In today's health care environment, the need to engage personnel in quality improvement to demonstrate value to patient care is vital. Health care executives are responsible for leading within their organizations, and athletic trainers (ATs), similar to other health care executives, have typically risen to positions of authority without leadership training.
To explore the lived experiences of ATs as health care executives, specific to their path to leadership and their role in leading continuous quality improvement.
Consensual qualitative research.
Web-based phone interviews.
A total of 20 participants (age = 41 ± 10 years; experience = 18 ± 10 years) indicated they held a position of authority, had personnel management responsibilities, and had influence over organizational change within their health care systems; however, after completing the interviews, we determined that only 17 participants met the inclusion criteria.
The primary investigator completed interviews. We analyzed the data with a 3-person data-analysis team and an internal auditor. Trustworthiness was established through member-checking and multiple-researcher triangulation.
Participants described various forms of preparation including mentors and both self-directed and required resources that assisted in preparing for their management and leadership roles. Participants described how they influenced personnel, including identifying individualized motivators, establishing goals, and building relationships. Participants explained the culture they hoped to establish, characterized by a growth mindset, transparency, and both self-reflective and systems-level improvement practices. Many of the participants depicted characteristics of strong leaders through an individual growth mindset, embodiment of the behaviors they wanted to see in their personnel, and transformational leadership strategies.
Athletic health care executive have the responsibility to lead and transform their organizations. However, few in these positions have had formal training to prepare them for the role. ATs seeking health care executive positions should seek formal training to acquire the skills necessary to create organizational change and serve as transformational leaders.
Many athletic health care executives experienced mentorship and sought out, through self-direction, resources to prepare them for their leadership and management roles.
To successfully meet the expectations of their positions, athletic health care executives worked to influence personnel by identifying individual motivators, establishing goals for personnel, and building both personal and professional relationships.
The athletic health care executives generally developed a culture of systems-level improvement through transparency and an organizational growth mindset.
Although not all, many of the athletic health care executives in this study demonstrated characteristics of strong leaders by having an individual growth mindset that allowed them to see failure as an opportunity, embodying the characteristics they wanted to see from their personnel, and demonstrating transformational leadership qualities.
Health care executives are often placed in their positions on the basis of clinical accomplishments; however, few have been trained for the responsibilities of leading in modern health care.1 Given the rapidly changing health care system, health care executives must be capable of clearly communicating the goals for change as well as how change will improve patient care.2 Moreover, well-equipped executives will be able to inspire, model, challenge, enable, and encourage the change necessary to improve patient care within the system. Yet, how do executives determine what change is necessary? Quality improvement is the effort to make change that results in better patient outcomes, systems performance, and professional development.3 The process requires a systematic approach to the analysis of practice that requires a teamed-approach to data collection, analysis, and testing of change.4
Leadership and management have often been compared and contrasted throughout the literature, and sometimes they have been used synonymously.5 However, in a recent review of the literature, management skills included planning, building, and directing, whereas leadership skills focused on potential change by establishing the direction and aligning, motivating, and inspiring personnel.6 Throughout this article, we will describe health care executives as those who may possess leadership or management skills or both in their position of authority. Health care executives oversee the functioning of a health care facility, including finances, policy, and personnel management and can include supervising and “head” athletic trainers (ATs) in traditional athletic training settings as well as hospital administrators. We will use the aforementioned definitions to differentiate between leaders and managers.
In athletic training, we have explored leadership in a variety of ways, but we have not yet evaluated how ATs, as health care executives, inspire, model, challenge, enable, and encourage quality-improvement practices aimed at supporting the patients' experiences. Previous literature in athletic training has indicated that ATs, as health care managers, needed additional knowledge and skills beyond professional education because there was no formal training7 and as students they did not typically see it as important in their early training.8 In this study, we aimed to investigate the lived experiences of ATs as health care executives, specific to their training and path to leadership, as well as their role in leading continuous quality improvement in their respective health care systems.
We used qualitative, semistructured interviews to answer the primary research aims. The consensual qualitative research tradition was used to analyze the data. This study was approved by the Indiana State University Institutional Review Board.
We used criterion sampling to identify eligible participants. First, we used an embedded (nested) technique, whereby a random sample of participants were recruited from the National Athletic Trainers' Association research-participant database for a related study. Participants who opted into that study and met the inclusion criteria were offered the option to complete an interview on a related topic. We also used social media recruitment to supplement our recruitment strategy. Eligible participants were athletic health care executives who were certified ATs in a position of authority, had personnel management responsibilities, and had influence over organizational change within their health care system. We interviewed 20 participants, but we determined that 3 individuals did not meet all the inclusion criteria, and they were excluded from analysis. Participants (age = 42.24 ± 10.49 years; years of experience = 19.24 ± 10.47) varied in experience and settings (Table 1).
The overarching purpose statement guided our semistructured interview script (18 items; Table 2). We asked several questions to contextualize the participants in their workplace (5 items) and their path to leadership (2 items). The interview script was developed from the available literature and then reviewed by 3 content experts (21 ± 14 years of experience; Table 3). We used the 5 practices of exemplary leadership as a framework9 for our questions regarding modeling, inspiring, enabling, encouraging, and challenging the organization relative to self-reflective practice and continuous quality improvement (10 items). At the end of the interview, we asked if there was anything else we needed to know about their leadership of health care delivery (1 item).
Once participants indicated their willingness to participate in an interview, the primary investigator sent an e-mail to schedule an individual Web-based interview. Once a time was agreed upon, participants received a scheduled meeting notification to join the primary investigator on a videoconferencing platform (Zoom Video Communications, Inc, San Jose, CA). At the scheduled meeting time, the primary investigator and participant met on the videoconferencing platform. The primary investigator read a prepared statement to (1) ensure that the participant met the inclusion criteria; (2) offer to answer any questions; (3) obtain verbal consent to conduct the interview and audio record the interview; and (4) to remind the participant of the project's purpose. All participants provided written and verbal informed consent to participate.
Once consent was received, the primary investigator conducted individual semistructured interviews. Each interview ranged in duration from 25–49 minutes (40.4 ± 7.1 minutes). At the conclusion of the interview, the participant was thanked for their time, the audio file was downloaded and saved. We then sent the audio file to an automated transcription service (Rev, San Francisco, CA; https://www.rev.com). The transcription file was deidentified and checked for accuracy against the audio file. At least 15 days after the interview, according to institutional review board protocol, we sent the deidentified transcripts to the participants for member-checking.10,11 No participants replied with any changes to the information in their interviews.
Data Analysis and Trustworthiness
The data analysis team (Table 4) engaged in a multiphase process to code the data.10,12 Using an inductive approach in phase 1, the team reviewed 6 transcripts representing the various settings of the participants. The team members independently developed a domain list reflective of the data and met to compare notes and come to consensus. During this meeting, the team created the initial codebook by discussing their respective domains and conceptualizing the core ideas. In phase 2, the initial codebook was applied to 3 of the original transcripts and 3 new transcripts to ensure that the codebook reflected the data. The team met to confirm the consensus codebook. During phase 3, the team applied the consensus codebook to the remaining transcripts. After each transcript was coded, the codes were confirmed by 1 other member of the team and diverging codes were discussed to achieve consensus. We ensured that the core ideas were accurately placed into categories using cross-analysis. We shared the interview script and 6 coded transcripts with the external reviewer and the consensus codebook was confirmed. At the completion of data analysis, we conducted a frequency count of the categories.12 Categories were assigned general if they were identified in all (17) or all but 1 of the cases (16), typical if identified in 9–15 cases, variant if identified in 4–9 cases, and rare if only identified in 3 or fewer cases.12
Four domains emerged from the data: (1) preparation, (2) personnel influence, (3) culture, and (4) characteristics of strong leaders. Table 5 details the frequency for the coded data per category.
In the preparation domain, we identified mentorship, resources, management role, and leadership role as categories. Participants often described mentors who were influential in their preparation to assume a leadership role in their position. These individuals ranged in proximity to their current position, from former supervisors to role-model stakeholders in other organizations. Participants also detailed self-directed and required resources that helped them prepare for their position. Self-directed resources often included advanced education, books, and podcasts, whereas required resources included mandatory, internal leadership development opportunities provided by their organizations. Participants demonstrated preparedness or a lack of preparedness for both their management role and their leadership role. Management roles often surrounded the operational duties of a person in a supervisory position (eg, budgeting, scheduling, policy development). Leadership roles characterized the preparation necessary to be an influencer within their respective organizations. Supporting quotes from each of the categories are available in Table 6.
In the personnel influence domain, participants explained how they identified individualized motivators, established goals, and built relationships to influence their respective staff members. The participants depicted strategies they used to identify what motivated their staff, so that they could effectively influence them to act or change. Participants described wanting to know what motivated their staff to help them be successful, but they also used individualized motivators to help staff create personal performance development plans. Those participants who had more-robust quality-improvement environments were likely to establish objective and measurable goals that aligned with the performance plans, allowing for effective staff assessment. Many participants described how important it was to build relationships with their staff, which helped them communicate that they cared deeply about them as people but also about the development of the organization. Supporting quotes from each of the categories are available in Table 7.
The culture domain was represented by improvement practices, organizational growth mindset, and transparency categories. Cultures that engaged in improvement practices often did so with self-reflective practices and/or with systems-level assessment. Self-reflective practices included subjective self-assessment and appraisal of the workplace, whereas systems-level assessment adopted a continuous quality improvement culture in which measures were objective and the personnel were engaged with the process. An organizational growth mindset was indicative of a culture that sought out growth opportunities and embraced failure as an opportunity to learn and grow. A culture of transparency was depicted by openness and an environment that embraced the voices or perspectives of all its stakeholders, especially its staff. Supporting quotes from each of the categories are available in Table 8.
Characteristics of Strong Leaders
The characteristics of strong leaders domain included categories of individual growth mindset, embodiment, and transformational leadership. Participants with an individual growth mindset discussed self-directed persistence and advocacy for one's self within the workplace. Embodiment was characterized by modeling the behaviors that the leaders wanted to see from their staff, specifically those related to self-assessment and systems-level improvement practices. This included being able to “walk in the shoes” of staff members, demonstrating vulnerability and sharing failures with staff and taking actions to decrease resistance to workplace expectations. Transformational leadership was identified in the participants who talked about encouraging, inspiring, and motivating employees to innovate and change. Strong leaders who described changing the mindset or philosophy of a staff or who listed innovation among their organization's core values were identified as demonstrating transformational leadership. Supporting quotes from each of the categories are available in Table 9.
Many leaders inducted into their roles have not had formal experiences in their professional preparation to meet the duties and responsibilities of their new positions. Several participants in our study described a lack of formal preparation regarding leadership, and given the curricular space and intellectual availability in professional preparation programs, this may be for the best. The Athletic Training Strategic Alliance has explicitly stated that a clinical doctorate should be reserved for advanced practice,13 and it is possible and practical that postprofessional degree programs should fill this gap of developing advanced-practice leaders in athletic training education, similar to how nursing has developed advanced-practice leaders through doctoral preparation.13 Professional preparation can and should be the level of education at which we focus on teaching the health care lexicon and the process of quality improvement,14 so ATs can better align themselves within the American health care system and engage in dialogue with other health care professionals. Ideal leadership development includes comprehensive leadership curricula, which may include personal competencies (eg, introspection, listening, empathy, awareness, altruism), differentiating competencies (eg, finances and economics, team building, conflict management, negotiation), and task-oriented knowledge (eg, health care regulations, legal issues, organizational and systems quality improvement, being a change agent).1 It is simply not achievable to expect professional programs to integrate this content into an already-substantial curricula. Therefore, it may be beneficial to introduce these concepts in professional education and provide discrete experiential learning opportunities, then rely on postprofessional education and continuing professional development to practice and reinforce these competencies.
Many participants filled their lack of leadership preparation through self-directed learning and mentorship. Self-directed learning integrates external management, cognitive responsibility, and motivational issues associated with adult learners.15 Learners are motivated to assume responsibility and self-monitor the process of gaining new knowledge in areas they believe to have worthwhile outcomes.15 The stated benefits to self-directed learning are thought to include the development of persistence, independence, self-discipline, self-confidence, and goal-centeredness16,17 ; however, some would argue those traits were present first, guiding self-direction.18 Self-directed learning may also result in missed or haphazard learning because individuals simply do not know what they do not know. Ideally, self-directed learning includes collaborative constructivism, because meaning from experiences cannot be made in isolation from the shared world.19
Mentorship is a critical part of preparing for an executive role.20 A mentor is a counselor or guide, and a mentor with real-life experience can help an emerging health care executive develop leadership style.1 Mentorship is a gifting of time and resources, without an expectation of return on the investment.21 Many participants in this investigation described the importance of mentors and how they helped create opportunities and served as a sounding board for their progression. As health care executives develop themselves, a critical component of their role is in future leadership development;1,22 the process of “paying it forward” and preparing future leaders.
In contrast, many participants described formal leadership development that they engaged with through their organization. Leadership development is $366 billion global industry23 and is of particular interest in health care due to the size of major health care organizations. Activities such as executive coaching, internal leadership training, and external training programs were seen as critical in developing some participants in their leadership roles. Effective leadership development programs often included facilitating a supportive culture, engaged mentorship, extended learning periods with support after the program, encouragement of ownership, and commitment to continuous quality improvement.24
On the contrary, those who struggled to describe their leadership positions beyond that of the operational tasks associated with an administrative position had limited leadership training and development. This has substantial implications for those that have positional authority but no personnel influence. Positional authority is often associated with a title or rank25 ; in the case of our participants, these were individuals who had a title of “Head Athletic Trainer” yet had no ability to influence other ATs within their facility, whether for structural reasons or because they had not yet found ways to be effective. Influence is the ability to effect and change those around you.25 These concepts, for some of our participants, were mutually exclusive. Additional training and a strong appreciation for an organizational growth mindset is needed to advance a manager beyond the roles of completing operational administrative tasks and into the role of leader.
Creating Change through Culture, Leaders, and Personnel
To effectively create an environment capable of change, the workplace needs effective leaders who have influence over both culture and personnel. In considering the characteristics of strong leaders, some of our participants described themselves as having overcome obstacles. This is consistent with previous literature1 that identified resilience and willingness to address failure as an opportunity for growth as characteristics of strong leaders. Moreover, effective leaders embody the characteristics they wish to see in their personnel. Modeling the way is among the 5 practices of exemplary leadership.26 In this particular study, we looked at how leaders modeled, inspired, enabled, encouraged, and embraced challenges when facilitating quality improvement. When the participants, who were characterized as leaders, described how they facilitated continuous quality improvement, they talked most about modeling vulnerability, openness, and a willingness to adapt to the demands of the workplace environment. Effective leaders also addressed a desire to change both the environment and personnel. These characteristics depicted a transformational leadership style, where individuals elevate others, facilitate others, and engage in forward thinking.1 Leadership in the 21st century is rapidly evolving, and a transformational leadership style may be critical to adapting to new trends and policies.22,27,28
A function of transformational leadership includes engaging individuals (ie, influencing personnel).27,29 As a leader, health care executives are responsible for identifying what really motivates health care workers. Identifying the motivators allows the leaders to establish goals and benchmark for success.1 These principles align both effective leadership strategies and basic steps of personal quality improvement. Specifically, a plan-do-study-act cycle includes self-auditing, goal setting, data collection, and analysis, all to set direction and enable progress.30,31 However, health care executives in modern health care can no longer focus on individual personnel development alone but must work to build strong relationships around a central mission, to improve patient outcomes through teamwork.22
Some participants in the study perceived themselves to be leaders due to their position title, whereas their role was predominantly managerial (organizing, planning, directing)6 with little leadership responsibility (motivating, engaging, and inspiring personnel).6 When pursuing the questions relative to inspiring, modeling, enabling, and challenging continuous quality improvement within their organizations, it became clear these participants either did not possess a reasonable level of influence to which their position entitled them or they were ill-equipped to exert influence. This created challenges for the participants when discussing their leadership responsibilities. This identifies an interesting phenomena within athletic training and beyond. Sometimes in athletic training and throughout health care, individuals are placed in positions of authority on the basis of age, productivity, or other skills, yet they are inadequately prepared to lead others.32
The characteristics of strong leaders and their ability to influence personnel are critical to developing a culture capable of change. As leaders enact their influence, they can create an environment with an organizational growth mindset engaged in systems-level improvement practices and transparency. An organizational growth mindset is one that embraces failure, encourages lifelong learning, seeks out challenges, pushes people beyond their limits, and values feedback.33 Participants in our study described looking for failures and considering those as opportunities for self-improvement, embraced teamwork, and believed new skills and contributions were attainable, similar to that which is described in the literature.33 Specifically, transparency, an open dialogue in the pursuit of truth and that ignores traditional hierarchy, helps to create an environment that solves problems sooner, embraces teamwork more easily, embraces authenticity, develops trust and loyalty, and results in overall better performance.5,34 An organizational growth mindset is facilitated by leaders who embody listening, awareness, persuasion, conceptualization, foresight, stewardship, and a commitment to grow people and the community.33,34 Participants in our study described these leadership values and behaviors resulting in a culture with an organizational growth mindset, whereby employees are empowered to use their strengths collaboratively to improve the health care system in which they work and, more directly, their patient care.
As we consider the future directions of research in athletic health care executive leadership, we must consider training and preparation as paramount. Although previous researchers have identified that some skills, such as emotional intelligence, teamwork, and collaborative care, are the foundation to leadership in health care, these are basic principles necessary to incorporate in professional-level education.1,22 The Strategic Alliance, and parallel organizations in other professions such as nursing,35 have left “space” for postprofessional education that may effectively fill the leadership gap in athletic health care. Advanced-practice leadership development in health care can address issues of finance and economics, team building, communication, conflict management, negotiation, vision development, adaptation, the ability to develop others and serve as a change agent.1,22,36 Future research should investigate the role of postprofessional education in the development of practice leaders who embody the characteristics of leaders prepared for the challenges and opportunities of current and future athletic health care.
Research, particularly qualitative research, has inherent biases; however, the consensual qualitative research approach and multiple-analyst triangulation makes effort to minimize those biases, requiring consensus in developing the codebook. Our investigation provided a broad view of athletic health care executives from all settings. Future investigations should seek to further generalize these findings and to identify any differences between settings. We did not collect data relative to the athletic training health care executive's workplace responsibilities, including the number of direct reports or the size of the overall organization. Future research should consider evaluating the impact of direct reports and organization size on the experiences of athletic training health care executives.
ATs are serving in health care executive positions, in traditional, hospital/clinic, and emerging settings, in which they have oversight to lead and create change within their organization. However, few of these ATs have had formal training to prepare them for executive positions. ATs with aspirations to rise to these health care executive positions should seek formal training to ensure that they possess the skills and mindset necessary to create organizational change and serve as transformational leaders.
Editor's note: This article was to have been published as part of the recent special issue on leadership (December 2020, 15). We apologize for the error.