Availability of athletic trainer (AT) services in US secondary schools has recently been reported to be as high as 70%, but this only describes the public sector. The extent of AT coverage in private secondary school settings has yet to be investigated and may differ from the public secondary school setting for several reasons, including differences in funding sources.
To determine the level of AT services in US private secondary schools and identify the reasons why some schools did not employ ATs.
Concurrent mixed-methods study.
Private secondary schools in the United States.
Of 5414 private secondary schools, 2044 (38%) responded to the survey.
School administrators responded to the survey via telephone or e-mail. This instrument was previously used in a study examining AT services among public secondary schools. Descriptive statistics provided national data. Open-ended questions were evaluated through content analysis.
Of the 2044 schools that responded, 58% (1176/2044) offered AT services, including 28% (574/2040) full time, 25% (501/2042) part time, 4% (78/1918) per diem, and 20% (409/2042) from a hospital or clinic. A total of 84% (281 285/336 165) of athletes had access to AT services. Larger private secondary schools were more likely to have AT services available. Barriers to providing AT services in the private sector were budgetary constraints, school size and sports, and lack of awareness of the role of an AT.
More than half of the surveyed private secondary schools in the United States had AT services available; however, only 28% had a full-time AT. This demonstrates the need for increased medical coverage to provide athletes in this setting the appropriate level of care. Budgetary concerns, size of the school and sport offerings, and lack of awareness of the role of the AT continued to be barriers in the secondary school setting.
In comparison with public-sector secondary schools, private-sector secondary schools did not provide adequate athletic trainer (AT) services to their student-athletes.
Larger private secondary schools were more likely to have AT services.
Barriers to AT employment were budgetary constraints, school size and sport offerings, and lack of awareness of the role of the AT.
Over the years, athletic participation has risen1 and correlated directly with an increase in the number of high school sport injuries.2 Over a 30-year period, the National Center for Catastrophic Sports Injury Research3 reported that 81% of all catastrophic injuries occurred at the secondary school level, a larger percentage than in the collegiate setting. This could be due to the greater number of individuals participating in secondary school athletics, as the reported injury rate for collegiate athletes (3.08 per 100 000 participants) was higher than the injury rate in the secondary school setting (0.85 per 100 000 participants).3 Despite the high percentage of catastrophic injuries at the secondary school level, many conditions can be prevented, recognized early, and managed appropriately if onsite medical coverage is available.4−6 As indicated by the American Medical Association and the National Athletic Trainers' Association (NATA), the most appropriate individual to provide this medical care is an athletic trainer (AT).4
Dating back to 1994, 35% of secondary schools had AT services.7 Since that time, research has evolved. As of 2005, a study conducted by the NATA8 revealed that high schools employing the services of an AT increased to 42%. In the 11 years from 1994 to 2005, AT coverage in US secondary schools increased by only 7%; however, these values may not capture the entire country, given that a limited number of states and schools were included in these surveys. The most recent investigation of AT services in public secondary schools,9 published in 2015, showed a significant increase. Of the reported 70% of public secondary schools providing services, 37% had full-time AT services and 55% provided AT coverage every afternoon.9 From 1994 to 2005 and continuing to the present, overall AT coverage at the secondary school setting has improved.
Yet despite the apparent rise in employment of ATs, many secondary schools do not currently employ an AT and therefore rely on sport coaches and other unqualified personnel to provide medical care to athletes.9 Coaches often lack the knowledge to recognize common causes of medical emergencies and treat life-threatening medical conditions.10−13 First-aid and cardiopulmonary resuscitation (CPR) training fulfills the medical requirement for an individual to become a sport coach in some states, but in other school districts, a large portion of the coaching staff is not certified in either first aid or CPR.14 This is especially concerning for the schools that do not employ an AT, thereby jeopardizing the health and safety of the athletes.
The private secondary school setting is unique and differs from public-sector secondary schools. A major difference is the yearly budget and how income is generated to support the annual budget.15 Public school budgets are often larger than private school budgets because they are generated through federal, state, and local taxes and are part of a larger school system. Private secondary schools, however, generate their own funding by charging tuition and through grants and fundraising.15 Within the public secondary school setting, a main barrier to providing medical coverage through the services of an AT is often fiscal. It is likely that this barrier also exists within the private sector, but such information was not available. Our purpose, therefore, was to determine the availability of ATs in the private secondary school setting and to identify reasons why private secondary schools did not employ ATs.
Our research design mimicked that of a previous study,9 which examined AT coverage in public secondary schools. We used both quantitative and qualitative methods to seek a greater understanding of the AT coverage at the private secondary school level across the United States. The design followed a concurrent method, which allowed us to collect all data from our respondents at 1 time. The simultaneous data collection allowed us to extrapolate on our findings and provide a more robust understanding16 of medical care services at the private secondary school level. One-on-one telephone interviews provided access to respondents at a large number of private secondary schools. The personal nature of the phone calls allowed for greater follow-up with the schools and helped to improve our response rate.16 The University of Connecticut Institutional Review Board deemed this study exempt from review.
A total of 5414 secondary private schools in the United States were identified for the study. Secondary school was defined as any school that included grades 9 through 12 in any variation. Secondary school was used instead of high school because some of the participating schools included grades lower than 9. We searched the Internet using the Google (Google Inc, Mountain View, CA) browser and the US Department of Education Web site for contact information. Private schools with an organized athletics program and containing at least 1 of grades 9 through 12 qualified to participate in this study. Schools were excluded if classified as any of the following types: public, alternative (ie, home school leagues), charter, magnet, technical, or vocational. Of the 5414 schools, 2044 responded to the structured interview (38% response rate). School administrators, either the athletic director (AD) or the school's principal, provided responses to the interview. Respondents represented wide geographic diversity across the United States, with representation from all 50 states and the District of Columbia (Table 1).
Our procedures were identical to those of Pryor et al,9 and therefore, we adopted the interview guide developed for the public secondary schools. A structured interview guide (Appendix) ensured that the same information was collected from each respondent, as multiple researchers facilitated the telephone interviews. Before the calls, all callers were trained and instructed to follow the interview guide. Each participant's responses were recorded.
The school administrator of every private US secondary school was contacted by phone or e-mail if an address was provided. Callers made 4 attempts to reach the school administrator; if the fourth resulted in no reply, the school was considered a nonrespondent. A fifth call was made only to nonrespondent schools in states that did not reach at least a 20% response rate. Because of various difficulties contacting ADs in the private sector, we concluded that a 20% response rate offered a well-represented sample of the population that was comparable with other survey response rates.17 Completion of the interview constituted informed consent. Data collection took place December 2013 through June 2014.
Data Analysis and Credibility
Qualitative data analysis followed a general inductive basic content analysis to examine trends and patterns in participants' responses. An open-coding procedure identified key themes in open-ended data. Similar responses were placed into categories, which became the overarching themes regarding barriers to AT employment. Descriptive statistics portray individual state data and are reported as percentages. School-size classifications were determined by student body populations and divided into 100-student increments for analysis (eg, 0−99 students = 1, 100−199 students = 2). Statistical analyses were performed in SPSS (version 20.0; IBM Corp, Armonk, NY).
To establish credibility of the data, we used intercoder triangulation16 and had 2 researchers code the data. Both coders followed the procedures described earlier to evaluate the qualitative data and used the purpose of the study as a means to examine them. After independent review, the 2 researchers compared their coding procedures to provide rigor to the analysis. During the comparison, codes were examined for content and labels. Negotiations were focused on labels, not content, and agreement was reached between coders before a peer review was conducted. A researcher with extensive knowledge of and experience with qualitative research collaborated to develop the data-collection procedures and interview guide. Experience is considered an important aspect of a sound qualitative study.16 The same individual also completed a peer review of the content analysis.
Of all 5414 private secondary schools in the United States, which were identified via an online database,18 2044 responded to our survey, resulting in a 38% response rate. Of the 2044 secondary schools that participated, 58% (1176/2044) had AT services and 84% (281 285/336 165) of all athletes had access to AT services. The number of athletes with access to AT services was determined by calculating the total number of athletes in schools providing AT services and dividing by the total number of athletes in all participating schools. Twenty-eight percent (574/2040) of our participating secondary schools had full-time AT services, 25% (501/2042) provided part-time AT services, and 4% (78/1918) had per diem AT services. A total of 20% (409/2042) of secondary schools had AT services outsourced from a clinic. Forty percent (767/1901) of schools had full practice coverage every afternoon, whereas 57% (190 634/336 165) of athletes had access to a full-time AT. Of the schools with AT services, 19% (198/1037) also hired the AT to teach a health or sports medicine class. On average, private secondary schools providing AT services employed 1 AT, except for Hawaii, whose private schools employed an average of 2 ATs. A breakdown of the extent of AT services by state and NATA district is in Table 1.
As school size increased, specifically schools with 100 students or greater, the percentage of private secondary schools providing AT services was higher. Only 15% of private schools with fewer than 100 students provided AT services, compared with 72% of schools with more than 100 students. A detailed presentation of AT services by school size for the private secondary schools is shown in Table 2. Secondary schools with ATs averaged 268 athletes, whereas schools without ATs averaged 73 athletes (Table 3). A categorization of school size and the extent of AT services in the private secondary schools is presented in Table 4 and Figure 1. As school size increased by 100-student increments, trend lines showed an increase in both total and full-time services, whereas the slope in the trend line for part-time coverage was less. This indicates that a larger percentage of full-time AT services was being offered at the larger private secondary schools. A breakdown of school size and the extent of AT services in private schools is presented in Table 5 and Figure 2. Trend lines in Figure 2 show that, with an increase in school size, more full-time than part-time and per diem services were being used.
The numerator represents the number of schools that described athletic trainer services. The denominator represents the total number of private secondary schools in that category.
Abbreviation: NA, not available (schools in the state did not meet the column qualifications).
Includes only those schools with full-time ATs.
When we assessed barriers to hiring an AT in the private secondary school setting, 3 major themes emerged from the data: budgetary constraints, size of the school and sport offerings, and lack of awareness of the role of the AT (Figure 3). Each theme is discussed in further detail with supporting quotes from participants.
Budgetary constraints were the main reason cited for those schools unable to provide AT services. When asked why there was no AT employed at the school, an AD from North Carolina stated, “That's a great question. I'd love to have one, but we just haven't been able to fit it in our budget.” An AD from New York shared his struggle with budget constraints when he replied, “[ATs] are not cheap. We have 15 sports, and to cover all of them would be difficult with our budget restraints.” Representing NATA District 4, a Wisconsin AD said, “We can't even afford our own gym.” An AD from California reported, “There are so few students that we can't afford it.” From District 10, an Oregon AD identified lack of budget as a barrier: “We do not have the funding available to employ an athletic trainer.” Budgetary constraint was a primary barrier to employing an AT in US private secondary schools.
School Size and Sport Offerings
Small school size and not having many organized sports teams were among the reasons for not employing an AT in the private secondary school setting. For example, an AD from a Florida school reasoned, “[T]his is a very small school, with very few sports teams and athletes.” An AD from a Connecticut school supported this theme: “We're not big enough for an athletic trainer.” A District 5 AD from Missouri explained, “We don't really need one because of the size of our school.” Similarly, a Colorado school from District 7 justified not having an AT with, “The numbers don't support the cost.” A respondent from California continued to cite school size, commenting that the school was “. . . so small that myself, the coaches, and the parents can take care of everything.” The latter part of the quote demonstrates a lack of understanding of the role of an AT in the secondary school setting, which is another overarching theme in this study.
Lack of Awareness of the Role of the AT
The data showed that ADs and principals did not hire ATs because they were unaware of their role in secondary school athletics. Respondents often reported that coaches were able to perform the normal tasks of an AT, mistaking them as adequate medical providers. Similarly, this lack of awareness of the AT profession was seen in ADs and principals who responded that there was simply no need for an AT at their schools. Some administrators even showed a lack of understanding about who qualifies as an AT, as well as credentialing criteria and the services ATs provide, when they stated they themselves were the ATs or that a coach fulfilled that position. This overall lack of awareness was further divided into 2 subthemes: coaches viewed as appropriate medical providers and lack of need.
Coaches Viewed as Appropriate Medical Providers
Given first-aid and CPR certification requirements to become a coach in most of the 50 states, with more than 35 states requiring new coaches to complete first-aid courses,19 some ADs did not hire ATs because they felt coaches provided adequate medical coverage. An AD from Georgia reported, “The coaches can handle normal athletic training tasks.” A participant from an Ohio school said, “Our coaches take care of minor injuries. . . bigger injuries the kids need to see their doctor anyways.” A Michigan AD illustrated the belief that coaches were appropriate medical care providers by concluding that the “basketball coach is sufficient coverage.” Representing New Mexico, a respondent spoke about having a coach who had experience with injury prevention and treatment, but although he acted like an AT, he was not officially employed at the school to fill that position. Surprisingly, not only were coaches seen as appropriate medical providers, but some ADs were also viewed as competent. An Oregon participant spoke about the AD doing it all, based on a good deal of experience. Many respondents believed that coaches or ADs were acceptable substitutes for ATs at their schools.
Lack of Need
When asked why no AT services were provided at the school, many participants responded that there was no need. From District 9, an Alabama AD stated that an AT was “not a necessary staff member,” and similarly, a Pennsylvania AD revealed that the school did not find it necessary. An AD from Virginia “would never hire someone to just do one job.” Expanding further on this theme, a California respondent expressed, “We haven't had a need for it yet. We have a couple parents that are doctors and act as athletic trainers if we need them.” Furthermore, an AD from Iowa expanded on the lack of need for an AT by identifying local people in the community who could help care for athletes when there were injuries. This barrier to employment also extended to District 10, as illustrated when a Montana participant stated concisely, “A need for it hasn't come up.” The belief in lack of need for an AT has kept ADs from pushing to hire one.
We examined AT services in US private secondary schools and determined that 58% had AT services to some extent. With 42% of schools lacking access to ATs and only 28% of AT services being full time, student-athletes are at greater risk for injury during sports games and practices. Without an AT, the outcomes of athletes' injuries or illnesses could be worsened if players are prematurely cleared to return to activity by a coach who lacks the proper knowledge to evaluate an injury and determine readiness to return to play. Similarly, if the environmental conditions on a practice day are not deemed safe (eg, heat, humidity, lightening), and an AT is not onsite, a coach may still hold practice. However, if an AT is present, his or her knowledge of injury prevention could result in practice being canceled due to unsafe conditions, thereby mitigating risk of injury or even death.
Lack of medical care in private secondary schools is consistent with that in the public sector. Recently, researchers9 reported that 30% of public secondary schools had no AT services. This is a smaller percentage than 20 years ago, when 65% of schools lacked AT services.7 Our results, in conjunction with current literature, describe the continual rise of AT services in secondary schools (ongoing room for improvement), which is paramount in ensuring the health and safety of student-athletes.9
Without appropriate medical personnel present at practices, athletes are at risk for serious injuries and sudden death. Examples include Max Gilpin20 and Jermaine Cullum,21 secondary school athletes who died from complications of exertional heat stroke and cardiac arrest, respectively. An AT was not available in either case, resulting in inadequate care and highlighting the need for appropriately trained medical staff at both practices and games.
Barriers to AT Services in the Private Sector
When identifying barriers to hiring an AT in private secondary schools, most respondents acknowledged budgets and school size as primary hindrances. In public secondary schools, budgetary concerns continue to be a major barrier, as previously indicated by Mazerolle et al.22 Funding sources for private schools differ from those of public schools, which provides some preliminary support for our findings.15 Private secondary schools are responsible for generating their own funding, as opposed to public schools, which receive their funding from state and federal taxes. Thus, budget development and decision making related to the distribution of funds in private secondary schools are heavily based on how much revenue is generated by student recruitment and enrollment.
Currently, many secondary schools face budget deficits for education, as evidenced by the combined $140 billion shortfall in 40 states out of 50.23 For this reason, schools have to find the means to fund activity programs. Unlike public schools, private schools can increase tuition as a way of increasing funds to support AT services. This is a unique aspect of the private sector in comparison with the public sector, which requires a tax increase to enhance funding. Also, some private schools offer boarding for students; boarding for an AT would both be an attractive benefit and offset salary costs for the school. Another suggestion, regardless of school type, is using a pay-to-play model to support AT services, whereby parents pay a flat rate to allow their children to play sports.23
Previous literature24 has shown that bringing ATs to secondary schools has potential cost savings. According to the 2014 NATA salary survey,25 the average annual wage for a certified AT at the private secondary school level was approximately $49 000. Although the school is responsible for covering this cost, employing an AT can reduce costs in other areas, such as liability and medical insurance and by providing in-house treatment and rehabilitation services. Therefore, instead of searching for ways to increase school budgets, simply hiring ATs could be more cost effective for secondary schools while also improving student-athlete health and safety. In addition to the potential cost savings in hiring an AT, student-athletes receive adequate medical care from health care professionals who are educated and trained in the prevention and care of athletic injuries. Another option is third-party reimbursement, in which allied health care professionals are reimbursed by third-party payers for the services they perform; this can assist school administrators in overcoming budget deficits as a barrier to AT employment.
The misperception that a coach can provide medical care in lieu of an AT is not uncommon, as Mazerolle et al22 found the same belief in public secondary school respondents. However, research10−13 indicates that coaches lack knowledge regarding the appropriate medical care of athletic injuries and, therefore, are not equivalent substitutes for ATs. In the Max Gilpin case, coaches provided inappropriate care while awaiting the arrival of emergency medical services, and only the head coach had attended heat-illness safety training.26 Barron et al11 found that secondary school athletic coaches were unable to achieve passing scores when retaking their basic emergency care examinations. Additionally, coaches are often guided by the desire to win, leading to decision making that may be biased and not focused on athlete safety.
The results of this study can be used to change the medical care currently provided to student-athletes in private secondary schools. The Inter-Association Task Force for Preventing Sudden Death in Secondary School Athletics Programs and governing bodies such as the NATA recommend that an AT be present in every secondary school for all games and practices to mitigate the risk of sudden death in sport.4,5 An increase in AT employment would ensure that more student-athletes are provided with adequate medical care.
One limitation of the study involves the definition of AT services. The school administrator determined full-time or part-time AT employment status at the school. Some administrators were unsure of who qualified as an AT: some responded that they themselves were the ATs or that a coach filled that position. These factors could alter the final calculations of schools with AT services and the breakdown of services offered, leading to more liberal findings than were actually the case.
Although all 50 states and the District of Columbia were represented and our response rate was higher than in other survey-based research studies,17 only 38% of private secondary schools responded. Despite our strong belief that this result accurately portrays AT services in the private secondary school setting, the actual percentage could be higher or lower. Our response rate could be explained by the various structures of the secondary school athletics departments and the availability of the AD during the day.
When no AD was employed at the school or if one was not available, the school's principal responded to the survey. Speaking to both ADs and principals may have altered the results slightly because of different perceptions of AT services.
Directions for Future Research
As recent authors9 have assessed the extent of AT services in public and private secondary schools, it is important to investigate the presence of ATs in specialty secondary schools, including alternative, charter, magnet, technical, and vocational institutions. The AT services at these schools may vary because of funding and enrollment differences, yet these services are necessary to ensure the wellbeing and safety of student-athletes participating at this level. Exploring medical coverage in the specialty sector will complete a representative picture of AT services in US secondary schools. Having the most accurate information about AT coverage in secondary schools will help identify which settings lack appropriate medical care and how to increase the employment of ATs.
Given that a major barrier to hiring ATs in the private secondary school setting was budgetary constraints, future researchers should focus on ways to advance funding to ensure that appropriate medical care is provided to all student-athletes. In addition, to better understand how the role of an AT is viewed in the secondary school setting, a study that surveys school boards, examining their level of understanding of an AT's role, will add to the existing literature on barriers to employment.
Lastly, for those schools that do employ an AT, it would be beneficial to ask administrators why and how they provide the level of coverage that they offer. This could assist in developing strategies and a framework for employing an AT in schools that currently do not provide AT services. It may also reveal how to overcome certain barriers in the process of hiring an AT.
Based on our findings, private secondary schools did not provide adequate AT services to their student-athletes. In comparison with the public sector,9 the private secondary school setting offered fewer services. Larger private secondary schools were more likely to have AT services. Regardless of setting, barriers to employing an AT were budgetary concerns, school size and sports, and lack of understanding of the role of an AT in secondary schools.
The NATA provided partial funding for this study.
Appendix. Interview Guide
Hello, may I speak to the Athletic Director?
(if no athletic director, ask if they have an athletics program or for principal)
Hello, this is XX from the Korey Stringer Institute with the University of Connecticut. We are calling with regards to a study about athletic trainers in the high school setting. May I ask you a few quick questions?
(should only take 1 minute)
How many athletes are in your school?
(total athletes, not per season)
How many students are in your school?
Do you have an athletic trainer at your high school?
If No: May I ask why you do not have one?
What is the medical coverage during home games? (ambulance, EMT, MD)
(make sure this is at all games, not just football)
If Yes: How many do you employ?
Are they full time, part time, from a clinic full or part time, or per diem?
Do they teach a sport medicine, athletic training, or health class?
Do they work all practices between approximately 2-6pm every day?
(as long as it sounds like they cover all practices)
If No: When do they work?
How often do they work?
If Yes: Do they work all home games for Football? Wrestling? Men's Basketball? Ice Hockey? Gymnastics? Skiing?
Thank you for your time.
Reproduced in original format.