Health care professionals such as athletic trainers (ATs) and athletic training educators should embrace contemporary leadership theories and practice leadership behaviors essential to professional responsibility.
This commentary discusses leadership behavior trends and the need for leadership development in professional athletic training education curricula and continuing education.
Traditional leadership theories focused on trait-based and “Great Man” characteristics. These theories suggest that leaders arise only through inherent or inherited leader-like behaviors. In contrast, contemporary leadership theories suggest that leaders can be developed and better promote the collegial leader-follower exchange that is needed to motivate, encourage, and support followers as well as a profession.
Contemporary leadership theories involve a leader-follower relationship that integrates a teamwork approach into the workplace setting. Athletic trainers practice leadership behaviors but are less likely to demonstrate leadership characteristics when not practicing in their AT roles. Existing evidence suggests that contemporary leadership development can be helpful in athletic training to identify and develop future leaders, to promote the profession, and to improve patient outcomes.
Transformational, team-centered leadership styles provide a growing opportunity for practicing ATs and athletic training students to expand into greater organizational leadership and decision-maker roles.
Athletic trainer leadership knowledge, skills, and abilities development and professional responsibility should be emphasized more in professional athletic training educational programs and continuing education.
Leadership behaviors that are effectively integrated into athletic training educational programs early and often may promote the profession by concurrently improving clinical and professional practice behaviors. Athletic trainers should practice leadership behaviors with greater frequency in differing societal constructs, communities, and complex health care systems.
Evidence supports the value of leadership development in health care professionals such as ATs.
Changes in health care system complexity have increased interdisciplinary leadership opportunities.
Athletic training students can benefit from early leadership training initiatives.
Leadership is the process of influencing others toward the accomplishment of intended outcomes or goals.1,2 Without leadership it is difficult to establish oneself or one's profession as a viable contributor to a community or to society.2 The importance of leadership skills used by health care professionals, and specifically athletic trainers (ATs), has been documented and reported within the past decade.1–6
In 2009, Peer6 wrote about the importance of practicing athletic training leadership behaviors to better develop professional identity and values. These leadership behaviors include cultural competence, ethical and legal responsibilities, professionalism, patient primacy, team decision making, and advancing knowledge within and outside of the profession in a manner that aligns with the seventh edition of the Board of Certification Practice Analysis (BOCPA).7 To reinforce profession credibility, Kutz and Doherty-Restrepo2 suggested that ATs should practice leadership behaviors both within their professional role and outside of that role in the greater community.
Effective collaboration toward common organizational goals in cooperation with other health care professionals is essential to leadership development.8 Leading health care teams in any setting is not only a professional responsibility but requires an interdisciplinary approach (eg, multidiscipline) when considering patient care needs.3 This is evident with evolving health care competencies and emerging trends in interprofessional education as highlighted in the Professional Education in Athletic Training document presented to the National Athletic Trainers' Association (NATA) Board of Directors in 2013.9 This important white paper strongly suggests that to achieve the core competency for delivering patient-centered care and serving as an interdisciplinary team member, the profession should consider a degree change to the master's level.9 Kutz10 adds that within these collaborative efforts, the AT must possess a high level of contextual intelligence, which is the ability to adjust behaviors according to key variables within the context of any given situation. Domain V in the seventh edition of the BOCPA emphasizes that ATs should possess the knowledge, skills, and abilities to improve organizational, personal, and stakeholder outcomes.7 Embedded within this domain is the suggestion that ATs should possess foundational leadership theory knowledge, skills, and abilities in providing situational and person-centered leadership, and contextual understanding of professional standards for athletic training practice and for other health care professions.7
Knowledge, skills, and abilities related to outcomes are essential to making ethical decisions consistent with professional athletic training practice and guidelines in addition to advancing the profession. Recent literature supports the need for leadership knowledge, skills, and abilities development within the athletic training profession.2,5,6,8,10 Therefore, the objective of this commentary is to discuss leadership behavior trends and the need for leadership training and development in professional athletic training education curricula and continuing education.
Evolving Leadership Behaviors
Leadership theories have evolved from more leader-centered “Great Man” and inherent trait-based theories to more team-centered approaches.5,11,12 The Great Man theory adopted the belief that leaders (always male) were born with certain heroic leadership characteristics, natural powers, and influence capabilities that distinguished them from nonleaders.12,13 The Great Man theory originated in the 1800s with social philosopher Thomas Carlyle and was grounded on a statement of faith rather than theory.13 Carlyle believed that “Great men were sent by God to be heroes and these heroes became leaders through the righteous process of hero worship.”13(p253) This traditional perspective does not consider more contemporary team-centered leadership theories based on relationship building, communication, and teamwork. Contemporary leadership theories such as transformational, charismatic, and servant leadership have gained popularity in organizations and health care settings.11 These leadership theories are characterized by a leader-follower exchange, in which leaders influence, encourage, and empower their collegial followers.11,12 The foundational difference between trait-based and transformational leadership theories is that transformational leadership skills represent learned responses rather than ingrained, or inherited personality characteristics.12 Transformational leadership is based on a foundation of universal ethical principles, feeling a sense of obligation to followers, empowering others, focusing on shared goals and objectives, and treating followers with respect.11,14 Bass and Avolio15 characterized transformational leadership as the demonstration of characteristics such as idealized influence, inspirational motivation, intellectual stimulation, and individualized consideration. In a transformational leader approach, the leader influences others toward desired outcomes and goals through collaborative decision making rather than by hierarchically driven orders or directives. Leaders who display transformational leader characteristics are more likely to form stronger and more lasting bonds with colleagues and obtain greater commitment from their followers.5,11,12 Building strong relationships with interdisciplinary colleagues, patients, and families is becoming increasingly important as health care system and workplace complexity contributes to heightened stresses such as burnout.16–19
Leadership Behavior Characteristics in Practicing ATs
Hazelbaker5 suggests that possessing a sound transformational leadership theory understanding provides the AT with the opportunity to develop a more complete organizational culture perspective, to build stronger, longer-lasting relationships, and to more adeptly reach conflict resolution. Sound transformational leadership theory foundation development also prepares the AT to achieve health care program and system improvement and organizational renewal.4 The AT may demonstrate transformational leadership behaviors such as athlete mental health need identification and better translate this recognition into the development and implementation of goal-directed educational programming.4 Another example might be advocacy initiatives to help advance state health care policies such as third-party service reimbursement for ATs by more effectively interacting with health care policy makers and key stakeholders.20
Although the importance of leadership knowledge, skills, and abilities has been identified in athletic training practice10 and that of other health care professions,3,18,19,21 there is limited evidence regarding exactly what leadership behaviors ATs should possess and how they should be instructed and measured. To better identify leadership behaviors and the frequency of their use when functioning in their formal AT role compared with outside of that role, Kutz and Doherty-Restrepo2 surveyed ATs in clinical and academic roles using the Frequency of Leadership in Athletic Training Scale (FLATS). Of the 47 total different leadership behaviors that they identified, 85% were practiced often or always by the AT within his or her professional work roles while only 51% were practiced often or always outside of his or her professional work role (eg, personal life).2 Additionally, 15% of these leadership behaviors were practiced “sometimes” during the professional work role while 49% were practiced “sometimes” when outside of the professional work role. The overall findings revealed that 94% (44/47) of leadership behaviors were significantly higher within the professional athletic training work role compared with outside of the professional work role. Kutz and Doherty-Restrepo2 suggest that ATs who fail to demonstrate leadership behaviors both within and outside of their professional work roles are at a disadvantage in contemporary health care because contemporary leaders need to possess the ability to recognize factors that affect differing situations and scenarios both within the athletic training profession and within more diverse, integrated practice environments.2 Kutz and Doherty-Restrepo2 argue that to meet the demands of growing health care system practice complexity, future health care leaders must practice multidisciplinary, interdisciplinary, and transdisciplinary leadership behaviors that transcend the formal professional athletic training work role and translate this professionalism into larger communities and society as a whole.
In surveying program directors and head ATs using the Leadership Practices Inventory (LPI), Laurent and Bradney1 demonstrated the importance of leader behaviors. The LPI is a valid predictor of leadership effectiveness, representing leader behaviors in 5 categories: model, inspire, challenge, enable, and encourage.1 Athletic trainers demonstrated encouraging behaviors similar to other health care professions, but used modeling and enabling behaviors more often than other leaders.1 Interestingly, athletic training program directors were more likely to practice leader behaviors such as inspiring, challenging, enabling, and encouraging, compared with head ATs. This was likely influenced by the differing primary job responsibilities and practice environments.1 Athletic trainers can benefit from understanding job responsibility differences between environments and situations. It is suggested that ATs who practice transformational leadership behavior characteristics positively influence the practice environment and the profession.1,8,11,19,22
Leadership Behaviors in Athletic Training Educational Programs
Athletic trainers with graduate degrees in athletic training place greater importance on practicing leadership behaviors than those who possess graduate degrees in other disciplines.2 Furthermore, the seventh edition of the BOCPA emphasizes leader behaviors important for health care administration and professional responsibility. For leadership behavior competency to progress from knowledge to skilled practice, Kutz and Scialli23 recommended that it should be taught early and often in professional athletic training educational programs as has taken place in nursing and medicine.3,18,21 For example, leadership training in nursing students has been found to improve critical thinking and technical skills such as health care resource allocation and prioritization.18,21 Advanced-practice nursing clinicians have also been found to practice leadership behaviors more effectively than less educated nurses.21 Likewise, athletic training educators perceive leadership behaviors to be important for athletic training curricula.23 In having an expert AT panel rate 31 leadership behavior content items based on perceived importance to athletic training educational programs, Kutz and Scialli23 found that legal issue risk management, team leadership, and evidence-based practice were the most important and most consistent behaviors rated regardless of degree type (bachelor's, entry-level master's, postgraduate certification programs, and doctoral degree programs). Furthermore, Peer6 reported that 100% of athletic training students surveyed in the State of Ohio reported that professional practice values were either important or extremely important to ATs. This finding strongly suggests that athletic training students perceive that it is essential to honor, respect, and, if necessary, to defend core athletic training professional practice values. Kutz22 also identified a positive relationship between demonstrated leadership behaviors (professionalism, attendance, effective communication, work quality, initiative, cooperation, attitude, and demonstrated professional interests) and the clinical behavioral characteristics displayed by entry-level athletic training students. Kutz's landmark study represents an essential first step in identifying the need to better develop athletic training leadership behavior knowledge, skills, and abilities in educational curricula. Katch et al24 related athletic training student leadership behavior development to enhanced intellectual development and interpersonal skills. Raab et al25 suggested that ATs with leadership behaviors were more likely to be perceived by others as better professionals. According to Laurent and Bradney's1 recommendation, leadership behaviors are behaviors that not only are learned through experiences but that also should be taught through entry-level formal education.
Leadership is the process of influencing others toward an accomplishment or goal.1,2 Contemporary leadership behaviors have evolved from natural, innate Great Man traits to team-centered approaches involving influence, inspiration, motivation, intellectual stimulation, and individualized consideration. Transformational leadership provides opportunity for leaders to influence others toward desired outcomes and goals through more collaborative decision making, encouraging follower commitment, and building stronger bonds between leaders and followers. To build stronger relationships with others, and for conflict resolution, health care professionals, including ATs, are practicing transformational leader behaviors to maximize interprofessional teamwork opportunities in complex health care environments. Previous literature has confirmed the importance of practicing AT leadership behaviors in both educational and clinical environments. However, Kutz and Doherty-Restrepo2 highlighted that ATs may not consistently demonstrate the same or similar leadership behaviors outside of their primary professional roles. Leadership behaviors studied in entry-level athletic training programs demonstrate a positive relationship to clinical behavioral characteristics, and athletic training students perceive professional values to be extremely important. Current literature supports the need to include leadership behavior development in entry-level curricular programs.
Evolving contemporary leadership behavior theories and practices have dramatically changed the manner in which leaders interact with others. This transition to a more transformational, team-centered leadership style provides a growing opportunity for practicing ATs and athletic training students to expand into greater organizational leadership and decision-maker roles.2 Transformational leader behaviors provide ATs with the opportunity to demonstrate professional advocacy. The Commission on Accreditation of Athletic Training Education has emphasized advocacy and professionalism with leadership behaviors in the updated 2020 Standards for Accreditation for Professional Athletic Training Programs.26 Therefore, it is imperative that educational curricula include formal leadership behavior development instruction. Herzog and Zimmerman19 provide a model for athletic training education programs to incorporate transformational leadership behaviors in their curricula to build stronger relationships and promote engagement with program faculty and clinical preceptors. Moreover, regardless of the specific athletic training practice setting, transformational leadership behaviors are instrumental to relationship building12 and to improving patient/client health and safety.20 Practicing ATs are expected to display daily leadership behaviors in overseeing patient care and by adhering to the NATA Code of Ethics.27
Kutz and Doherty-Restrepo2 suggest that ATs may not consider themselves as true leaders unless they explicitly possess an official leadership title or formal authority. One plausible explanation for this is that the absence of a foundational leadership behavior understanding may lead to a weakened personal sense of its importance and relevance. Conceivably, athletic training educational programming may be so focused on context-specific leadership behavioral roles (ie, overseeing an athletic training facility and patient care) that the importance of expanding these behaviors to more general community and societal leadership experiences remains underappreciated.2 Therefore, it is recommended that athletic training education programs identify and develop strategies and tactics to improve how the athletic training student develops leadership behaviors as an ethical practice foundation.27 This should be essential to educational program planning, particularly as programs transition to professional master's degree-level curricula as the athletic training profession evolves to a required master's degree for entry-level practice. The intended outcomes of this transition are to enhance professional education, to advocate for the continued progression of ATs as accepted allied health care providers, to encourage interprofessional education, and to positively influence AT compensation and employment opportunities.7,9
While more research on leadership development programs in athletic training educational program curricula is necessary, learning about contemporary leadership behaviors and theories can be helpful for entry-level ATs as they move into leadership roles. Additional leadership behavior research of practicing ATs would be helpful to better understand existing needs in a wide variety of practice settings. Programs such as iLEAD, an athletic training student-leadership conference hosted by the NATA, and the NATA Leadership Academy program may represent excellent resources that can be incorporated into workshops, conferences, and course objectives for leadership development.
Based on existing evidence, it may be particularly important to define leadership behavior development steps and feedback opportunities in existing and developing professional master's degree athletic training programs as well as essential knowledge for practicing AT postgraduate continuing education. Based on this synthesis, leadership behaviors that are effectively integrated into athletic training educational programs early and often may promote the profession by concurrently improving clinical and professional practice behaviors (Figure). To leverage this vital opportunity, the AT must possess a strong appreciation for and foundational understanding of leadership behavior theory and the ability to translate this knowledge into the abilities and skills needed to positively transform contemporary health care, improve patient outcomes, advance the profession, and effectively participate in interdisciplinary teamwork.