2011 National Athletic Trainers' Association (NATA) membership statistics,16 the highest percentage (21.5%) of certified athletic trainers are employed in the clinical setting.Athletic trainers working in a clinical setting are likely to find themselves in an environment where they interact with a variety of other health professionals (eg, physical therapists, occupational therapists, nurses) on multidisciplinary teams that provide patient services. Scholars have expressed concerns about how health professionals understand the roles of others when functioning in an interdisciplinary team environment,17,18 such as the clinical setting. This concern, coupled with many disciplines' "turf wars" and tensions among rehabilitation professionals,19 requires a better understanding relating to the socialization process of athletic trainers in the clinical organization and how this process influences the execution of their professional roles. Therefore, the purpose of this study was to gain insight and understanding about the organizational socialization of athletic trainers working in multidisciplinary clinical rehabilitation settings. The following questions guided the study: How do athletic trainers describe the socialization process they were exposed to in their first several years of practice?How do athletic trainers describe their professional interactions with others in the clinical environment?How do athletic trainers describe others' perceptions of their role in a clinical rehabilitation setting?MethodThis qualitative research study was exploratory in nature and had the goal of describing the organizational socialization experiences of athletic trainers in the clinical setting. We initially collected data electronically with asynchronous, structured interviews using SurveyMonkey as the online platform. This allowed us to obtain data from a larger sample by minimizing the logistical challenges of telephone or in-person interviews.20 The study received appropriate institutional review board approval prior to data collection.ProceduresWe worked with the NATA Member Services Department to purchase the contact information of individuals in our target population. At the initiation of the study, the December 2009 NATA membership statistics identified 2477 individuals as having worked in the clinical setting, designated as the Outpatient/Ambulatory/Rehabilitation Clinic subcategory,16 and 1158 of these individuals allowed their e-mail addresses to be distributed by NATA Member Services for the purposes of research. Thus, a total of 1158 e-mail solicitations were sent to NATA members who are certified athletic trainers. Sixty-two (5.35%) individuals agreed to participate, but only 52 (83.9%) submitted responses. A final iteration of questions was also completed by 46 respondents, but these data are primarily related to exploring work–family conflict and are not presented herein.ParticipantsFifty-two participants, with a mean age of 37±10 years, participated in the study. The participants averaged 12±9 years as athletic trainers and were in their current position for 7±7 years. Twenty-seven (51.9%) participants were women, 24 (46.2%) were men, and 1 (1.9%) was undisclosed. Participant demographic information is shown in Table 1.Table 1 Study Participants' Demographic Information (N = 52)DEMOGRAPHICNO.%aGender Women2751.9 Men2446.2 Not specified11.9Highest degree obtained Bachelor's2548.1 Master's2446.2 Doctorate35.8Current job parameters Full-time clinical2650 Part-time clinical47.7 Clinical outreach1834.6 Other47.7Ethnicity American Indian or Alaska Native11.9 White4994.2 Not specified23.9NATA district (state) 1 (CT, MA, ME, NH, RI, VT)35.8 2 (DE, NJ, NY, PA)35.8 3 (DC, MD, NC, SC, VA, WV)47.7 4 (IL, IN, MI, MN, OH, WI)1732.7 5 (IA, KS, MO, NE, ND, OK, SD)59.6 6 (AR, TX)23.8 7 (AZ, CO, NM, UT, WY)59.6 8 (CA, HI, NV)11.9 9 (AL, FL, GA, KY, LA, MS, TN)59.6 10 (AK, ID, MT, OR, WA)11.9 Not specified611.5Abbreviation: NATA, National Athletic Trainers' Association.aPercentages may not total 100 due to rounding.Data Collection and AnalysisData were collected via 3 iterations of online, asynchronous interviews (approximately 1 week apart) during a 3-week period with participants answering structured interview questions using an online survey platform. Follow-up e-mails were used to clarify information submitted by participants. A total of 398 correspondences were exchanged during the asynchronous electronic interview process. The interview guide (Table 2) was based on previous socialization research13,14 and was reviewed by a 2-person panel of individuals with experience conducting qualitative research. The panel validated the content of the questions as they related to the purpose of the study, and subtle changes were made to 3 questions as a result.Table 2 Interview Questions Relating to Organizational Socialization1.Describe your career path and how you came to work in the clinical setting as a certified athletic trainer.2.Describe your current work setting for me. For example, what are your primary responsibilities? What is your typical day like?3.When you first started working in the clinical rehabilitation setting, what was the work orientation like? For example, was "learning the ropes" in the setting a formal process? An informal process? Please explain.4.What other health care providers work in this clinical setting?5.How would you describe your relationship with these other health care providers? Explain what your primary role is compared with the other health care providers you work closely with.6.How are the other health care providers likely to view your role in the work environment? For example, if you work with a physical or occupational therapist, what would this individual say about your abilities in the clinical rehabilitation environment?7.How has working in a multidisciplinary setting (working with other health care providers) influenced your professional development?8.What are the advantages of working in a multidisciplinary clinical rehabilitation setting?9.What are the disadvantages of working in a multidisciplinary setting?10.Please provide any additional thoughts you have related to working with other health care providers in a clinical rehabilitation setting.In addition to online interviews, the participants were provided with the opportunity to engage in a telephone interview after the electronic data collection was completed. Ten individuals participated in follow-up interviews that were designed to verify the findings (member check). The member check process involved sharing emergent themes with participants and, based on the individual's experience, obtaining verification that the themes were logical. Telephone interviews were recorded and subsequently transcribed verbatim. One participant requested that the interview not be recorded; therefore, notes were taken during the interview.The electronic and telephone interview textual data were analyzed using an inductive content analysis.21,22 An inductive content analysis involved reading the textual data for meaning, assigning it a label, and organizing the conceptual labels into themes.22 Member checks23 were performed as part of the telephone interview process with 10 participants; peer debriefing21–23 was also performed to ensure trustworthiness. The peer debriefing process was conducted by a peer (with qualitative research experience) who reviewed the data along with the analysis scheme. The purpose was to ensure that data were collected and analyzed in a logical and systematic manner, as well as to ensure that the findings were reasonable based on the textual data collected from participants.ResultsOur results are based on an inductive analysis of the textual data from both the electronic interviews and telephone interview data. We also report the number and percentage of participants who described various experiences. We believe these data provide appropriate descriptive information related to variations in athletic trainers' experiences in the clinical setting, although they are not consistently reported in qualitative studies.Three higher-order themes emerged from this study: (1) wide-ranging socialization experiences, (2) athletic trainers' roles in professional collaboration, and (3) perceived improvement of patient care. The Figure presents a schematic of the higher-order and lower-order themes. Each of the higher- and lower-order themes are presented below, with direct quotes from the participants as evidence. In all instances, pseudonyms are used to protect participant confidentiality.Figure. A graphic representation of the emergent themes is presented. The higher order theme, Wide Ranging Socialization Experiences, is composed of the lower order themes entitled Formal Processes, Semi-formal Processes, and Informal Processes. The Athletic Trainers' Role in Professional Collaboration is composed of the lower order themes, Athletic Trainers are Integral Team Members and Athletic Trainers Have a Relegated Role. Factors related to the athletic trainers' relegated role include Others' Lack of Understanding the AT (athletic trainer's) Ability, state Practice Acts, and Reimbursement Issues. The final emergent theme, Multidisciplinary Collaboration Improves Patient Care Outcomes, is composed of the lower order themes Facilitated by Communication and Management Support, and Inter-professional Learning: Expanding Knowledge, Skill, and Treatment Options.Wide-ranging Socialization ExperiencesThe first theme, wide-ranging socialization experiences, relates to how athletic trainers are oriented to their role in the clinical setting during the induction period. The socialization experiences described by participants were schematized as unstructured/informal, semistructured/semiformal, or structured/formal based on the description of their experiences.Unstructured/Informal Induction Process. Twenty-five (48%) participants experienced unstructured and informal induction processes. Dunn described the unstructured nature of the process as follows: Learning the ropes was a very informal process. I was thrown to the wolves and expected to fit in and do the job. When I started, the PT [physical therapist] made the rehab programs and I instructed patients on what to do and monitored them. Now I know what the PT is going to set up, so I make the programs and the PT reviews them at convenient times. Patient set up became a secondary role after one of our two PT's [sic] was laid off. There was no formal learning process or time when I was monitored. I started and asked questions as needed and figured out the ropes on my own.Another participant, Darrin, described a similar circumstance: [My induction experience] was kind of learn as you go. You basically got in there and learned by doing and following pre-established protocols, learning how the physical therapist liked to do things and then developing your own style on how to deal with each individual patient. The outreach program, on the other hand, was just to go out and see what works and what did not, and make up my own program.An unstructured and informal induction process involved the clarification of information by asking the participants to explain their organizational process. Maurine articulated this process by saying: It was a very informal process. Things were explained to me as they came up. I trained for about 1 week by another ATC [sic] before I was transferred to the clinic I work at permanently. Even once I was there, I continued to learn about the clinic.Semistructured/Semiformal Induction Process. Fourteen (27%) individuals indicated their induction procedure was semistructured or semiformal. This form of orientation commonly involved instruction of duties and overview of record keeping and medical documentation, which required participants to transition to patient care with little direction. One participant, Tammy, explained the semistructured nature of her induction as follows: The orientation process had both formal and informal aspects. Formally, we had one and a half days of hospital orientation followed by a half day of department specific orientation. We also had designated meetings once per week for a month to learn the sports [rehabilitation] protocols and physician preferences. The remainder of the training was informal. We were expected to utilize [the] patient care committee to discuss complex cases with more experienced members [and] colleagues.Quinn had a similar experience. He stated: When I first started, it was a mixture of both formal and informal processes. The athletic trainer I was hired to replace did a good job showing me the ropes, but once he was gone I had to figure things out for myself.Structured/Formal Induction Processes. The remaining 13 (25%) participants articulated having experienced a more structured and formal orientation program related to patient care, medical documentation, and departmental procedures. The use of a structured formal induction process tended to occur when a clinical setting was associated with a larger health care system, as Lance explains: Since I work at a clinic that is associated with a larger hospital, one of the largest in the [region], I had a very formal orientation. [I received] two full days with over 100 new employees in various departments, covering all aspects of the hospital. The third day was spent in the Sports Medicine Clinic for tours, meet and greet, and just, get to know my new work environment. Since I already did an internship here 4 years ago, I was very familiar with most of everything. I also had to take four separate computer courses through the hospital so I can have access to patients' records, set patient appointments, etc.This form of organizational socialization was also described by Scott: Because I am working for a physician's office that is part of a large medical system with several hospitals, the original orientation was a formal process. The on the job training was a bit different because I had to learn quickly what was thrown at me over a short period of time. There was also a certain amount of information that was thrown at me that I was only vaguely familiar with…and now I use that information every day.In summary, a wide range of socialization experiences were identified by study participants. The more structured and formal socialization tactics were experienced by athletic trainers working in complex medical centers. The participants articulated that working in multidisciplinary settings benefited the patients, regardless of the organizational induction experience or whether an athletic trainer had a relegated role in a multidisciplinary setting.Athletic Trainers' Role in Professional CollaborationThe second higher-order theme, athletic trainer role in professional collaboration, consisted of two second-order themes: (1) athletic trainers are an integral members of the treatment team, and (2) athletic trainers have a relegated role. The Figure provides a visual representation of the themes.Athletic Trainers Are Integral Team Members. Forty-one (79%) participants reported being integral members of a team approach to health care, whereby they had a key role in patient treatment and rehabilitation. When describing the interactions and relationships with others, these athletic trainers expressed excellent working relationships. Paula, for example, described her clinical relationships as collegial in that the various health care providers were always "working together as a team to achieve the best results in a timely manner for the benefit to the patient/client." Similarly, when asked about the relationship with other health care providers, Carl articulated that they work together "very well. [The interaction] has provided the opportunity to see how the team approach works best in delivery of care with everyone having similar knowledge in certain areas." The athletic trainers' role as an equivalent team member in the clinical setting was also identified by Boyd: Personally, I believe the majority of [other health care providers in the clinic] would speak very highly about my abilities. I have been told frequently that my abilities surpass anything that they have ever seen out of an athletic trainer, specifically in the rehabilitation setting. The majority would see me as an equivalent or better in skill and abilities.Another study participant, Erin, described the relationship between the health care providers at the clinic as "very good, open communication, give and take conversations." She went on to say that "there is a misconception about how much ATC's [sic] are allowed to do or what they are capable of doing. Fortunately, at my office I am used to my full potential and respected as such."Although the majority of athletic trainers in this study discussed using their full level of expertise in the clinical setting, many articulated being limited in their role. The following lower-order theme describes these experiences.Athletic Trainers Have a Relegated Role in the Clinical Setting. A smaller portion of the participants (21%, n = 11) had roles whereby they were consigned to assist, support, or aid the roles of other health care providers (eg, physical therapists). This group of participants perceived that they were not able to perform to their full potential as athletic trainers in the clinical setting. In most instances, the athletic trainers described their role as tertiary to other providers by "assist[ing] PTs with their patients" or being "support" personnel. For example, Andrea stated: In my particular clinic, I am not able to use many of my skills. The PTs [physical therapists] do not utilize me, as they choose not to/or cannot bill for my services. I may assist people with their rehab exercises only, fold and wash laundry, and keep up with flow charts.Similarly, Robyn articulated: I do not feel my full knowledge, skills and abilities are used. Currently where I work, we are not allowed to do initial assessments. I think with assessing many orthopedic injuries I am as capable or more capable of assessing these cases than a physical therapist. After the initial assessment, however, I do have the ability to give input through completing interims and progression of treatment programs.Study participants further explained the underlying reasons for their relegated role, including reimbursement issues, state practice acts, and a lack of understanding by others of athletic trainers' expertise. Luis, who was dual credentialed as a physical therapist, stated: Well, I am also a PT [physical therapist], so I have more leeway to use my athletic trainer skills from a rehab standpoint. That being said, I know how athletic trainers are used in clinics, and I imagine that most of them would say that they feel like they are 'PT techs' because billing for athletic trainers' services clinically is not done in many states.Carson submitted an electronic response that captured the complexity of issues that cause an athletic trainer's role to be relegated: 1.Some PTs [physical therapists] do not accept that athletic trainers have training and skill that allow them to fully engage the [patients] and utilize our skills. Some PTs do recognize and feel comfortable allowing treatment to progress under their eyes and with little input.2.Some PTs aren't comfortable with anybody, doesn't matter what certification they have, they just can't let go of the reins.3.The interpretation of the practice acts is varied within companies and regions, (even look at our guidelines across the nation).4.Medicare is a driving factor in the insurance world, they set up guides and the others jump in line; because [Medicare] doesn't recognize ATC [athletic trainer], but the PTA [physical therapy assistant] is. I cannot legally treat and bill for these [patients] in the clinic setting. I can with other insurances.5.Some of the [patients] are not within my "scope of practice," and I recognize this; but in outpatient orthopedics I am very comfortable.6.I don't think that we will be able to change a rule that will go across all of the states and all of the insurance companies and get on equal ground with [patients]/athletes in 'PT' clinics.7.We used the ATC [sic] billing codes as a trial a year ago and got a negative result: insurance companies did not recognize them. If they did, they always asked for additional paperwork and justification; the time spent and reimbursement was not enough to encourage continued use in the clinic.This was corroborated by Franklin, who explained the nature of the limitations placed on athletic trainers in the clinical setting: The first limitation is the clinician[s] themselves. Whether through inadequate continuing education, poor time management, or limited experience, the greatest limiting factor on the clinician is the clinician[s] themselves. The second limitation is the clinical setting. In the clinical site of a physical therapy clinic, the greatest limitation to an athletic trainer is billing for services. Some private insurance companies pay quite well, some moderately well, and some not at all; not to mention the Medicare discussion. This provides for unique challenges in scheduling as to whom the certified athletic trainer can 'see.' While the certified athletic trainer is certainly qualified to evaluate and treat musculoskeletal and nervous conditions, the insurance fight is one that still is a limiting factor to the certified athletic trainer who practices in a physical therapy clinical setting.For those participants who experienced a relegated role at one time or another in the clinical setting, a lack of understanding about athletic trainers' abilities was a common reason for the occurrence. For example, Jenna described a previous clinical position where her role was relegated: I have worked for other therapy clinics. I was treated like a quack where it was basically, [do the] laundry and [give] ultrasound [treatments], and so I've worked the whole spectrum of rehabilitation setting with athletic trainers. I think a lot of people aren't even familiar with our education and what we do know and how we are trained, and so with [my current physician director] I'm lucky because he knows [what we do]. I think a lot of [other health care providers] think we tape ankles and put icepacks on and we, you know, basically have the educational background of maybe an EMT [emergency medical technician], and therefore they don't trust or have faith that we have the knowledge base of…what they have.Perceived Improvement of Patient CareParticipants articulated that working in a multidisciplinary environment facilitated improved patient care, which is the third and final theme. Clayton relayed the benefits of the clinical environment concisely, as he stated: "I believe an interdisciplinary approach significantly enhances the patient's outcomes." Boyd corroborated this concept by saying: [You get] different views and approaches to specific injuries, and treatment protocols are brought to the table. The best [treatment strategy] is found. I feel this not only benefits us as clinicians, but more so the patient and their outcome.Participants expressed that the perceived improvement of patient care was the result of the multidisciplinary interactions expanding one's knowledge, skill, and treatment options. Addressing this point, Susie stated that the multidisciplinary setting has "been very valuable in adding to my knowledge and skills in many different areas. I am constantly learning from my coworkers." Nyles also commented on the interactive environment leading to increased knowledge and, ultimately, improved comfort with treating patients: I have gained knowledge from all of the different people I work with. I have become more interested in things I used to be less interested in, such as concussion management. I never really felt very comfortable in the past dealing with concussions. Now I feel much more comfortable and interested in working with these athletes.From the perspective of the participants, the organizational mission and support tended to facilitate positive team interaction toward a focus on enhanced patient care. For example, Jenna reported that the clinic director where she works placed personnel together with a common goal of high-quality patient care and that it resulted in positive interprofessional relationships. She stated: I really think it was the doctor putting people together that he felt would match that role, because the physical therapist we work with is also very willing to work with athletic trainers and, you know, share his knowledge and teach us along the way, and he doesn't have [a] 'it's me and it's you' kind of attitude, which I've run into in the past. I really think everybody here has the common goal of having a good outcome with the patient.Another participant also articulated that not only was a focus placed on patients' treatment goals, but effective communication helped to create a team environment that facilitated improved care: I would say first and foremost, communication between all parties involved in patient care helps everyone be on the same level, and just all working together for the same patient goals it's not like we have our own patients, so it's all those things.DiscussionThe purpose of this study was to gain insight and understanding about the organizational socialization of athletic trainers working in the clinical setting, which, according to the NATA membership statistics, is the largest practice setting for athletic trainers. Little information is available on the process by which the athletic trainers gain understanding of their role within this setting. Moreover, the way in which health care providers engage in their professional practice is linked to the manner in which they are socialized,1 thus indicating the need to explore this process for the athletic trainer. Organizational socialization has be