Athletic Trainers’ Shared Professional Values: A Report From the National Athletic Trainers’ Association Professional Responsibility in Athletic Training Committee

The purpose of study 1 was to identify PVs alternatives and validate the survey instrument. The identification of PVs was based on the Raths et al⁵  values clarification method. According to this model, establishing consistent values-based behavior leading to good and right responsible conduct first requires clarification of the values that are important. This 7-step consciousness-raising process (Table 1) is used to separate true values from more immature wants, needs, and aspirations. Our research focus was on the choosing phase of the values clarification process, allowing participants to choose PVs freely from among alternatives after thoughtful consideration of the consequences of each option.

Participants were the 98 leaders of the Athletic Training Strategic Alliance (Strategic Alliance), which included the NATA, the BOC, the Commission on Accreditation of Athletic Training Education (CAATE), and the Research and Education Foundation (Foundation). Three of the 98 participants held positions in 2 of the 4 agencies; therefore, 95 participants received the survey.

To identify PVs alternatives in the development of the survey inventory, we searched for articles relating to PVs in health profession journals using PubMed, National Center for Biotechnology Information, and Google Scholar. Key search words were ethics, ethical values, professional values, values/personal values, social contract, professionalism, common values, inter-professional values, interdisciplinary values, competencies, multidisciplinary values, and collaborative values. The search yielded 47 articles, 2 of which were excluded on the basis of foreign language or unrelated content. The 45 references included the NATA Code of Ethics,¹  BOC Standards of Professional Practice,²  and CAATE Standards of Accreditation⁶  and resulted in 234 potential PVs for consideration. Appraisal by the expert panel reduced this number to 42 by eliminating PVs that appeared in fewer than 4 articles. The panel further reduced the number of potential values by eliminating those that did not represent professional behavior or give meaning to professional practice. Finally, values with similar meaning were combined (eg, caring and compassion), resulting in 16 potential PVs alternatives for survey inclusion.

The Athletic Training Professional Values Inventory, version 1.0 (AT PVI-1)⁷  is the only known survey instrument for the identification and ranking of athletic training PVs. The AT PVI-1 consisted of a list of 14 PVs alternatives from which participants identified PVs that were either unfamiliar or important; they were then asked to rank their top 3 PVs. The current survey instrument (AT PVI-2) includes the following demographic questions: Strategic Alliance member status, sex, and number of years of certified athletic training experience. The 16 PVs alternatives from the literature review were used, with the addition of a 17th PV, self-interest, as an attention variable to ensure participant diligence in making response selections. The AT PVI-2 measures the strength of agreement with the 17 PVs, and each is rated on a 7-point Likert scale (ranging from 1 = very important to 7 = unfamiliar with this term). We selected a 7-point scale to provide a balance between having enough points of discrimination without offering too many options. Participants were asked to rank which PV was most, second most, and third most important. Other questions asked respondents to rate the level of importance of PVs articulation to the participant and the level of importance for the professional body to explicitly articulate PVs to ATs. Both questions used a 6-point scale ranging from very important to totally unimportant. In an open-ended question, participants were also given the opportunity to provide other PVs not included in the PVs alternatives.

An expert panel consisting of 4 ATs with legal, ethical, regulatory, and professional standards experience and serving on the Professional Responsibility in Athletic Training Committee research team, along with an instrument development expert, identified PVs alternatives and assessed face validity for survey development. To minimize the potential for bias, all members of the research team created and approved the research plan. Furthermore, statistical analysis duties were shared among the team members, and outside peers with related expertise reviewed the research plan and results. We electronically administered the AT PVI-2 survey to the 95 leaders of the Strategic Alliance. Data were collected and managed using REDCap (Research Electronic Data Capture), hosted at Vanderbilt University.^8,9 

We used frequency count and cumulative percentage tabulations for each item and each PVs alternative. Strength of agreement was determined by the frequency and percentage of PVs selected as very important. We analyzed the internal consistency among survey items using the Cronbach α. Data were analyzed using SPSS (version 24.0; IBM Corp) and Excel 2016 (Microsoft Corp).

The response rate was 64% (61/95) with representation from each of the 4 Strategic Alliance agencies (Table 2). Respondents were categorized by sex, member status, and years of experience. Relative to the most important rating for each PVs alternative, the rank order for the first, second, and third values was integrity, respect, and competence, respectively (Figure 1A and B). Participant responses to rating how important PVs were personally as a certified AT were all in the very important (86.9%; 53/61) and important (9.8%; 6/61) categories. Responses to the importance of the professional body explicitly articulating PVs showed that 65.6% (40/61) deemed it very important and 34.2% (21/61), important. Respondents were provided the opportunity to identify any PV that was not included among the listed alternatives. Eight additional values were provided; however, no value was listed more than once. Therefore, we determined that the PVs list of alternatives was complete. Item validity was established on the basis of the expert source, and the Cronbach α demonstrated good internal consistency (0.847) for the AT PVI-2 survey, indicating that the contemporary PVs alternatives reasonably represented a complete list of PVs in athletic training.

The purpose of the second study was to rank the PVs from a provided list of PVs alternatives and determine the consistency and construct validity of the PVs list.

Athletic training members in the NATA who consented to surveys and inquiries (n = 35 279) received a survey link to participate in this research to ascertain the shared PVs of ATs.

We modified the AT PVI-2 survey by replacing Strategic Alliance–specific demographic questions (eg, Strategic Alliance member status) with AT demographic inquiries on sex, ethnicity, years of certified experience, employment setting, NATA district, and state (location) of practice. The PVs alternatives were reduced from 17 to 16 by removing the attention variable of self-interest because it was selected by only 1 respondent in study 1 and had no effect on the other responses. The ranking of the most, second most, and third most important PVs in the pilot survey did not provide any insight into the relative importance of any given PV beyond what was already apparent from the frequency counts and percentages for each PV. Some participants selected the same PV for the first and second or second and third ranks, creating redundancy; therefore, we asked the participants to rank only the single most important PV, as this would be the primary determinant for final PV selection.

An NATA special projects coordinator disseminated requests to participate in this survey research in 4 email communications (initial email and 3 follow-up emails). The survey was electronically administered through Qualtrics survey software (QualtricsXM).

We tabulated frequency counts and percentages to establish the strength of agreement with each PV. Percentages were calculated on the basis of the number of participants who provided a specific response out of the total number of responses for each item. The Cronbach α for internal consistency was calculated to determine whether the participants answered questions that were related similarly.

Further survey analysis included a principal component analysis to characterize constructs in the survey based on how the participants answered. The desired outcome was to identify some complexity in the items, which would indicate that they did not all represent 1 construct.

The survey response rate was 13.7% (4837/35 279), and the representation was comparable with published NATA member demographic data for sex, ethnicity, years of experience, setting, and district (Table 3). The ranking based on most important and very important responses for each of the 16 PV alternatives is reported in descending order (Figure 2A and B). The top 3 ranked PVs were consistent with the study 1 results: integrity and respect were among the values deemed most important. When asked “How important are professional values to you?” the vast majority responded that PVs were very important (79.7%) or important (19.4%). Participants were also asked “How important is it for the professional body to EXPLICITY articulate professional values?” The combined categories of very important and important totaled 90% (51.5% = very important and 39% = important). Respondents answered related questions similarly, demonstrating good to excellent internal consistency (Cronbach α = 0.853).

From a scree plot of the principal component analysis, we determined that 2 constructs explained 47% of the total variance among the 16 PVs (Figure 3). The first construct was the stronger of the 2, explaining 38% of the 47%. The PVs identified as more important in the first construct were associated with professional responsibility (respect, integrity, responsibility, trust, accountability, competence, caring and compassion, and empathy). The PVs that were identified as more important within the second construct were related to social consciousness (justice and fairness, social justice, advocacy, and autonomy).

The objective of the third study was to develop a definition and list of sample behaviors for each PV.

All chairs and members of NATA committees and task forces (N = 423) were contacted to complete the PVs definitions and sample behavior survey. This group was selected because it represented volunteer leaders across all demographics (eg, sex, ethnicity, special interest groups, practice settings) of athletic training.

The NATA Board of Directors reviewed the survey results from study 2, selecting the following 5 PVs from among the top 7 ranked as most important: caring and compassion, integrity, respect, competence, and accountability. Trust was the PV among the ranked top 6 that was not selected on the grounds that trust, along with truth and honesty, which was ranked as seventh, represents a component of integrity. Definitions and sample behaviors for the 5 identified PVs from the survey (study 2) were developed into a 10-item survey so that we could determine face validity of the shared PVs definitions and 5 behavioral indicators for each PV.

A panel of 5 ATs with extensive experience and expertise in legal, ethical, regulatory, and professional standards reviewed the health care and medical literature to find possible definitions and sample behaviors for each of the 5 approved PVs. The definitions and behaviors formed the content for the survey that was administered using Qualtrics survey software. Each participant was asked to choose the strength of agreement of the definition and sample behaviors with the corresponding PV. A 3-point Likert scale (1 = clearly representative, 2 = somewhat representative, 3 = not representative) was used to establish the strength of agreement with the definition and the 5 corresponding behaviors for each PV.

We calculated frequencies and percentages (the number of participants who provided a specific response out of the total number of responses for each item) to indicate the strength of agreement with each PV definition and each of the 5 behaviors listed for each PV. Survey face validity was demonstrated via item scrutiny by ATs who were chairs or members of NATA committees and task forces to assess the suitability of the definition and representative professional behaviors of each determined PV. Face validity of the survey was also assessed to ensure that each PV (item), its definition, and sample behaviors were unambiguous and applicable to the target population of athletic training committee and task force members of the NATA.

A total of 311 of the 423 NATA committee and task force members participated, for a 74% response rate. Only completed surveys (n = 277) were analyzed; therefore, 34 surveys were excluded due to missing responses. The strength of agreement with the definitions, as indicated by clearly representative, ranged from 72% (respect) to 87% (accountability). No definition was identified as being not representative of the corresponding PV. The definitions and specific levels of agreement for each of the 5 PVs are provided in Table 4. The Cronbach α for all 30 items (5 PVs and 25 sample behaviors) was 0.92. Although the Cronbach α for all 5 behavior indicators for each of the 5 PVs was strong at 0.91, the Cronbach α for the top 3 behavior indicators for each PV was also very good at 0.87. Endorsed by the NATA Board of Directors, we selected the top 3 behaviors to represent each PV to further support ATs’ requests for streamlining legal, ethical, regulatory, and professional standards information. The ratings for all behavior indicators are shown in Table 5.

On the basis of the results of the survey (study 2), the NATA Board of Directors pronounced caring and compassion, integrity, respect, competence, and accountability asthe profession’s shared PVs. These 5 simple, yet exceptionally meaningful, values now afford ATs the opportunity to apply a values orientation to emerging professional situations. When combined with a compliance orientation, NATA members will be able to use a mixed-orientation approach that inspires good and right responsible conduct.

We drew upon early PVs research in athletic training, conducted in 2005 through 2007,⁷  using the pioneering work of the Raths et al⁵  values clarification method. Whereas the method was the same, a need existed to review the former survey instrument (AT PVI-1) and provide new and contemporary value alternatives for the AT PVI-2. Given the historical changes in a rapidly evolving health care system, advances in technology, a shifting workforce, and social and cultural events, it is good practice for professions to reexamine their unique set of PVs over time.¹⁰  As such, the AT PVI-2 provided new contemporary value alternatives.

The AT PVI-1 and -2 value alternatives are compared in Table 6. The earlier work²  represented the collapsed results from 4 studies and revealed that the most important values were caring, integrity, respect, truth and honesty, and accountability.¹¹  We found that the most important values were caring and compassion, integrity, respect, competence, and accountability. When we compared the results of the 2 studies, it was interesting to note that truth and honesty only appeared on the list of the top 5 important PVs in the previous research²  and competence only appeared in the top 5 important PVs of the current study (Table 7). Given an element of truth and honesty in the value of integrity, this redundancy could explain why it did not make the list of important PVs. Also, competence was not included among the PVs alternatives to the original PVs in athletic training research, yet it was an important value in our investigation. Another curious observation relates to core PVs, which are enduring traits that rarely change over time.¹²  Results from the original and current research suggest that 4 PVs (caring and compassion, integrity, respect, and accountability) could be viewed as core athletic training PVs.

The AT PVI-2 included open-ended questions that were not formally qualitatively analyzed; however, a review of these responses revealed an interesting theme regarding the value of respect. Some participants interpreted respect as something to receive, rather than something that ought to be given to others. This was not the predominant view about the value of respect, but it certainly raises a noteworthy discussion point.

As demonstrated in Table 8, impressions regarding the importance of PVs and the importance of articulating PVs remained relatively consistent over time. When the extremely important and important categories were collapsed, 97% of participants in the original athletic training PVs research²  and 99% of participants in the current research believed that PVs were essential. The same trend was seen with collapsed categories (extremely important and important) relative to the participants’ views of the importance of explicitly articulating PVs (97% in the previous work²  and 91% in our study).

Values form the basis of human behavior and are expressed in decisions and actions. Given their moral nature, they represent basic convictions of good and right responsible conduct.¹³  People typically act in ways that are congruent with their values, even when they are not consciously thinking about them.³  Our third study explicitly elucidated a definition and good and right responsible behaviors (sample behaviors) for each PV. These were selected according to the level of agreement among the participants, who represented diverse leadership in athletic training (NATA committee and task force chairs and members).

Because of the nuances and distinctions within each practice setting, ATs are encouraged to develop practice setting–specific behaviors that align with the NATA–endorsed sample behaviors. Currently, the NATA shared PVs are being integrated into the NATA Code of Ethics. As such, the Code will provide a mixed-orientation approach to assist ATs in ensuring good and right responsible conduct. To use a mixed-orientation (values and compliance) approach, the AT first draws upon a values orientation composed of the shared PVs to provide intuitive judgment and initial action at the outset of a developing situation. This is followed by a standards- and rules-driven compliance orientation to logically review and determine ongoing action.

Weaver and Trevino⁴  postulated that when the 2 orientations are mixed, members of an organization are more likely to consistently abide by group norms. Whereas the characteristics of each orientation are different (Table 9), the outcomes are the same: to bring consistency to behaviors and conformity to the organization’s norms. Professional organizations have found it useful to incorporate both orientations to encourage group norms.

To date, good and right responsible conduct in the profession of athletic training has relied solely on a compliance orientation, requiring adherence to the standards and rules found in professional documents such as the NATA Code of Ethics,¹  NATA Membership Standards,¹⁴  BOC Standards of Professional Practice,²  and state practice acts.¹⁵  Thus, compliance orientation makes practice expectations and standards and rules explicit. Furthermore, the focus is on vertical accountability, reporting, and penalties. Violation of 1 or more standards and rules of the professional practice documents results in a punitive measure. Each agency of the Strategic Alliance (NATA, Foundation, CAATE, BOC) has developed a unique process of adjudication and penalties. As such, a compliance orientation maintains conformity by way of a threat of discipline.⁴ 

A compliance orientation also demands reasoning that is deliberate, methodical, and time intensive. Its complexity is apparent from the number of moral theories (ie, deontology, teleology, virtue ethics). Moreover, it is timely to weigh and consider the elements of a situation within the theory’s framework to determine the appropriate action.

Conversely relative to the values orientation, Haidt¹⁷  contended that moral “intuition,” as opposed to moral “reasoning,” gives rise to a moral awareness that is values based. Values orientation has been described as automatic, effortless, and swift. To that point, moral intuition was defined as the sudden appearance in consciousness, or at the fringe of consciousness, of an evaluative “gut feeling” (like or dislike, good or bad) about the character or actions of a person, without any conscious awareness of having gone through the steps of searching for evidence, weighing the evidence, or inferring a conclusion.¹⁸  Furthermore, a values orientation creates a process of peer and self-correction, promoting mutual accountability. A review of both orientations demonstrates that they are not mutually exclusive but rather complementary. When mixed, values and compliance orientations play critical temporal roles in guiding good and right responsible conduct.

The mark of excellence in an organization is the extent to which core values are common and shared.¹⁹  This distinctive feature is illustrated in the health care professions and medical specialties (Table 10). Nursing, occupational therapy, physical therapy, internal medicine, and orthopaedics are examples of health care professions and medical specialties that have identified and explicitly articulated their PVs. Of the 5 professions (Table 10), the PVs of altruism and accountability appear in 4. Similarly, accountability was important to athletic training. On the other hand, altruism, the unselfish regard for the welfare of others,²⁰  was not deemed to be important by ATs, and 7.4% curiously reported it as an unfamiliar value.

Medical specialties have drawn upon PVs to serve as a scaffold for professionalism. Toward the end of the 20th century, the medical profession was challenged by market forces, increased governmental regulation, and the demands of commercialism.²¹  As such, physicians believed their autonomy was diminishing and turned to professionalism to recover their authority to provide quality patient care.²¹  Medicine found itself in an awkward position with no definition of professionalism and turned to PVs to underpin and elucidate this abstract construct.

Because medicine is not monolithic, the individual medical specialties approached professionalism and PVs in unique ways. In 1994, the American Board of Internal Medicine²²  took the lead and collaborated with the American College of Physicians and the European Federation of Internal Medicine to develop “Medical Professionalism in the New Millennium: A Physician Charter,”²³  which reaffirms the importance of the fundamental and universal principles and values. Furthermore, to facilitate the transition to practice, candidates seeking internal medicine board certification must demonstrate consistent values-based behaviors that are acquired in the specialty.²² 

The orthopaedic medical specialty addressed the notion of professionalism in 1998 when the Academic Orthopaedic Society surveyed 186 leading surgeons to reach consensus.²³  A 7-point Likert scale, similar to that on the AT PVI-2, was used to identify important values (Table 10) and characteristics. To support residents’ professionalism, the Academic Orthopaedic Society championed the integration of PVs into the curriculum and encouraged PVs assimilation as manifested in professional behaviors.²¹  Whereas the American Board of Internal Medicine and Academic Orthopaedic Society arrived at their PVs in different ways, both specialties realized the importance of intentionally incorporating PVs into the professional curriculum.

Several health care professions (eg, nursing, occupational therapy, and physical therapy) have identified unique PVs. In nursing, Schank and Weis²⁴  in 1989 were the first to examine nursing PVs in their attempt to learn about the relationship between nursing students and the PVs in the nursing code of ethics. In 1998, the American Association of Colleges of Nursing identified human dignity, integrity, altruism, autonomy, and social justice as the core nursing PVs and incorporated them into their baccalaureate programs.²⁵  Recently, the American Association of Colleges of Nursing updated the “Essentials: Core Competencies for Professional Nursing Education,” as well as revised the PVs (Table 10), changes that are expected to be transformative in the preparation of future professionals.²⁶ 

In 1985, the American Occupational Therapy Association Executive Board charged the Standards and Ethics Commission with creating a statement that would depict the attitudes and values that support the profession of occupational therapy.²⁷  The 7 PVs (Table 10) are reflected in the association’s official documents and reside in their code of ethics²⁸  to encourage ethical conduct.

In 2000, physical therapy began its transition to requiring a doctoral degree for professional practice. As did medical professionals, physical therapy professionals realized that the construct of professionalism needed to be delineated. As such, a consensus conference of physical therapists was convened. Eighteen professionals with expertise in practice, research, and education gathered to develop a document that would expound professionalism by identifying the PVs that underpin this construct. This work was adopted by the Board of Directors and integrated into “A Normative Model of Physical Therapist Professional Education.”²⁹  Similar to internal medicine, nursing, and occupational therapy, the PVs of physical therapy (Table 10) were not only integrated into the curriculum but also embedded in their code of ethics.³⁰ 

With the NATA’s pronouncement of shared PVs, the athletic training profession now has pertinent evidence to further develop a values orientation to support a mixed-orientation approach leading to good and right responsible conduct, as well as the notion of professionalism and the formation of professional identity. Conceptually, professionalism has changed over the last 40 years. Originally, models of professionalism were based on virtues reflected by strong character traits, such as moral values and ethics. However, more recently, in response to a gap between ethical instruction and ethical action, a behavior-focus model was developed. Current professional identity formation models integrate values with aspirations and behaviors in the field.³¹  Yet neither character traits nor behaviors seemed to reach the heart of the matter: “Acting as a professional” is not the same as “being a professional.”³²  More recently, the medical and health care professions have explored the notion of professional identity formation as an extension of professionalism. This was largely prompted by the Carnegie Foundation report³³  that stated the pillar of medical education is professional identity formation, which is the development of PVs, actions, and aspirations. In terms of education, the purpose of professional identity formation is to help students internalize the meaning of their professional experiences, which develops an identity that aligns with the profession’s shared PVs.³⁴ 

Raths et al⁵  reported that values are learned, evolve from experiences, establish a basis for behavior, and are evident in consistent patterns of behavior. The acquisition and internalization of PVs begin with a didactic introduction to the PVs that guide professional behaviors and practice.³⁵  Furthermore, learned PVs guide decision-making, improve critical thinking and communication, and influence a professional’s ability to solve conflicts. In general, professional academic programs in medicine and health care serve to transform and expand student values in preparation for a professional role.³⁶  The process of PVs acquisition and internalization is intentional and staged, beginning with an intellectual understanding of PVs in the professional program.³⁵  Medical and health care education have integrated their unique PVs into professional education.

After students are introduced to PVs didactically, their internalization strengthens when they are given the opportunity to reflect on their experiences and consider those values that emerge and resonate most with their worldview.³⁵  If personal values are incongruent with shared PVs, purposeful conversations can help the student work through this internal dissonance.

The acquisition and internalization of PVs must proceed at the individual’s pace. Weis and Schank³⁶  contended that incomplete PVs development hinders the professional progression from novice to expert. Using 3 levels, Stephens and Ormandy³⁷ described the extent to which a professional has adopted and internalized PVs in the following manner:

• Level I: Compliance—The professional acts in a particular way to gain positive feedback.

• Level II: Identification—The professional chooses certain behaviors but not values.

• Level III: Internalization—The professional accepts the norms and values of the professional role because he or she believes in them.

Our research had several limitations. The literature review for the development of a thorough PVs alternative list was restricted to articles published in the United States. For all 3 studies, dissemination of the survey link and subsequent acceptance of the invitation depended on correct email addresses in the NATA membership database. Only ATs who consented to receive research participation requests through the NATA were invited to participate, and no incentives were offered for involvement in the survey. A 13.7% response rate was low but deemed acceptable given that it exceeded return rates for other NATA–disseminated surveys. Finally, we assumed that participant responses were truthful, which is another possible limitation of these studies.

The recently pronounced NATA shared PVs not only serve to guide good and right responsible conduct but also to advance the constructs of professionalism and professional formation in athletic training. Equally important, professional students can benefit from formal exposure to shared PVs when the PVs are intentionally and skillfully integrated into the professional curricula. In this way, newly credentialed ATs will not only “do” athletic training but also “be” ATs.

In 2017, the NATA Professional Responsibility in Athletic Training Committee set a goal of developing an approach that easily channels good and right responsible conduct that is in accordance with legal, ethical, regulatory, and professional standards documents in athletic training. A values-orientation approach was pursued, given that values are simple, easy to recall, and inspire good and right responsible conduct. With the support of the NATA Board of Directors, the Professional Responsibility in Athletic Training Committee workgroup surveyed ATs. Based on the evidence, the NATA Board of Directors pronounced that caring and compassion, integrity, respect, competence, and accountability (CIRCA) are the most important shared PVs. Furthermore, an overwhelming majority of ATs found the PVs to be important and thought they should be explicitly articulated by the profession.

The results of this AT-driven research convincingly indicates that the profession should continue to advance and give voice to our shared PVs in athletic training to help students assimilate into their professional roles. This approach is consistent with the future of medical and health care education.

We thank NATA past-President Tory Lindley, MA, ATC; the NATA Board of Directors (2016–2020); NATA Senior Special Projects Coordinator Katie Scott, MS, ATC, and NATA staff; NATA Professional Responsibility in Athletic Training (PRAT) members Riana Pryor, PhD, ATC, and Carolyn Peters, MA, ATC; ethics/values expert and educator Kimberly Peer, EdD, ATC; and literature reviewers Evan Wilson, ATC, Alison Nutt, MS, LAT, ATC, and AJ Rucker, MS, LAT, ATC.