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1 20 UNDERSTANDING THE PERCEPTIONS OF PROFESSIONALISM IN ATHLETIC TRAINING WITH THE USE OF A PROFESSIONALISM QUESTIONNAIRE BLINDED TEMPORARILY BY KIMBERLY S. PEER (July 2015) ALL AUTHORS MAINTAIN FULL AUTHOR RIGHTS 2 UNDERSTANDING THE PERCEPTIONS OF PROFESSIONALISM IN ATHLETIC TRAINING WITH THE USE OF A PROFESSIONALISM QUESTIONNAIRE Abstract Context: Professionalism is the combination of clinical competence, legal/ethical understanding, knowledge and humanistic qualities. In athletic training education, professionalism is a foundational behavior of professional practice that should transcend all aspects of the educational program. Very few objective measurements of professionalism have been used to investigate athletic training students or certified athletic trainers. Objectives: To examine the overall perception of professionalism in athletic training to determine if athletic training student perceptions differ from certified athletic trainers. Design: Survey Setting: Twelve, CAATE-accredited, Undergraduate Athletic Training Programs (ATPs) in the Mid-American Athletic Conference. Participants: Seventy-four participants, including students (pre professional and professional phase) and certified athletic trainers (graduate students and faculty/staff). Instrumentation: The Penn State College of Medicine Professionalism Questionnaire (PSCOM-PQ), a valid and reliable instrument, was used. It represents the American Board of Internal Medicine’s (ABIM) six a priori elements of professionalism. Data Analysis: A 4x6 (group: Pre-Professional Student, Professional Student, Certified Graduate Student, Certified AT x element: Accountability, Altruism, Duty, Excellence, Honesty and Integrity, Respect) Analysis of Variance (ANOVA) with repeated measures on the ABIMs six a priori elements of professionalism was performed for aggregate rating and rank ordering scores. Post hoc analyses consisted of Independent sample T-Tests by group. Results: There were no significant differences between students and certified athletic trainers. However, Pre-professional students significantly differed from professional phases students in 4 of 6 a priori elements of professionalism. They included accountability (t=1.8, p=.03), altruism (t= 1.4, p= .04), excellence (t= 1.53, p= .011) and respect (t= 1.04, P= .04). Pre-professional students significantly differed from graduate students in the a priori element of excellence (1.72, p= .04). Pre-professional phase students significantly differed in honor/integrity (t=1.56, p=.03) when compared to graduate students in the rank ordering analysis. Conclusions: Athletic training students do not differ significantly in their perceptions of professionalism when compared to certified athletic trainers. Key words: Socialization, Competency, Foundational Behaviors of Professional Practice Introduction Perceived decline in professionalism within the medical community has prompted an extensive review and reflection of the concept.1-8 No clear consensus on the definition of professionalism is universally agreed upon. Project Professionalism9 defined professionalism as intrinsic qualities of healthcare providers such as altruism, compassion/caring, honesty/integrity, respect and commitments to practicing medicine at the highest levels of excellence and ethical judgment. Professionalism is a crucial component of the overall professional development of healthcare providers. Medicine (and health care providers) seeks to maintain a fiduciary responsibility and serve the contractual obligation to society is dutifully noted in literature.6,8, 10 The Council on Accreditation for Graduate Medical Education has adopted ‘professionalism’ as a competency for residents and medical students.9,11 Professionalism education has shifted from students informally learning professionalism to formal and explicit professionalism and humanism education.13,14 A broad array of professionalism assessment techniques and methods has been documented in literature. 14-16 While abundant literature exists relative to professionalism in medicine, less has been published on professionalism in athletic training.17,18 As allied healthcare providers recognized by the American Medical Association, the link to the medical literature is important but not sufficient to define the professionalism in the athletic training field. Although the profession of athletic training has evolved substantially from its inception in the 1950’s, as a whole it continues to face several critical issues with professionalism and professional identity.19 As recently reflected in modern media and contemporary research, the perception of professionalism in healthcare is lacking .5-8,14 As healthcare providers, athletic trainers are not immune from this dilemma nor should they be so naïve to think that the lack of professionalism among other health professionals will not or has not transcended into athletic training.17,18,20 A multitude of factors contribute to this issue including a perceived lack of professionalism in medicine by society, lack of operational knowledge/definition of professionalism and changing healthcare/ educational systems.21 The perception of decreasing professionalism within medicine is cause for concern and served as a catalyst for the professionalism movement in medicine. Abundant literature on professionalism in medicine has been published, especially in the last decade.1-10 Healthcare providers have obligations to patients, and themselves but, most importantly, to society as a whole. Inherent to medicine and allied health (AH) is a contract with society; and at the center of that contract is the concept of professionalism.22,23 Physicians, AH care providers and athletic trainers are committed to this societal contract through their daily interaction with patients, athletes and other professionals.24 Various studies in medicine and other AH disciplines have documented the need to develop, foster and formally instruct/assess professionalism.25-28 Professionalism remains one of the more highly debated yet least understood competencies in the health professions education.4-6,15,21 As a relatively new profession, athletic training is continuously evolving and is currently struggling with issues such as third-party reimbursement, equal access to patients, an improved professional identity and state licensure.29,30 Other AH disciplines have completed a transition to doctorate level to practice, thus providing them with a higher level of professionalism or perceived professionalism that does not exist in athletic training.31,32 If athletic training is to continue to develop as a profession, further improvement on and fostering of professionalism is crucial. By improving the professional identity and demonstrating congruent level of professionalism with other health care providers, athletic training can have an improved status and presence in today’s health care arena.31,33 Athletic training education has endured drastic changes and reform in recent years. Historically, an internship-based route to certification existed, whereas today, successful completion from an accredited athletic training program is the sole path to certification.30 Athletic training education incorporates various instructional methods including formal didactic instruction and clinical, as well as situational-based experiences.34-36 Formal and explicit education, demonstration/assessment of professionalism and professional behaviors are warranted in medical education.3,10,13-14, Research has also demonstrated that the much of the information and knowledge conveyed to athletic training students is done via the “hidden curriculum”.2,12,17,37 This informal instruction remains an integral component of medical and athletic training education.17 Athletic training students learn differently depending on the situation, clinical experiences and clinical instructors.36 Therefore it seems logical that knowledge retention, skill acquisition and perceptions of professional roles/responsibilities would differ among students.17-20,33 Contemporary thought regarding the concept of professionalism reflects that students adopt the attitudes, attributes and values demonstrated and instructed to them.17,35 Athletic training educational programming reflects this concept by delineating seven Foundational Behaviors of Professional Practice38, as defined by the National Athletic Trainers’ Association, which must be taught and assessed throughout athletic training education. Professionalism is included as a Foundational Behavior along with: primacy of the patient, teamed approach, legal/ethical practice, knowledge advancement, cultural competence, legal and ethical practice as a foundational behaviors.45 Furthermore, professional development and responsibility remains an area of competency assessment by athletic training education programs. The professional socialization process is a model of transitioning students into professionals by preparing them for the roles and responsibilities of a profession through development and promotion of core values, professional behaviors/attitudes and clinical competence.39,40 Athletic trainers are socialized throughout their academic career and even into their professional practice.40,41 While it is documented that athletic training students are versed in professionalism and professional development, little is known about what attitudes, behaviors or values students actually perceive as “professionalism.” Furthermore, literature suggests that differences between what is being taught (classroom) and what is being demonstrated (clinical setting) is different, even reflecting significant conflict with what is taught in the formal instructional components of the curriculum.12,40,41, 44 Without understanding what Athletic Training Students (ATS) and Certified Athletic Trainers (ATCs) perceive as core components in professionalism, little can be done as a far as fostering, assessing or evaluating professionalism. As athletic training continues to move toward obtaining goals of professional credibility, professional identity, autonomy and equal access to third party reimbursement; the concept of professionalism will continue to evolve.20,33 The purpose of this study was to further understand the concepts, themes and perceptions of professionalism in athletic training and to determine if differences in professionalism among athletic training students and certified athletic trainers exist. This research aims to promote discussions within athletic training on professionalism, specifically with regard to a consistent definition of professionalism in the athletic training profession. Methods A survey methodology using a convenience sample was used. Following institutional review board (IRB) approval from the Kent State Institutional Review Board, data collection was performed using a validated, adapted by permission, electronically distributed professionalism questionnaire, Penn State College of Medicine Professionalism Questionnaire14 (PSCOM-PQ). This valid and reliable instrument represents the American Board of Internal Medicine’s9 (ABIM) six a priori elements of professionalism (Accountability, Altruism, Duty, Excellence, Honesty and Integrity, Respect). Electronic surveys designed using Survey Monkey45 software were distributed electronically to a convenience sample of 12 Athletic Training Program Directors for CAATE-accredited Undergraduate Programs affiliated with the Mid American Athletic Conference. Snowball sampling occurred as Program Directors forwarded the instrument to faculty, staff, graduate students and athletic training students associated with the program. Follow-up emails were sent to the program directors as reminders at regularly scheduled intervals. Participants Seventy-four (n=74) usable, individual questionnaires were electronically submitted. They were divided into two categories: athletic training students and certified athletic trainers. Pre-professional phase students (n=19) were students enrolled in pre-major. Professional phase students (n=18) were students ranging in academic standing from sophomore to senior, enrolled in the athletic training major at the institution and were not currently Board of Certification (BOC) certified athletic trainers. The graduate student group (n=18) was comprised of graduate/teaching assistant certified athletic trainers enrolled in graduate coursework through their institution. Finally, participants were required to be BOC certified and employed by their institution as an academic faculty member, clinical staff or both to be included in the faculty/ staff group (n = 19). The certified athletic training group included graduate students (n=18) and academic faculty/staff (n=19). Table 1 illustrates the demographic information of all participants. Instrumentation At the time of this study, no previous inventories, questionnaires or surveys had been utilized in the athletic training to assess professionalism. Therefore, a previously validated questionnaire was sought for use in this study. Due to the close alignment of the elements and the alignment of athletic training as an AMA recognized health care field, The Penn State College of Medicine Professionalism Questionnaire14 (PSCOM-PQ) was adopted by permission as the primary instrument for this study. Permission was granted by the primary author of the instrument and reviewed following modification to ensure the integrity of the