Context

Limited research exists regarding athletic trainers’ (ATs’) perceptions of professionalism.

Objective

To explore the lived experiences of ATs and their perceptions of professionalism.

Design

Qualitative study.

Setting

Participants were ATs who completed a semistructured interview protocol via audio-only recording conferencing.

Patients or Other Participants

Seventeen participants (age = 33 ± 8 years; range = 25–56 years) who were certified ATs with an average of 10 years of experience (SD = ±8; range = 1–33 years) were interviewed.

Data Collection and Analysis

Individuals self-identified their interest in participating in a follow-up interview recruitment located within a survey. Interviews occurred until saturation was met and included a variety of participants. Demographic information was gathered from the survey for each person. All transcripts were audio recorded, transcribed verbatim, and coded using a 3-person coding team following the consensual qualitative research protocol. Member checking, auditing, and triangulation established trustworthiness and credibility in the data-analysis process.

Results

A total of 4 domains with supporting categories were identified. Athletic trainers spoke of the employee environment that affected perceptions of what was determined to be professional, specifically in various settings or situations. They shared their personal determination of outward appearance and expression when differentiating what was deemed professional, including references to cleanliness, judgment of self-expression, and implicit bias. Whether intentional or unintentional, participants made comments that demonstrated a bias toward sex or race and ethnicity when determining outward appearance appropriateness. They noted various cultural awareness situations, including progression of perceptions over time, external pressure, and internal dialog. Respondents shared discourse regarding an internal struggle of what was right and wrong in their responses. They discussed professionalism based on the provider’s conduct, mainly in terms of communication and patient care. Participants shared that communication occurring through both verbal and nonverbal means is vital to the perceptions of professionalism for ATs.

Conclusions

Current views of professionalism in athletic training were shaped by various lived experiences. With the movement toward athletic training becoming more diverse, equitable, and inclusive, antiquated professionalism ideals need to shift to provide a better work environment for all.

Key Points
  • Athletic trainers’ definitions of professionalism were rooted in various lived experiences.

  • The definition of professionalism may change over time, as athletic trainers are exposed to diverse groups, settings, and workplaces.

  • A concerted effort to shift the definition of professionalism and allow for different gender, cultural, racial, ethnic, and age perspectives is warranted to enhance inclusivity in the workplace.

Professionalism can be defined as “the conduct or qualities that characterize a professional person, or a profession.”1  Because this definition encompasses behaviors and characteristics relating to professionalism, such as autonomy, altruism, collegiality, integrity, morality, responsibility, and the pursuit of excellence, agreeing upon 1 consistent definition is difficult. Furthermore, conceptualizing professionalism can be personal and may not include all these characteristics. For health care providers, professionalism should be based on the quality of services or treatments delivered; however, other stakeholders may base their opinions on physical attributes or first impressions.

For example, when asked what professional dress is for an athletic trainer (AT), “khakis and a polo” could be the most popular answer because that has long been the expected professional dress for an AT. Historically, athletic training was a male-dominated profession, with clinicians most closely associated with coaches.2  Although the origin of khakis as the choice of AT dress is perhaps an unwritten rule, the style of pants is understood by many. In 2013, athletic directors reported ATs in khakis to be more skilled, approachable, educated, competent, and experienced than those in professional dress or workout attire.3 

In addition to clothing, tattoos, hair, and jewelry also play a role in physical first impressions.4  Some limitations (eg, length of fingernails, hair kept out of the face) are in place to satisfy Occupational Safety and Health Administration regulations5  and maintain employee safety, yet certain limitations may have roots in the institutional or professional culture6  or expectations of others.7  For instance, in medicine, authors have described appropriate dress for health care providers in a hospital setting, often in clothing that separates 1 profession from another, which also separates clinicians from patients.7 

It has been suggested that many of these professional norms are rooted in White, Western, male culture.8  Something as simple as the temperature in an office that is identifies as business professional is governed by a model of appropriate temperature for men of a specific size and age wearing a suit.9  Workplace hair biases exist for Black women that may lead to negative outcomes, including emotional conflicts and attrition of employees who feel pressure to conform.10  The Creating a Respectful and Open World for Natural Hair (CROWN) Act was drafted to help create environments free of race-based hair discrimination for natural hair styles.11  Patients often have expectations of what their provider should look like, including negative opinions of nontraditional piercings in physicians12  and visible tattoos in dental hygiene students.13  In short, defined dress codes and interpretations of professional dress often fail to account for individuals’ ability to express themselves or their culture and may negatively affect people in minoritized groups, including racial and ethnic minorities, women, and the lesbian, gay, bisexual, transgender, queer, questioning, intersex, asexual, and others community.14 

Research on patients’ expected professional dress norms for physicians, nurses, and dental professionals exists, but the interpretation of professionalism among colleagues has not been well described. Additionally, among rehabilitative professionals (ie, ATs, physical therapists), no form of professional dress is universally accepted. Though dress is often considered when people are asked about professionalism, other components can be examined. Therefore, the purpose of our study was to explore the lived experiences of ATs and their perceptions of professionalism.

Study Design

This project was part of a larger study in which participants were shown pictures of a rehabilitative health care professional and asked whether the person appeared professional. If they responded unsure or no, they were prompted to write an open-ended response describing why they chose that answer. In the survey, participants could opt in for the interviews that were conducted for this analysis. The consensual qualitative research (CQR) approach was used in the current project to identify domains and categories in the participant responses. We followed the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist to ensure that this qualitative research demonstrated rigor and provided high-quality results.15  Before data collection, this study was approved by the Temple University Institutional Review Board.

Interview Protocol

The concept of having individuals define professionalism in the rehabilitative sciences by photo determination is novel. Two researchers (E.R.N., J.L.M.) created the semistructured interview protocol based on the research question and previous information regarding how professionalism was determined. The interview protocol went through 2 rounds of review by 3 external reviewers to validate the instrument. We conducted an initial interview to determine if the interview protocol met the needs of the research team. Changes were made only to the order of questions. This interview was not included in the final analysis process to ensure consistency in the protocol. The final interview protocol can be seen in Table 1.

Table 1.

Interview Protocola

Interview Protocola
Interview Protocola

Procedures

Interviews were conducted in November and December 2022. We used multiple recruitment efforts, including the National Athletic Trainers’ Association survey distribution service, listservs to athletic training program administrators, and posting on various social media platforms. Participants were able to click on the link for an online survey (Qualtrics) that brought them to a written informed consent outlining the research project. In the survey, respondents shared demographic information (10 questions).

If a participant opted in to the interview, a member of the research team (E.R.N.) sent the individual a link to sign up for an interview. The interviewer was a female certified and licensed AT. At the time of the interview, the participant was asked for permission to record the interview and to provide oral consent for the study on an audio-only, online platform (Zoom Video Communications). Respondents were then asked 10 semistructured interview questions with follow-up questions about professionalism terminology, expectations, and beliefs for rehabilitative health care professions. After the interview, the audio files and transcripts were downloaded and saved to the team member’s secured cloud storage system. The transcript was then deidentified and cleaned to match the audio file. The final transcript was sent to each AT to ensure that the description of his or her lived experiences of professionalism was accurate. At that time, the individual could send back any additions or corrections to the transcript; however, no participants made changes.

During the data-collection process, the interviewer maintained a list of the respondent demographics to ensure diversity of age, race, and ethnicity. After 12 interviews were completed, which is in the range described by Hill et al for best practice in CQR,16–18  the interviewer determined that, although saturation had been met, the sample was not diverse enough to ensure that the results could represent the largest number of people, and more interviews needed to be conducted. Six participants who had signed up for interviews were cancelled due to their demographics aligning with those of most of the individuals who had already completed the interview. An additional 5 ATs were included, as they represented different genders, ages, and ethnicities. After these interviews, the interviewer concluded that saturation had been met and included a variety of participants. A total of 17 interviews were conducted and analyzed.

Data Analysis

A 3-member team plus an additional auditor completed the coding for this project using the CQR design, and the CQR method was followed for the analysis.19  In the first round of analysis, the coding team (E.R.N., J.L.M., D.M.M.) reviewed 4 transcripts to identify common themes. A preliminary codebook was then created. Phase 2 consisted of the coding team reviewing 2 transcripts from phase 1 and 3 new transcripts to evaluate if the initial codebook could be applied to the full range of participants. At that time, the team determined that aspects of the participants’ data were not well represented in the initial codebook. A second codebook was created to better reflect the information in the transcripts. To check if this codebook better reflected the results, the coding team used the updated codebook on 2 additional transcripts. This codebook more accurately reflected the information in the transcripts. In phase 3A, the transcripts were divided among the 3 members of the coding team, and the new codebook was applied. In phase 3B, the transcripts were divided among the other 2 members of the coding team for consensus. Any disagreements or changes were brought to a group meeting at which a two-thirds vote had to be secured to verify the coding. The codebook and coding process were verified by an auditor (S.B.) for the final step in the CQR process.

At that point, all codes in the transcripts were separated by domains and categories into an Excel worksheet (version 16.83; Microsoft Corp) for the research team to review. Classification of the frequency counts was based on the Hill et al CQR principles.19  For this study, general was defined as appearing in 16 or 17 transcripts, typical as 9 to 15 transcripts, variant as 3 to 8 transcripts, and rare as 0 to 2 transcripts. Frequency counts and CQR terminology from the codebook are shown in Table 2.

Table 2.

Consensual Qualitative Research Frequency Counts

Consensual Qualitative Research Frequency Counts
Consensual Qualitative Research Frequency Counts

Participants

A total of 17 respondents (age = 33 ± 8 years; range = 25–56 years) with an average of 10 years of experience (SD = ±8; range = 1–33 years) participated in the interview for the qualitative portion of this study (average = 24 ± 7 minutes; range = 16–42 minutes). The demographics of the interviewees are provided in Table 3.

Table 3.

Participant Demographicsa

Participant Demographicsa
Participant Demographicsa

Four domains emerged from the analysis of ATs’ perceptions of professionalism (Figure).

Figure

Consensus codebook with domains and categories.

Figure

Consensus codebook with domains and categories.

Close modal

Employment Environment

In this domain, ATs discussed various components of their employment that had a direct effect on what they deemed professional. Two constructs that frequently emerged were the specific setting in which they were working and various situational details. See Table 4 for more quotes in addition to those that follow.

Table 4.

Additional Supporting Quotes From the Participants

Additional Supporting Quotes From the Participants
Additional Supporting Quotes From the Participants

Setting

Participants typically (frequency count 14/17) spoke to the differences in the various athletic training settings as part of their employment environment. Differences were perceived in what was deemed professional when practicing in a clinic versus the collegiate setting. Ray, who currently works in the secondary school setting, shared:

If you’re patient facing, there are different expectations of, yes, you need to wear the company logo. We’re less strict on if your pants must be black or khaki, as long as you work with your definition of professional.

Doug commented that the language used in the environment affected professionalism:

Working in an outpatient orthopaedic clinic, your kind of rapport and language may be different than utilized in a baseball clubhouse. I don’t think that one is more or less appropriate than the other. I think that being adaptable to your environment, so like I said, really getting that patient buy-in can be really, really important.

Situational

What was determined as professional by all individuals was often generally characterized by specific situational components at work for the day (frequency count 17/17). Respondents spoke to appropriate attire based on game days versus practice days or in-clinic treatments. Gina offered her thoughts on determining which situations made certain clothing appropriate:

I would say, just making sure, depending on what your event is, so [if] it’s practice and we don’t have any events, I’m a little more comfortable wearing joggers and a T-shirt especially, but if it’s a game day, I always look to make sure that I am in nice pants and a polo or a nice top.

Participants also described attire variations being allowed for indoor or outdoor patient care as well as for weather-related differences. Charles added:

When I was working either in a high school or collegiate setting, basically, you’re dressed for the weather because, obviously, you know weather. It’s not a factor inside of a building… As a former traditional athletic trainer, you dress for the weather.

Charles focused on his attire being comfortable for the weather and functional. Doug’s view was that specific items should be considered for various events the AT may be working:

If someone is wearing very scantily clad, or if someone who’s working at a football practice on a sideline and is not wearing a shirt, I’ll probably find that unprofessional. If we’re covering a ski event outside and they’re not wearing a coat to try to appear tough, I might consider that not really the best way.

Determination of Outward Appearance and Expression

The domain of determination of outward appearance and expression examined the effect of first impressions. Participants often noted perceptions of cleanliness of both practitioners and their space. In their responses, they were often judgmental about the self-expression of others and expressed implicit biases.

Cleanliness

The ATs noted various components of hygiene, overall cleanliness of the athletic training facility, and specific national regulations, including from the Occupational Safety and Health Administration, in their responses to determining professionalism as an AT. A total of 11 (frequency count 11/17) ATs typically spoke to the importance of cleanliness. Hygiene was important for practitioners in their outward appearance. Sophia shared:

And rather when it comes to hair, tattoos, and piercings, I think, in general, if you’re presenting yourself well bathed, you take care of yourself, I think that is more important than to cover up a tattoo or piercing.

Just as Sophia focused on general hygiene components, other participants focused in-depth on the habits of ATs. Terry addressed the concept of maintaining clean hair hygiene:

I would say that, I mean, just as long as it looks somewhat clean, not necessarily ratty and all tangled up and looking like you just rolled out of bed, is probably a good start, but other than that, I don’t know [if] that particularly matters. Whether you have a buzz cut or you have dreadlocks or whatever it may be, I don’t know, as long as it’s a clean look. It doesn’t matter what the exact hair style is.

Others noted how important a clean medical facility was in expounding upon their perceptions of professionalism. Regarding the athletic training facility, Marissa said:

I think the physical space that you work in really can communicate the standard that you have for yourself, that you have for your field, your profession. So your athletic training facility or clinic or the health care office that you work in or whatever it is, I think that your organization, your cleanliness, your resources, the people that are in your facility can potentially give a negative message really easily without someone, you know, really understanding. I’m a big stickler for facility maintenance, stability, and cleanliness.

Judgment of Self-Expression

Every participant (frequency count 17/17) generally provided opinions on what was considered acceptable regarding outward appearance. For the context of this study, we defined judgment of self-expression as creating parameters for why certain things were deemed permissible in some contexts but not in others. Personal judgments regarding beliefs and perceptions of professionalism were seen in various responses. One such judgment targeted what types and where on the body tattoos and piercings were acceptable versus unacceptable.

Michael conveyed his thoughts on tattoos:

You know, people have tattoos on their face or their knuckles or things like that. Unfortunately, it’s going to be interpreted poorly by the average person, unless they happen to be a tattoo aficionado themselves. You know, we live in a society where people judge you by your looks, like it or not.

Charles also shared his personal perspective on appearance-based professionalism:

If it’s okay to have blue hair in the clinic or bright green hair, bright pink hair, going on to the piercings, as long as the piercing appear[s] to be in, I wouldn’t say normal positions because normal may be different to other people. Typically, your piercing on the face should only be in the ears, and anywhere else should be covered up during a professional setting. What about skin art and tattoos? Typically, in an office-type setting, you may have most of those covered, but when wearing either shorts or more short-sleeved shirts in a traditional [setting], you want to make sure that there’s no offensive, vulgar language or images on those and make sure that they don’t take away from the care that you’re going to be providing your athletes. I do have a visible tattoo when I’m wearing shorts, and obviously, some of my former patients and athletes saw that when I was in that traditional setting.

How ATs conduct themselves was also discussed as a personal judgment on performance. Marissa noted:

I’m not going to judge someone based off of their clothing, but I guess it is judgmental. How this is right? This is a judgment. It doesn’t bother me if someone’s sitting on the golf cart, but if someone’s sitting on the golf cart with their legs up, and they’re scrolling through their phone or whatever it is, that’s something that personally bothers me because anyone can see that and take whatever opinion it is that they want.

Implicit Bias

Whether intentional or unintentional, participants made comments that demonstrated a bias toward various sexes or races and ethnicities when determining outward appearance appropriateness. A total of 14 (frequency count 14/17) respondents typically displayed implicit biases in their responses. In many cases, these centered on sex or race and ethnicity.

Adrian observed:

And I know, right now, our profession is going through some very tough times, and I feel we should find ways to make it better for everybody more or less, even the playing field, because, you know, especially women I feel like are very judged based on what they wear all the time, and I don’t want that to be the norm, and I want to find ways to make that better for them. It’s not fair to them at all.

Ray focused his response on professionalism through a diversity, equity, and inclusion (DEI) lens:

Looking into the DEI, diversity, equity, and inclusion principles and how you implement those in the workplace and in your communications, one of the things that really stuck out to me was initially “professionalism” was used to kind of gatekeep others from less privileged backgrounds from entering the higher level.

Gina spoke to a belief about appropriateness in terms of what was covered by her clothing:

The 3 B’s was appropriate. That’s a them thing, you know. Your butt, your boobs, and your back are covered, I think, was so [ingrained] when I would go shopping for clothes. I would always make sure that like I would, you know, do crazy movements in the dressing room to make sure that, you know, none of it’s going to show.

Sharon spoke to her personal experiences of sexism as a woman in athletic training and what she believed the root of the problem was:

I think the reason [was] my views have evolved. I think the definition of professionalism is rooted in sexism and racism and ageism and ableism, so many of the -isms, right? … I think I’ve had experiences of, I think, sexism throughout my career, and it was really—why did it have to be the way it was? Women in a couple of my settings were supposed to be present but not really seen or heard. That went along with the way you just—how you interacted with people. So there are 2 very, very different standards.

Cultural Awareness

Participants noted that it was difficult to define culture and how their personal perceptions evolved from their childhood, religion, community, and professional education. Some individuals demonstrated a progression over time of what was characterized as professional. Others reflected on how external pressures shaped their beliefs, which often resulted in an internal dialog. In this internal dialog, the respondents would describe their thinking, which caused some to change their minds as they were talking.

Progression of Perceptions Over Time

Even though many participants noted shifts in their personal beliefs regarding the determination of professionalism, some shared how their stance had not changed. A total of 15 (frequency count 15/17) ATs typically alluded to their progressions of perceptions of professionalism throughout the years. Some commented that their definition of professionalism was shaped in their professional athletic training program. Over time, participants such as Kevin attributed changing views on professionalism to increasing DEI efforts and awareness:

But as I’ve grown and learned a little bit more of access to certain things, maybe somebody doesn’t have access to afford the khakis and the polo, so they need to wear what they have, and I think it’s allowed me to become a little bit more humanized into what that translate[s] to be able to provide health care, being able to be who you are individually, and not allowing what an external standard has defined as professionalism.

Similarly, Amy acknowledged changes in the profession regarding what was considered right and wrong:

I believe, to be a beneficial change in the people who are serving in this profession, I feel like there’s a pretty big difference between some of the older athletic trainers who have this mindset of, “Well, this is the way things have always been done. This is what you have to wear. This is what you have to do,” and then you’ve got this generation of people who are kind of coming up and being like, “I’m going to make my own rules of what professionalism is, and you know how I’m supposed to look and how I’m supposed to act, and kind of like screw your old thinking,” and I love that, and I feel like I’m in that age gap of there’s things that I agree with athletic trainers who have come before me, and there’s things that I agree with the people who are coming after me. It’s a very fascinating spot to be in because I’m learning from both sides. I definitely think there’s good opportunity here for this next generation of athletic trainers to pave their own way and decide what this profession gets to be. I can say with almost absolute certainty that there is not going to be an emphasis on khakis and polos anymore, and I love that.

External Pressure

All participants (frequency count 17/17) generally shared how they felt societal external pressures to present themselves in a specific way, whether that be with attire, methods of self-expression, or their everyday conduct and mannerisms. Charles explained how a potential employer managed tattoos for its employees:

It’s not just an image from something from my college years, so I never deemed it to be unprofessional, but I also did have 1 job interview probably about 8 or 10 years ago where they asked me if I did have any visible tattoos. They actually told [me] in the interview that, if I was going to wear shorts, that tattoo on my lower ankle would need to be covered with socks.

Jake offered a different perspective on how external pressures shaped his views of professionalism:

I think that, as the world diversifies, and diversity, inclusion, and equality are taking a forefront, especially in health care roles, I think we’re going to see more loosening of the reins with professional appearance and with dress codes and things like that because there are so many great ways to show personality and character through skin art and some great piercings.

Internal Dialog

For this study, we defined internal dialog as participants having a discourse with themselves about what was right and wrong in their responses. Often this presented as an internal struggle that weighed several factors, including past education, personal beliefs, and trying to be mindful and inclusive of changes in the world, while also consciously or unconsciously recognizing some limitations of knowledge. In these areas, all respondents (frequency count 17/17) generally underwent internal dialog during the interviews. Marissa spoke about her perceptions of concerns among ATs:

I think also there’s a saying something to the effect of when your house is on fire, don’t worry about the drapes, just get out. I think sometimes in athletic training, we can hyperfocus on things when there are much bigger issues, and so if we can put some of our energy into some of our bigger issues that we’re currently facing rather than chastising people for what it is that they’re wearing or hair color, it may be [a] better one.

When expanding on her responses from reviewing the ATs in the photos from the survey portion of this research, Trudy pointed out the specific outfit an AT was wearing and how that translated to a real-life scenario for her:

The only one [photo from the survey] that gave me any pause for a second was—I think it was a woman or a woman-presenting person wearing like a blouse and spandex shorts. I was like, “That blouse looks too nice to be in athletic training. Like what if it gets ruined?” But ultimately, whatever, if that’s what you want to wear, live your best life, and then for the shorts, initially, I was like, “Oh, this looks short,” but I that’s because I personally wouldn’t be comfortable wearing them. It looks like the clinician could do their job well and was performing their duties. So ultimately, that’s what made me decide they were all professional.

Adrian noted that there can be more to people than the initial impression their appearance may give:

What I had trouble with is understanding context of like why each person wore what they wore just because I believe something may look or may not look professional. I’ll understand what they’re going through… So it wasn’t as easy as you would have thought it would have been.

Provider’s Conduct

Finally, participants described various aspects of the provider’s conduct, which was defined as the way providers interacted with patients. The provider’s conduct aligned with areas of communication with patients and the quality of care that was delivered.

Communication

All participants (frequency count 17/17) generally indicated that communication occurring through both verbal and nonverbal means was vital to perceptions of professionalism for ATs. Terry addressed the importance of the spoken and unspoken word:

I think about going through their body language, just the way that they are able to connect with different patients. You’re going to treat people that are on a very wide spectrum, whether that’s introverts, extroverts, athletes, nonathletes, and I think that being able to connect appropriately to each of the patients is a big aspect when it comes to professionalism and just being able to stay unbiased.

Ray appreciated the roles of patient education and communication in the overall job of the AT:

I think it just kind of goes back to their communication. I think, if you’re a professional, then that means you are engaging with your patients. You are talking with them throughout the session. You’re giving them updates. You are communicating with the family as appropriate. If you are not doing that in that interaction, you can look however you want, but that feeds into it as well.

Patient Care

Another important component for ATs regarding professionalism was the quality of patient care provided. All participants (frequency count 17/17) generally shared their version of how this was part of professionalism. Charles stated:

I would say your professionalism comes down to being empathetic and always understanding that. You know, everything that the patient sees and hears is going to relay back to their perception of the care that they’re given… If you are enjoying yourself and you feel that your practitioner is competent and confident, that typically subconsciously does [help to] aid your rehabilitative state. Typically, people do get better outcomes when they perceive that they are getting better care.

When deciding about attire, Karen expressed how she believed that some were more concerned with how other ATs were dressed than their code of conduct and how they conducted themselves as a professional:

I’ve seen people who have the image of what we could—what society can deem as professional of the button-down shirt, polo shirt, khakis, dress pants, but they’re not able to establish that relationship, that trust with their patients, and you have somebody who wears like athletic shorts or leggings and a hoodie, and so they’re able to provide exceptional care and build that trust and that relationship with the athlete that they’re able to provide care and be a source or resource for those individuals. Professionalism is how you carry yourself and how you act more than the image.

Amy described a holistic view:

So not only are they doing their job well, but how they treat other people that are kind of unaffiliated with their main goal in their job, I think that’s really telling as well because it tells me about the person that you are.

Despite every participant in the current study noting that perceptions of professionalism were heavily weighted by external factors, limited research exists on what constitutes appropriate work attire as viewed by peers, patients, or the public. This indicates that some of these external pressures were likely coming from educational, societal, or familial sources and may not be tied specifically to the profession of athletic training. Although work attire has historically been a predominant focus of what is considered professional,20  our study participants often included other components, such as patient care and communication and their adaptations to the changing workplace environment.

Employee Environment

Athletic trainers are currently employed in a variety of settings. Specifically in our study, respondents often spoke to the differences among ATs in the secondary school and clinic settings and what constitutes appropriate professional behaviors. Additionally, many variations in attire were noted depending on game versus practice days, inside versus outside events, and weather-related considerations. Many individuals were unsure of specific institutional dress code policies, yet the culture in most settings seemed to align with that of the coaching staff. In certain sports, if the coaches wore business formal clothing, ATs were expected to align even to the detriment of function, although this has been changing.21 

Determination of Outward Appearance and Expression

Several categories emerged in the domain of the determination of outward appearance and expression, including cleanliness of the provider and facility, a judgment of the self-expression of others, and implicit biases. Despite cleanliness being required within health care facilities, only 11/17 participants cited its importance. It is imperative that ATs continue to maintain high standards of personal hygiene and facility management to ensure a safe environment for both patients and providers.

Similar to body art, hair is another tool used to express oneself, and with that expression, the opportunity for biases becomes more evident. Natural hair bias can often lead to concerns about inequality.22  Although our participants noted inclusion for those with natural hair, researchers have indicated that this is not always the case. The CROWN Act prohibits the rejection of employment and educational opportunities because of hair texture or protective hairstyles as well as discrimination based on natural hair style and texture or hair kept in an uncut or untrimmed state (ie, locs, cornrows, twists, braids, Bantu knots, fades, or Afros).11  Because federal laws currently only focus on a person’s unchangeable characteristics, room for bias toward a Eurocentric definition of professional hairstyles exists. The CROWN Act seeks to have natural hair discrimination classified as racial discrimination rather than appearance bias and is a key component in combating existing implicit and explicit hair biases.23,24 

Additionally, hair textures, styles, and coverings have been further incorporated into professional appearance standards.25  In some professions, Black women with natural or curly hairstyles have been perceived as less professional or competent than other Black women who have straight hair or White women with curly or straight hair.22  Pressures to conform to the Eurocentric norm of smooth and straight hair are heavily exerted on Black women.10  Natural hair is frequently stigmatized as unprofessional and less beautiful,10  and the pressure to conform can have negative consequences in the workplace, including employee loss and conflicts.10 

Often, participants described some external characteristics as being acceptable for others but then discussed how they would never have them (eg, vibrant hair color, visible tattoos). As these comments came across as elitist and as a double standard, we determined that they were a form of judgment of others, whether the participant was intentional or not about the judgment. Many times, these were components of personal self-expression that would not affect patient care, including piercings, tattoos, and hair color. Several respondents noted that, although they chose to never have a visible tattoo, they believed that it was permissible for others to self-express in that way.

In our study, individuals expressed concerns about the attire of those who appeared to present as women. Several ATs described the appropriate length of shorts and needing to cover specific parts of the female anatomy as required components of professional dress. This belief aligns with other, more dated findings that women were to be held to a stricter standard, with an expectation that women should dress more conservatively.26  At least 2 participants specifically addressed the 3 B’s (ie, belly, bottom, and breast), a misogynistic viewpoint to ensure female modesty.27 

Cultural Awareness

For the context of our work, we defined cultural awareness as being mindful of the effect of individual culture, including external pressure, one’s own cultural influences on their internal dialog, and their growth over time. Throughout the interviews, respondents discussed the pressure they felt from others to dress and act in a specific way. This result was consistent with master’s research (2013) in which the author demonstrated that athletic directors believed that, for an AT to be noticed and respected, he or she must wear khakis and a polo.3  This judgment extended into the belief that ATs dressed in khakis and polos were more skilled, approachable, educated, competent, and experienced than those in formal dress or workout attire.

In other medical professions, the attire clinicians most preferred differed from the perceptions and preferences of most patients.28,29  For example, although physicians preferred formal attire, patients described trusting physicians wearing formal attire with a white coat.30  Similarly, most patients believed that the white coat contributed to greater comfort and confidence in their physicians.26,28,31  Nurses preferred printed scrubs, whereas patients described nurses wearing solid-colored scrubs30,32  as more caring. In occupations such as dentistry, formal attire was highly preferred by other professionals and contributed to more competence and reliability overall.33 

Limited research has been conducted on professional dress for ATs. From a review of the literature, it is important to acknowledge the lack of information on what constitutes professional dress for health care providers as a whole. Most studies were published more than 5 years ago and all before the COVID-19 pandemic, which has changed workplace culture and acceptable norms.34  In our study, participants discussed the change to wearing scrubs while providing patient care after the onset of the pandemic.

Another form of progress we observed was participants being able to self-reflect and identify personal areas of growth. Several ATs discussed how their ideals, which were initially shaped by their personal experiences and academic preparation, have adapted over time. Several reflected on their conscious efforts to be more inclusive, as the workplace and the world have shifted postpandemic35  and after social justice movements (eg, Black Lives Matter) to focus on DEI. Respondents described shifting societal norms and attaining a better understanding that “some criteria of professionalism [are] rooted in bias.” Interestingly, some participants expressed a personal social awakening and yet offered contradictory perceptions of professionalism.

Provider’s Conduct

Throughout the interviews, individuals often voiced the importance of the provider’s communication through both verbal and nonverbal cues. Many commented on the importance of the relationships and patient care provided. Participants frequently described the provider’s conduct as more significant than the outward appearance. Kyra specifically shared the idea that how ATs presented themselves was more important than how they were dressed or demonstrated self-expression, similar to previous research in which authors showed that physician attributes strengthened relationships more than their attire.36  When considering social determinants of health, specifically the 2030 focus, ATs should focus on the language and literacy skills of patients, emphasizing the need for quality communication as discussed by our respondents.37  This is not novel, as communication has been seen as an important aspect of a qualified AT,38  an AT’s empathy toward patients,39  and the interprofessional health care team.40 

The definition of professionalism varies among individuals and is often rooted in first impressions and physical characteristics. We believe that the definition of professional can be fluid. The current antiquated ideas for professionalism are based on White, Western, male norms and are harmful for people in minoritized groups. The profession of athletic training cannot truly move toward DEI unless a reframing of professionalism is instituted. We recommend quality patient care and interactions as driving forces behind a revised definition of professionalism.

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