EVALUATING ENTRY-LEVEL ATHLETIC TRAINING STUDENTS’ COMFORT LEVEL ON PSYCHOSOCIAL INTERVENTIONS AND REFERRAL COMPETENCIES A THESIS Submitted to the Faculty of the School of Graduate Studies and Research of California University of Pennsylvania in partial fulfillment of the requirements for the degree of Master of Science by Gina Rose Palermo Research Advisor, Dr. Joni Cramer Roh California, Pennsylvania 2010 ii iii AKNOWLEDGEMENTS This is the one part of my thesis that I have been looking forward to, thanking everyone who has help me along my journey. First, I would like to thank my advisor Dr. Joni Roh, for her compassion and willingness to always help me. To my committee, Dr. Tom West and Dr. Bill Biddington, thank you for all of your invaluable inputs into my own masterpiece. I would like to thank my parents who were always willing to guide me through my travels in this place called California, PA. Thank you for your love and support. I would like to thank my brothers, Robert and Michael for giving me the unconditional love and support that I need this past year. I know at times I am not the easiest person to deal with but thank you for pushing me to some place I never thought I would be able to reach. I would like to thank all of my classmates both the class of 2005 and 2006 who made this year fly by like the snap of fingers. You guys are the greatest friends I could of ever dreamed of for to spend here. Especially, Sarah Paugh thank you so much for being my close friend here at Cal, I would of never of made it out alive without you. Thank you for letting me vent and being my buddy. Matt Bigas I want to thank you for always making me laugh and never letting me get homesick. Lastly, I would like to thank all the sports medicine staff at Rutgers University. To Dr. Feigley, who doubted I would even graduate from Rutgers. This thesis is dedicated to you. To David McCune, who never stopped believing in me when I stopped believing in myself. You always opened my eyes to new and interesting areas of athletic training. Thank you for being a mentor who always made me laugh and a good friend too. I want to deeply thank my wonderful boyfriend Brendan, who always keeps me laughing and pushed me to do better than my best, without you I would have never of finished my thesis. I love every one of you and I can express my thanks over and over again. iv TABLE OF CONTENTS Page SIGNATURE PAGE . . . . . . . . . . . . . . . . ii ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . iii TABLE OF CONTENTS . . . . . . . . . . . . . . . iv LIST OF TABLES . . . . . . . . . . . . . . . . vii INTRODUCTION . . . . . . . . . . . . . . . . . 1 METHODS . . . . . . . . . . . . . . . . . . 9 Research Design. . . . . . . . . . . . . . . 9 Subjects. . . . . . . . . . . . . . . . . . 10 Preliminary Research Instrumentation . . . . . . . . . . . . 11 . . . . . . . . . . . . . . 11 Procedures . . . . . . . . . . . . . . . . 13 Hypotheses . . . . . . . . . . . . . . . . 14 Data Analysis . . . . . . . . . . . . . . . 15 RESULTS . . . . . . . . . . . . . . . . . . . 16 Demographic Data . . . . . . . . . . . . . . 16 Hypotheses Testing . . . . . . . . . . . . . 24 Additional Findings . . . . . . . . . . . . . 27 DISCUSSION . . . . . . . . . . . . . . . . . 30 Discussion of Results . . . . . . . . . . . . 30 Conclusions . . . . . . . . . . . . . . . . 35 Recommendations REFERENCES . . . . . . . . . . . . . . 36 . . . . . . . . . . . . . . . . . 38 v APPENDICES . . . . . . . . . . . . . . . . . 40 A. Review of the Literature . . . . . . . . . . . 41 Introduction. . . . . . . . . . . . . . . 41 Education in a Competency-Based Curriculum . . . 41 Athletic Training Educational Competencies . . . 44 Psychosocial Interventions and Referral . . . 48 Psychological Problems in Rehabilitation . . . 49 Education and Training Suggestions for Athletic Training Students . . . . . . . . . . . . . 56 Summary . . . . . . . . . . . . . . . . . 59 B. The Problem . . . . . . . . . . . . . . . 62 State of the Problem . . . . . . . . . . . . 63 Definition of Terms . . . . . . . . . . . . 64 Basic Assumptions . . . . . . . . . . . . . 64 Limitations of the Study . . . . . . . . . . 66 Significance of the Study . . . . . . . . . 67 B. Additional Methods . . . . . . . . . . . . . . . 69 Psychosocial Intervention and Referral Athletic Training Survey for Entry-Level Athletic Training Students (C1) . . . . . . . . . . . . . . 70 Psychosocial Interventions and Referral Competencies (C2) . . . . . . . . . . . . . 85 Approval from the National Athletic Trainers Association Education Council (C3) . . . . . . 93 vi Institutional Review Board (C4) . . . . . . . 95 Cover Letter to Athletic Training Students (C5) . 101 REFERENCES ABSTRACT . . . . . . . . . . . . . . . . . 103 . . . . . . . . . . . . . . . . . . 107 vii LIST OF TABLES Table Page 1 Frequency Table of Gender . . . . . . . . . . 16 2 Distribution of Entry-level Athletic Training Students Education . . . . . . . . . . . . . 17 3 Frequency Distribution of Cognitive Competencies Comfort Level in Psychosocial Intervention and Referral . . . . . . . . . . 17 4 Frequency Distribution of Psychomotor Competencies in Psychosocial Intervention and Referral . . . . . . . . . . . . . . . 18 4 Frequency Distribution of Affective Competencies in Psychosocial Intervention and Referral . . . . . . . . . . . . . . . 19 6 Frequency Distribution for was it Taught Question For Cognitive, Psychomotor, and Affective . . . 20 7 Frequency Distribution for Where it was Taught Question for Cognitive, Psychomotor, Affective and Age . . . . . . . . . . . . . 22 8 Independent t-Test Comparing Comfort Level Between Gender . . . . . . . . . . . . . . 24 9 Correlation Coefficient for Comfort Level And Age . . . . . . . . . . . . . . . . 25 10 Mean Scores of Athletic Training Competencies Comfort Levels . . . . . . . . . . . . . . 27 11 Cognitive Domain Mean Score between Gender . . . 27 12 Psychomotor Domain Score between Gender 13 Affective Domain Score Between Gender . . . . . 28 14 Comparing Year of School Mean Score between Comfort Level . . . . . . . . . . . . . . . 29 . . . . 28 1 INTRODUCTION It is approximated that 17 million sports injuries occur amongst American athletes every year.1 High school football has roughly 1 million injuries and 10 fatalities per year. 1 Even though the reasons for these injuries were without a doubt physical and biomechanical in character, stresses from an outside source may also contribute to the psychological distress of an athlete when performing. Psychological stress appears to be a continuous chain of events in the world of sport. For example, emotional stress can be a precursor to injury, as well as concern for post injury and rehabilitation.2 Athletic injury can cause a great deal of stress to an athlete of any age group.3 Additional life events, such as a death of a parent or spouse can play a role in the predisposition to psychological distress of an athlete.4-6 The responsibility of the athletic trainer in counseling athletes is currently receiving a significant amount of attention.7 A Certified Athletic Trainer (AT) is often a professional whom an athlete can turn to for assistance should he or she become injured or anguished with psychological distress.3,6-8 Most importantly an AT is 2 expected to be able to identify, screen and manage psychological needs within the realm of competency.7 However, if ATs are not trained or are uniformed of the proper areas to identify the psychological components then these areas are possibly overlooked, which may delay the healing process, or predispose the athlete to further or new injury.6,9 For example, 71% of ATs report that athletes commonly encounter stress and anxiety, yet only 23.9% reported a counseling referral.4 It is understood that Athletic Training Students (ATS) have had training to identify physical maladies since the early years of the athletic training profession. However, it has not been until recently that students are expected to be trained to identify psychological stresses and be able to implement psychosocial interventions and referral accordingly.10 Specific to the Role Delineation study the National Athletic Trainers’ Association (NATA) approved competencybased education in 1999.10 Athletic Training Students are expected to graduate from an accredited program with the knowledge to identify, intervene, and manage psychological disturbances with possible referral if necessary. However, until 1999 when the most recent Role Delineation study was presented, the only requirement for an ATS to sit for the Board of Certification (BOC) exam relating to psychology or 3 counseling was a general psychology course or referral from another class.11 Even today, there is not a course specifically designed in the AT education to encompass all of the psychological/counseling competencies, and there is no formal training for the undergraduate ATS to learn all of these competencies. Therefore, throughout the United States, ATS are gaining knowledge from their AT mentors either as instructors in the classroom through various courses or in the clinic as approved clinical instructors (ACI). There is no guarantee that the ATs that are teaching our new professionals have had any formal education in psychology/counseling, thus providing outdated or poor information. As a result, ATS and AT who are not familiar may have an adversity to psychology/counseling and not provide the referral when necessary due to a lack of instruction and the ATS may not receive the comprehension of the content. Therefore, the student may not receive the expected knowledge. With the invent of the competency based instruction it is the Program Director’s job to report to the Joint Review Committee Athletic Training (JRC-AT) where each competency is taught and further mastered by each student. If the psychology competencies are taught by an ACI or an AT who was not exposed to the proper knowledge to identify, manage, intervene and refer, 4 then the students may not receiving the appropriate education and may not successfully answer those questions on the BOC exam.7 In a study completed by Newcomer and Perna9, adolescent athletes might experience injury-related distress despite having physically recovered from their injuries which is comparable to findings with adult athletes and other medical populations. Adolescents could possibly increased the risk for developing psychological distress, particularly posttraumatic distress. Yet, if the ACI or the AT is not able to identify the signs and symptoms, then the ATS under them may not either. Furthermore, they may not be able to refer to the proper care provider. In a study completed by Moulton et al7, athletic trainers were given an open-ended questionnaire pertaining to questions on counseling college athletes. This study reported that ATs believed that their role went further than the role of prevention and care of athletic injuries. Athletic trainers reported that their role encompassed being an educator, as well as a counselor. The questionnaire discovered that 86% of the athletic trainers believed that they are experienced enough to discuss personal issues with athletes if they were approached by them with an issues, However, only 36% believe they 5 received adequate training in counseling techniques to aid athletes with their personal issues. Athletic trainers are sometimes placed into situations where they are not ready to adequately fulfill the task of counseling of an athlete that might need it.7 Brewer and Petrie3, devised a study that questioned a select portion of sports medicine physicians with psychological backgrounds. Those physicians believed that they themselves were completely qualified to recommend a psychologist if an athlete exhibited psychological distress. Some physicians indicated that they would send an athlete to a psychologist, if necessary. In this case, physicians understand the psychological referral model but, are ATS learning it in an entry-level athletic training program? Are ACI/ATs teaching this to the ATS and do the students sense comfort with the competencies outlined by the NATA? An ACI and an AT should be teaching an ATS when to properly refer an athlete that is in need of psychological help. Researchers have focused on explaining why the referral process is significant if an athlete show signs of psychological distress.1 It is also important that an entrylevel ATS, who is preparing to sit for the BOC examination, have complete knowledge in the area of Psychosocial 6 Interventional and Referral. According to the NATA competencies, an ATS should be taught how they can relate the same abilities that are taught for rehabilitation techniques towards working among injured athletes when they seem to exhibit psychological difficulties.2 Therefore one should ask, where does an ATS receive this education? There is currently no class required to teach the competencies of psychosocial interventions and referral domain, yet the competencies in the section account for nearly 22% of all the competencies in athletic training. It is required by the accrediting body for entry-level ATS is to receive an athletic training background and knowledge on all six domains and 12 specific topic areas, before graduation from an approved program. Psychosocial interventions and referral competencies may be an area where most ATS are not comfortable with the material learned, since there is no designated class for it. An ATS, upon graduation, as well as an AT should have had experience with athletes who have had to cope with a high level of distress and know how to properly identify, intervene, manage and refer the athlete to the correct mental health professional, if needed.8 Athletes may experience psychological distress during their athletic career, which has been associated with the 7 feeling of solely being held responsible for their injury.11 Other distresses that athletes have reported may reach clinical levels of anxiety, and depression following a severe injury which may last up to 1 month.3 If an AT was comfortable with intervention, and manage of psychological distress then that the AT may be able to ask the appropriate questions to assist the athlete in the time of need. Thereby, athletes in need may have the comfort in confidence in the AT. However, if an AT does not have comfort in the psychological stress, intervention, and management skills then the athlete may sense this and not sense comfort with the AT. Furthermore, the athlete may sense that he or she is bothersome for the ATC treat them within the rehabilitation setting.12 It is important as entry-level ATS entering the world of sports medicine that they must distinguish the likely signs of psychological distress associated with an athletic injury. The athletic trainer should also be able to know how and when to refer the athlete to the proper care they might need if the assistance is beyond an ATC knowledge or competency level. Upon researching the literature, there is reason to believe that an ATS and/or an AT might not know the proper way to assess an athlete who is psychologically distressed and then how to intervene, identify, manage, or refer the 8 individual if necessary. However, more research is needed. It is important to the field of sports medicine that an AT should be able to recognize that athletes may be psychologically distressed and may need assistance with mental recovery. By recognizing the early signs of distress, with the proper educational background the athlete can be helped early in the rehabilitation phase.1-2 In general, it would be imperative to identify which psychological competencies (41) that an ATS is comfortable set forth by the NATA and the BOC upon completion of their formal education. It would also be interesting to research whether there is a difference between gender for comfort level of Psychosocial Interventional and Referral competencies? Furthermore, does age relate to comfort level? The purpose of the present study is an attempt to answer these questions concerning ATS and their knowledge of Psychosocial Interventional and Referral competencies set forth by the BOC and NATA. 10,12 9 METHODS The purpose of this study is to evaluate entry-level athletic training students (ATS) and their comfort level of the 41 Psychosocial Interventional and Referral competencies, based on the 3rd edition set forth by the NATA.10 The methods section describes the procedures that were used to conduct this study and its findings. The section is subdivided into the following topics: Research Design, Subjects, Preliminary Research, Instrumentation, Procedures, Hypotheses, and Data Analysis. Research Design A descriptive research design using a selfconstructed survey was used for this study. The independent variables in this study included gender, lifetime experience, whether the ATS were enrolled in an undergrad or gradate Athletic Training Education Program (ATEP), where the instruction was obtained and if it was taught. The dependent variables in this study included the comfort level of Psychosocial Interventional and Referral competencies. 10 It is desirable to the researcher to obtain a 40% return rate of the surveys. controlled in this study. No other variables will be This study will contribute to the comfort level of entry-level ATS of the 41 Psychosocial Interventional and Referral competencies. Subjects The number of participants (N=403) completed the self constructed instrument via electronic mail. These participants were undergraduate and entry-level graduate ATS from accredited programs by the Commission on Accreditation of Allied Health Education Program (CAAHEP) and NATA, respectively. The participants were undergraduate and gradate ATS who were eligible to sit for the Board of Certification (BOC) examination, given in June of 2005. Names and electronic mailing addresses of candidates were provided by the BOC and used in the study. The participants represented all 10 NATA districts. Of the 3,000 eligible candidates the BOC sent the researchers self-constructed survey out via electronic mail to only 1,000 eligible subjects. Informed consent was implied by anonymous response to this survey. Of the 452 responses that were 11 returned, 403 were fully completed and used for statistical analysis. Preliminary Research The researcher asked two members to serve as the panel of experts to review the instrument to be used for the content validity. The panel of experts was chosen based on their knowledge with the athletic training educational competencies particular in the area of Psychosocial Interventional and Referral competencies and affiliations with a licensed sport psychologist, Dr. Sam Zizzi, who is familiar with the NATA competencies and Dr. Ronald Wagner, ATC former program director made up the panel of experts. Instrumentation The instrument used (Appendix C1) in this study was a self constructed survey devised by the researcher and the advisor based on 41 competencies obtained in the psychosocial intervention and referral content area (Appendix C2). The instrument was based on the 41 cognitive, affective, and psychomotor domains. Permission from the NATA education council was granted to use the 41 12 Psychosocial Interventional and Referral competency statements10 (Appendix C3). Part A of the survey consisted of three demographic questions, which consists of, gender, year (undergraduate or graduate) and lifetime experience. Part B of the instrument consisted of questions regarding education competencies. These questions are specific to the 41 competencies outlined by the NATA and the BOC. These questions were designed to assess the degree of comfort the student had with psychosocial interventions and referral competencies throughout their educational career prior to sitting for the national exam. Part B, asked the students to evaluate three questions for each of the 41 Psychosocial Interventional and Referral competencies under the three domains (cognitive, affective, and psychomotor): 1) “was it taught”, 2) “where was it taught”, and 3) their personal “comfort level”. Was it taught section of the question the student was to mark “yes”, “no”, or “not sure” for each of the competencies. In the “where was it taught” portion of the question asked the student to indicate where the competencies were taught 1)sport psychology class, 2)sport injury class, 3)clinical experience/field, or in 4)another class other than in the athletic training classes. Comfort level was than scored 13 on a 5-point Likert scale 5) Very Comfortable, 4) Quite Comfortable, 3) Neutral, 2) Somewhat comfortable, and 1) Not Comfortable at all. The higher the number, the more comfortable the ATS were with that particular competency. Part C the students were asked to rate his or her comfort level of each topic area, which was based on a, 5point Likert scale from one to five, (1= “not comfortable at all” to 5= “extremely comfortable”) All parts of the survey were transferred to Survey Monkey for electronic mailing purposes. Procedures The researcher applied for and received approval by the California University of Pennsylvania Institutional Review Board (IRB) (Appendix C4) before conducting any research. The study was distributed through an electronic mail distributed to 1,000 students who were eligible to sit for the BOC examination. The survey was accompanied by a cover letter (Appendix C5) explaining the purpose of the study asking for the assistance of the recipients in completing the survey. Results were returned to research in an anonymous manner, and the statistical data was 14 analyzed. One additional mailing was necessary to receive a return rate of 40%. Hypotheses The following hypotheses are based on a review of the literature. 1) Females will be more comfortable with Psychosocial Interventional and Referral competencies than male entrylevel athletic training students. 2) There will be a negative relationship between lifetime experience and comfort level of psychosocial interventions and referral competencies. 3) ATS will have a lower comfort level score in psychosocial interventions and referral compared to the rest of the athletic training competencies. 15 Data Analysis All data were analyzed using appropriate statistical techniques on SPSS 15.0 statistical computer program using α < 0.05 level of significance. Hypothesis 1: An independent t-test was used to determine whether there is a significant difference between gender with the comfort level of Psychosocial Interventional and Referral competencies. Hypothesis 2: A Pearson Product Moment Correlation was used to determine if lifetime experience was positively related to the comfort level of ATS comfort level on Psychosocial Interventional and Referral competencies. Hypothesis 3: Normative Data was used to measure the mean comfort scores of the athletic training competencies using frequency tables. 16 RESULTS Demographic Data The sample consisted of athletic training students who were eligible to sit for the BOC June 2005 examination. All subjects that were included in this study were first time test takers. All 10 NATA districts were represented in the study as well. The entire population of eligible candidates consisted of 3,000 candidates. However a sample of 1,000 was e-mailed a survey. Over 40% responded (N=403). A majority were males (56%) (Table 1. The sample consisted of entry-level 224 undergraduate and 180 graduate students (Table 2). The lifetime experience range of the subjects within the population was 21 to 41 years of age 23.50 ± 3.073, with nearly 90% of the ATS sampled were under the age of 25. Table 1. Frequency Table of Gender Gender Frequency Male 226 Female 177 Percent 56.1 43.9 17 Table 2. Distribution of Entry-level Athletic Training Students Education Year Frequency Percent Undergraduate 224 55.6 Graduate 179 44.4 Table 3 represents the cognitive competency data mean scores. The overall mean comfort score was 2.43 (± .995). Sixty-seven percent of the students answered that the cognitive competencies were taught primarily in another setting. Table 3. Frequency Distribution of Cognitive Competencies Comfort Level in Psychosocial Intervention and Referral Competency Comfort SD Mean 1 2.76 1.01 2 2.31 1.01 3 2.54 1.05 4 2.54 .98 5 2.32 .98 6 2.31 .98 7 2.54 1.05 8 2.32 1.04 9 2.37 1.00 10 2.06 1.06 11 2.31 .98 12 2.55 1.05 13 2.54 1.06 14 2.31 .98 15 2.64 1.06 16 2.54 1.04 17 2.06 1.06 18 2.64 .98 19 2.32 .98 20 2.37 1.05 21 2.31 .98 22 2.54 .98 23 2.64 .98 24 2.31 1.04 25 2.64 1.06 18 A frequency table of the mean scores for the psychomotor domain under the competency of psychosocial interventions and referral is represented by Table 4. The scores for comfort level have a mean of 2.38 (± .22). Sixty-five percent answered that the psychomotor competencies, were taught primarily in the clinic or field setting. Table 4. Frequency Distribution of Psychomotor Competencies in Psychosocial Intervention and Referral (SD) Competency Number 1 2 3 4 5 Comfort Mean 2.37 2.54 2.06 2.31 2.64 SD 1.05 .98 1.06 1.06 .97 A frequency table of the mean scores for the affective domain under the competency of psychosocial interventions and referral is represented by Table 5. The scores for comfort level have a mean of 2.34 (± .18). Sixty-seven percent answered that the affective competencies were taught primarily in the clinic or field setting. 19 Table 5. Frequency Distribution of Affective Competencies in Psychosocial Intervention and Referral Competency Comfort SD Number Mean 1 2.06 1.06 2 2.32 1.04 3 2.37 1.50 4 2.54 2.54 5 2.31 1.06 6 2.06 1.06 7 2.54 .98 8 2.64 .97 9 2.32 1.04 10 2.31 1.06 11 2.32 1.04 A frequency distribution table of was taught is depicted in Table 6. A range of 24% to 29% indicated receiving instruction for competencies 1-41. Ranges of 9.9% to 20% were not sure if the competencies were taught and finally a range of 32% to 57% indicated no instruction. The scores for yes, no and not sure are represented for each of the competencies. 20 Table 6. Frequency Distribution for was it Taught Question for Cognitive, Psychomotor, and Affective Domain Competency Yes % No % Not % sure Cognitive 1 109 27 194 48.1 94 23.3 Cognitive 2 98 24.3 230 57.1 75 18.6 Cognitive 3 147 36.5 208 51.6 48 11.9 Cognitive 4 118 29.3 230 57.1 55 13.6 Cognitive 5 162 40.2 180 44.7 61 15.1 Cognitive 6 155 38.5 187 46.4 61 15.1 Cognitive 7 117 29.0 217 53.8 69 17.1 Cognitive 8 126 31.3 216 53.6 60 14.9 Cognitive 9 190 47.1 171 42.4 42 10.4 Cognitive 10 159 39.5 176 46.7 68 16.9 Cognitive 11 171 44.2 187 46.4 45 11.2 Cognitive 12 178 44.2 184 45.7 41 10.2 Cognitive 13 143 35.5 201 49.9 59 14.6 Cognitive 14 109 27.0 231 57.3 63 15.6 Cognitive 15 138 34.2 201 49.9 64 15.9 Cognitive 16 134 33.3 211 52.4 58 14.4 Cognitive 17 165 40.9 182 45.2 56 13.9 Cognitive 18 131 32.5 218 54.1 54 13.4 Cognitive 19 112 27.8 227 56.3 64 15.9 Cognitive 20 132 32.8 209 51.9 62 15.4 Cognitive 21 150 37.2 213 52.9 40 9.9 Cognitive 22 126 31.3 211 52.4 66 16.4 Cognitive 23 153 38.0 208 51.6 42 10.4 Cognitive 24 133 33.0 198 49.1 72 17.9 Cognitive 25 116 28.8 221 54.8 66 16.4 Psychomotor 1 138 34.2 210 52.1 55 13.6 Psychomotor 2 135 33.5 186 46.2 82 20.3 Psychomotor 3 109 27.0 223 55.3 71 17.6 Psychomotor 4 132 32.8 198 49.1 73 18.1 Psychomotor 5 137 34.0 211 52.4 55 13.6 Affective 1 165 40.9 183 45.4 55 13.6 Affective 2 109 27.0 231 57.3 63 15.6 Affective 3 134 33.3 205 50.9 64 15.9 Affective 4 127 31.5 225 55.8 51 12.7 Affective 5 129 32.0 197 48.9 77 19.1 Affective 6 198 49.1 157 39.0 48 11.9 Affective 7 217 53.8 130 32.3 56 13.9 Affective 8 125 31.0 210 52.1 68 16.9 Affective 9 145 36.0 186 46.2 72 17.9 Affective 10 129 32.0 320 57.1 44 10.9 Affective 11 122 30.3 230 57.1 51 12.7 21 The most popular for receiving instruction specific to the Psychosocial Interventional and Referral competencies was clearly by “other” avenues ranging from 59.6% to 72.55%. The second most popular format for receiving instruction was from a sport psychology class ranging from 8.4% to 36.7%. Receiving instruction from the clinic/field (6.5%-25%) and psychology of sport injury class (6.2%-22%) were the least popular format (Table 7). A frequency distribution table of where it was taught is represented by Table 7. Table 7. Frequency Distribution for Where it was Psychomotor, and Affective Domain Competency Psychology % Sport of Sport Psychology Injury Cognitive 1 25 6.2 54 Cognitive 2 34 8.4 48 Cognitive 3 45 11.2 53 Cognitive 4 27 6.7 66 Cognitive 5 29 7.2 50 Cognitive 6 33 8.2 43 Cognitive 7 25 6.2 39 Cognitive 8 89 22.1 148 Cognitive 9 26 6.5 34 Cognitive 10 28 6.9 45 Cognitive 11 25 6.2 39 Cognitive 12 27 6.7 66 Cognitive 13 27 6.7 66 Cognitive 14 26 6.5 34 Cognitive 15 25 6.2 39 Cognitive 16 30 7.4 53 Cognitive 17 34 8.4 48 Cognitive 18 45 11.2 53 Cognitive 19 27 6.7 66 Cognitive 20 27 6.7 66 Cognitive 21 30 7.4 53 Cognitive 22 34 8.4 48 Cognitive 23 45 11.2 53 Cognitive 24 27 6.7 66 Cognitive 25 34 8.4 48 Psychomotor 1 30 7.4 53 Taught Question for Cognitive, % Clinic/Field % Other % 13.4 11.9 13.2 16.4 12.4 10.7 9.7 36.7 8.4 11.2 9.7 16.4 16.4 8.4 9.7 13.2 11.9 13.2 16.4 16.4 13.2 11.9 13.2 16.4 11.9 13.2 68 38 26 69 34 44 47 103 50 69 47 70 70 51 47 55 38 26 69 69 55 38 26 69 38 55 1 9.4 6.5 17.1 8.4 10.9 11.7 25.6 12.4 17.1 11.7 17.4 17.4 12.7 11.7 13.6 9.4 6.5 17.1 17.1 13.6 9.4 6.5 17.1 9.4 13.6 256 283 279 241 290 283 292 52 290 261 292 240 240 289 292 265 283 279 241 241 265 283 279 241 283 265 63.5 70.2 69.2 59.8 72.0 70.2 72.5 12.9 72.0 64.8 72.5 59.6 59.6 71.7 72.5 65.8 70.2 69.2 59.8 59.8 65.8 70.2 69.2 59.8 70.2 65.8 Psychomotor 2 Psychomotor 3 Psychomotor 4 Psychomotor 5 Affective 1 Affective 2 Affective 3 Affective 4 Affective 5 Affective 6 Affective 7 Affective 8 Affective 9 Affective 10 Affective 11 27 45 28 30 45 27 34 45 30 27 34 45 30 34 34 6.7 11.2 6.9 7.4 11.2 6.7 8.4 11.2 7.4 6.7 8.4 11.2 7.4 8.4 8.4 66 53 45 53 53 66 48 53 53 66 48 53 53 48 48 16.4 13.2 11.2 13.2 13.2 16.4 11.9 13.2 13.2 16.4 11.9 13.2 13.2 11.9 11.9 69 26 69 55 26 69 38 26 55 69 38 26 55 38 38 17.1 6.5 17.1 13.6 6.5 17.1 9.4 6.5 13.6 17.1 9.4 6.5 13.6 9.4 9.4 241 279 261 265 279 241 283 279 265 241 283 279 265 283 283 59.8 69.2 64.8 65.8 69.2 59.8 70.2 69.2 65.8 59.8 70.2 69.2 65.8 70.2 70.2 24 Hypotheses Testing Hypotheses one and two were tested at an alpha level of .05. Hypothesis 1: Female entry-level athletic training students will be more comfortable than male entry-level athletic training students. An independent t-test was used to determine if there was a significant difference between genders on comfort level with regards to Psychosocial Interventional and Referral competencies. Conclusion: An independent t-test was calculated comparing the comfort level of female and male athletic training students on Psychosocial Interventional and Referral competencies. No significant difference was found (t(401) = 1.488,P > .05). The mean scores of the males (M = 2.51, SD =.46) was not significantly different from the mean scores of females (M = 2.44, SD = .492). Table 8. Independent t-test comparing comfort level between gender. Gender N M SD t P Male 226 2.51 .46 1.488 .38 Female 177 2.44 .492 25 Hypothesis 2: There will be a positive relationship between age and comfort level of Psychosocial Interventional and Referral competencies. A Pearson Product Moment Correlation was used to determine if there was a positive relationship between age and comfort level of the three major competency subsections (cognitive, affective, and psychomotor) in Psychosocial Interventional and Referral competency Conclusion: A Pearson Product Moment Correlation coefficient was calculated for the relationship between age and comfort level of entry-level athletic training students on Psychosocial Interventional and Referral competency. A significant negative relationship was not found (r (403) = .138, P > .05), indicating no significant linear relationship between the two variables. Table 9. Correlation Coefficient for Comfort Level and Age Variable N Correlation P Coefficient Lifetime experience & .138 .074 403 Comfortable Hypothesis 3: Athletic Training students will have a lower comfort level score in Psychosocial Interventional and Referral competency compared to the remaining athletic training competencies. 26 Conclusion: Normative data was used to measure comfort level scores for all 12 content areas. Psychosocial Interventional and Referral means scores were the fourth lowest of the 12 content areas. Normative data was used for the relationship between Psychosocial Interventional and Referral competency compared to the remaining athletic training competencies. As illustrated in Table 10, Psychosocial Interventional and Referral ranked fourth lowest among the 12 athletic training competencies. The domains that ranked lower than Psychosocial Interventional and Referral on comfort were 1) were professional development and responsibilities (2.19 ± 1.10), 2) assessment of injury and illness (2.19 ± 1.02), and 3) general medical conditions and disabilities, respectively (2.13 ± 1.08). 27 Table 10. Mean Scores of Athletic Training Competencies Comfort Levels Competency M SD Rehabilitative Techniques 2.91 .99 Health Care Administration 2.64 .97 Therapeutic Exercise 2.55 1.14 Pharmacology 2.55 1.0 Weight Management and Body Composition 2.54 .98 Pathology of Injury/Illness Medical Ethics and Legal Issues Risk Management and Injury/ Illness Prevention Psychosocial Interventions and Referral 2.54 2.37 2.32 2.31 1.10 1.04 1.04 1.06 Professional Development and Responsibilities 2.19 1.10 Assessment of Injury/Illness General Medical Conditions and Disabilities 2.19 1.02 2.13 1.08 Additional Findings In addition to hypothesis testing, independent t-tests were calculated and analyzed to find a difference between gender and year of school. An independent t-test was calculated to determine if there was a difference between gender among cognitive, affective and psychomotor domains (Table 11, 12, 13). Table 11. Cognitive Domain Mean Scores between Gender Gender N Mean SD T Sig. (P) Female 177 2.42 .47 .921 .338 Male 225 2.50 .45 28 Table 12. Gender Female Male Psychomotor Domain Scores between Gender N Mean SD T Sig. (P) 177 2.29 .53 .913 .340 225 2.38 .50 Table 13. Gender Female Male Affective N 177 225 Domain Scores between Gender Mean SD T 2.36 .55 3.374 2.40 .50 Sig. (P) .067 Conclusion: No significant difference was found (t(403) = .921, P > .05) for the cognitive domain. The mean of the females for the cognitive domain (2.41 ± .47) was not significantly different from the mean of males for the cognitive domain (2.50 ± .45). No significant difference was found (t(403) = .913, P > .05) for the psychomotor domain. The mean of the females for the psychomotor domain (2.29 ± .53) was not significantly different from the mean of males for the cognitive domain (2.38 ± .50). No significant difference was found (t(403) = 3.374, P > .05) for the affective motor. The mean of the females for the affective domain (2.36 ± .55) was not significantly different from the mean of males for the cognitive domain (2.40 ± .50). An independent t-test was calculated to determine if there is a difference between the years of school. 29 Table 14. Comparing Year of School Mean Comfort Score between Comfort Level Gender N Mean SD T Sig. (p) Undergraduate 223 2.45 .47 .057 .811 Graduate 179 2.38 .45 Conclusion: No significant difference was found (t (403) = .057, P > .05) for total comfort level. The mean of the undergraduate (2.45 ± .47) was not significantly different from the mean of graduate (2.38 ± .45). 30 DISCUSSION This section contains the following subsections: Discussion of the Results, Conclusion, and Recommendations. Discussion of Results This study primarily focused on the comfort level of entry-level athletic training students in regards to the competencies of Psychosocial Interventional and Referral. Research that has been completed in this area has focused on the ability of an ATC to respond to an athlete that may need psychological assistance when coping with an injury. The results of the Evaluation of Entry-Level Athletic Training Students’ Comfort Levels on Psychosocial Intervention and Referral Competency are subjective and some subjects may be more or less competent than they believe to be. Since this was not a standardized surveying instrument, there is margin for error in assessing the subjects’ true perception on comfort level. Items that the students were asked to rate based on their comfort level were actually competencies in Psychosocial Interventional and Referral that were obtained from the NATA Education Council. 31 The first hypothesis assessed whether female athletic training students were more comfortable than male athletic training students. Although no significant difference was found between gender, males had a slightly higher comfort level in all three major competency subsections (cognitive, affective, and psychomotor). The researcher hypothesized that the scores for females would be higher because of mother-like qualities that females express. The results may suggest that both male and female ATS have similar comfort levels relative to psychological/counseling proficiencies. Hypothesis two acknowledged that there would be a negative relationship between age of the ATS and comfort level of Psychosocial Interventional and Referral competency. The researcher had thought that the younger an athletic training student was the more comfortable the student would be with assisting an athlete with an injury, because the student went through a competency-based curriculum program requiring the Psychosocial Interventional and Referral to be taught whereas, the older ATS may not have been exposed to the specific competencies. Although a significant linear relationship was not found, younger ATS did have higher competency levels than older students. The researcher believes this occurred, 32 because students, who go through a competency-based education program, may have focused more on instruction to these specific competencies. However, based on the survey 60% indicated that they had not received instruction in this area. The final hypothesis examined if the competency of Psychosocial Interventional and Referral would be lower than the remaining athletic training competencies. After using normative data for the comfort level of all 12 athletic training competencies it is believed General Medical Conditions and Disabilities is the competency students feel the least comfortable and Rehabilitative Techniques was the most Comfortable. The Psychosocial Intervention and Referral competency was calculated in the lower 1/3 of all AT competency categories. Additional tests were completed to determine if there was a difference between gender and cognitive, affective, and psychomotor domains, no significant difference was found. An independent t-test was calculated to determine if there was a difference between total comfort level and year of school. No significant difference was found, although undergraduate students did report more confidence than graduate students. 33 This study revealed that even though the competencies are set forth by the NATA, students who are eligible may not have comfort with the Psychosocial Intervention and Referral competencies. This study indicated that ATS were somewhat comfortable, but not completely comfortable with Psychosocial Interventional and Referral competencies. However, only 36% of the AT believed they have the knowledge to handle psychological concerns of athletes. As educators for ATS, how confident will the ATS be when they become certified?7 ATS should have a sound understanding of Psychosocial Intervention and Referral competencies prior to sitting for the exam. This area is very important in athletic training like all other areas and should not be over looked. In a previous study completes by Larson, Starkey and Zaickowski4 nearly 71% of ATCs reported that athletes commonly encounter stress and anxiety, yet only 23.9% reported a counseling referral. support to this claim. This study provides Students are not sure of when to refer an athlete in a time of need. Psychosocial Interventional and Referral is important to athletic training just as any other competency. Students only feel somewhat comfortable referring an athlete, and coming from accredited program they should feel quite comfortable. 34 Students who are reporting lower comfort level scores may not have confidence in the process of management intervention or referral therefore, the ATC is not providing the athlete with the complete healing process. This study also revealed that the majority of the Psychosocial Interventional and Referral competencies were taught in the clinic/field or by other means of instruction, rather than a formal course, such as Sport Psychology or psychology of sport injury with over 60% of the students indicating that they obtained the competency through other means (other than clinic/field, sport psychology course, or psychology of sport injury course), may be the reason why over half to 2/3 of the students indicated that they were either not sure or did not receive instruction for each of these competencies. Thereby, not providing the ATS an opportunity to be held accountable for the competency and learning about it. Additionally, Moulton7 reported that 36% of AT have an understanding of these components, but is this enough for the ATS to become competent in the psychosocial interventional and referral skills required by the NATA? to these findings. This study provides support For example, if the AT does not have the proper knowledge of knowing when to refer an athlete with a mental health issue then the AT is not providing the 35 best care for that athlete. Psychosocial Intervention and Referral is just as important to athletic training as any other competency. This study also revealed that the majority of the Psychosocial Intervention and Referral competencies were not taught through a formal process such as, a psychology of sport injury or a sport psychology class. Conclusions This study demonstrated that even though Psychosocial Intervention and Referral competencies are being taught, students are not completely comfortable with them nor can they remember the competencies being taught. These findings lead to the conclusion that students do not have a high comfort level on Psychosocial Intervention and Referral competencies. It was also concluded that students do not feel completely comfortable with all the 12 athletic training competencies only somewhat. Furthermore, there was no relationship between the undergraduate or graduate student athletic trainer or their comfort level on Psychosocial Intervention and Referral. Finally, regardless of ones age or lifetime experiences, there was 36 not a large degree of comfort indicated for these competencies. Recommendations The researcher makes the subsequent recommendations for further study related to this topic. Population size could be broken up by district and size of school. Men and women alike do not have a high comfort level in Psychosocial Interventional and Referral area. Therefore, instruction in this area needs to be reconsidered. The necessity for education in counseling for athletic trainers is clear. Therefore, a course that is designed to meet the criterion for the competencies mandated by the NATA should be implemented into ATEP curriculums with a qualified instructor. As a result, a designated class should be designed for the content area to be taught. The education of future athletic trainers should be implemented into entry-level curriculums to provide the necessary skills to effectively communicate and evaluate athletes. Psychosocial Interventional and Referral does make up 22% of all athletic training competencies and this area as well as other areas should not be over looked. Curriculums should do a better job with increasing confidence and the 37 comfort of not only the Psychosocial Intervention and Referral competencies, but all other content areas. Athletic trainers might then be competent and confident when assisting athletes who express psychological distress. 38 REFERRENCES 1) Heil J. Psychology of sport injury. Champaign, IL: Human Kinetics; 1993:5. 2) Taylor J, Taylor S. Referral for psychological problem In: Psychological Approaches to Sport Injury Rehabilitation. Gaithersburg, MD: Aspen Publication; 1997:57-94. 3) Brewer BW, Petrie, TA. A comparison between injured and uninjured football players on selected psychosocial variables. The Academic Athletic Journal. 1995;11-17. 4) Larson GA, Starkey C, Zaichkowsky LD. Psychological aspects of athletic injuries as perceived by athletic trainers. Sport Psychologist 1996; 10:3747. 5) Petrie, TA. The moderating effects of social support and playing status on life-stress relationship. J of Applied Sport Psychology, 1993; 5:1-16. 6) Wiese-Bjornstal, DM. &, Shaffer, SM. (1999). Psychological dimensions of sport injury. Counseling in Sports Medicine, 1999; 23-41. 7) Moulton MA, Molstad S, Turner A. The role of Athletic Trainers in counseling collegiate athletes. JAT. 1997;32:148-150. 8) Ray, RT, Hough T, The role of the sports medicine professional in counseling athletes. Counseling in Sports Medicine, 2001; 3-21. 9) Newcomer RR, Perna FM. Features of posttraumatic distress among adolescents athletes. JAT. 2003;38:163-166 10) NATA Athletic Training Educational Competencies. 3rd Edition. Dallas, TX: National Athletic Trainers’ Association; 1999. 39 11) Wiese-Bjornstal DM, Smith AM, and Shaffer SM. An integrated model of response to sport injury: Psychological and sociological dynamics. J of Applied Sport Psychology. 1998;10:46-49. 12) National Athletic Trainers’ Association, Inc. Role delineation validation study for entry-level athletic trainers’ certification examination. Dallas, TX.1999 13) Harris LL, Demb A, Pastore DL. Perceptions and attitudes of athletic training students towards a course addressing psychological issues in rehabilitation. J of Allied Health. 2005;34:101109. 14) Prentice W. Arnhiem’s principles of athletic training: A competency-based approach. 11th edition McGraw-Hill 2003. 15) Rosenfield LB, Richman JM, Bowen GL. Supportive communication and school outcomes for academically “at-risk” and other low income middle school students. Communication Education. 1998;309-325. 16) Leddy M, Lambert M, Ogles B. Psychological consequences of athletic injury among high-level competitors. Research Quarterly for Exercise and Sport.1994;347-354. 40 APPENDICIES 41 APPENDIX A Review of the Literature 42 REVIEW OF THE LITERATURE Introduction During any type of practice or game the first person to respond to that athlete’s injury is usually a certified athletic trainer (AT). The ATC may also be responsible for administering the athlete’s rehabilitation during their athletic injury. However, the AT not only has to acknowledge and assist with the athlete’s injury as a physical stress, but also the mental distress of fully recovering from that injury. Therefore the ATC must properly know how to identify, intervene, and manage, psychological distresses within their competencies when necessary. The Review of Literature will be divided into four sections: (1) Education in a Competency-Based Curriculum (2) Athletic Training Educational Competencies (3) Psychological Problems in Rehabilitation (4) Education and Training Suggestions for Athletic Training Students, and (5) Summary. Education in a Competency-Based Curriculum Athletic training education programs are accredited by Commission on Accreditation of Allied Health Education 43 Program (CAAHEP) through the Joint Review Committee Athletic Training (JRC-AT) and can lead to a bachelors or masters degree in athletic training.1 The Educational Council sets the standards for all educational programs that are accredited by CAAHEP. Prior to graduation, an ATS must have completed a major of Athletic Training before sitting for the Board of Certification (BOC) exam. Therefore, athletic training certification is granted by the BOC, upon graduation and successfully passing the BOC exam. The National Athletic Trainers’ Association (NATA) has developed an entry-level athletic training education that uses a competency-based education in both the classroom and clinical settings to meet all necessary requirements for graduation. 1 The competency-based model was adopted in 1996.1 Each CAAHEP program must have classes that are designed in the areas of foundational education. ATS who are enrolled in a CAAHEP must obtain formal instruction in the specific subject material areas. Foundational education areas include human physiology, human anatomy, exercise physiology, kinesiology/biomechanics, nutrition, therapeutic modalities, acute care of injury and illness, statistics and research design, and strength training and reconditioning. 1 44 Throughout an ATS career, Approved Clinical Instructors (ACIs) have been trained to instruct and evaluate clinically each ATS competency. An ATS must also receive proper education in the 12 competencies that span across all six domains. The areas that are included are: 1)risk management and injury/illness prevention, 2) pathology of injury/illness, 3)assessment of injury/illness, 4)general medical conditions and disabilities, 5) therapeutic exercise, 6)rehabilitative techniques, 7) health care administration, 8) weight management and body composition, 9) Psychosocial Interventional and Referral, 10) medical ethics and legal issues, 11) pharmacology, and 12)professional development and responsibilities.1 Students are instructed and evaluated by ACIs. Each of these 12 competencies listed above have been subdivided into cognitive, psychomotor and affective domains. Athletic Training Educational Competencies Supporting the patient in psychological recovery is vital to achieving the goals of rehabilitation.2 The AT is responsible for this process because of the role they play in the patients’ response to injury and commitment to the 45 rehabilitation program.2 Throughout a student’s education in athletic training certain competencies are learned that are relevant to the different areas of athletic training. Throughout a student’s education in athletic training certain competencies are learned that are relevant to the different areas of athletic training. The Professional Education Committee of the NATA wrote the original competencies of athletic training in 1983 as behavioral objectives.3 The objectives were printed in the Guidelines for Development and Implementation of NATA Approved Undergraduate Athletic Training Education Programs. 3 This was first revised in 1988. However, in 1992 they were renamed and called the Competencies in Athletic Training which were rewritten by the Professional Education Committee (PEC) and were reviewed by the JRC-AT.4 They were later reviewed by the Joint Review Committee on Educational Programs in Athletic Training (JRC-AT). The 1992 modification lead to the division of competencies into six areas specific to injuries and common illnesses of athletes and included the following divisions: 1) prevention, 2) recognition and evaluation, 3) management/treatment and disposition, management/treatment and disposition, 4) rehabilitation, 5) organization and administration, and 6) education and counseling.5-7 In each of the six 46 competencies three domains were include. Upon graduation from a NATA approved educational program it was expected that all competencies were taught in either the classroom or clinical/field setting for all ATS. In 1997, the Education Council formed the Competencies in Education Committee. This committee consisted of 10 ATC from all over the country representing all levels of education; the clinical setting was included as well. This committee worked to identify current skills and knowledge for ATS. As an outcome the committee acknowledged 12 universal areas of knowledge/skills that all ATS should have upon graduation from a CAAHEP program. The following are the 12 areas of content: 1) risk management and injury prevention, 2) pathology of injury, 3) assessment of injury/illness, 4) general medical conditions and disabilities, 5)therapeutic exercise, 6) rehabilitative techniques, 7) health care administration, 8) weight management and body composition, 9) Psychosocial Interventional and Referral, 10)medical ethics and legal issues, 11) pharmacology, and 12)professional development and responsibilities.3 Clinical proficiencies are associated to the content areas and consist of the universal knowledge of athletic training that all ATS need to posses before sitting for the BOC exam. The 12 areas of 47 content are further divided into three domains which include cognitive, psychomotor and affective. There are a total of 191 competencies in all. At hand there are currently 25 cognitive, 6 psychomotor and 10 affective competencies for the Psychosocial Interventional and Referral content area. Forty-one are represented in Psychosocial Interventional and Referral category. The greater part of theses clinical proficiencies are cognitive.3 In 1999, the competencies and clinical proficiencies were revised through several drafts and approved by the NATA Board of Directors. These were published as the National Athletic Trainers’ Association Athletic Training Educational Competencies. The 1999 edition contains the most recent clinical proficiencies as well as recent identified content areas that athletic trainers saw as critical for ATS to learn and become certified before entering into the workforce.3-5 The new competency-based model of learning assures that no matter where the ATS got their education, whether at a big university or small college, that it is the same universal education, and the ATS would have the same knowledge as another ATS in a different area of the country.3 The education content of competency-based 48 curriculum is structured on domains, and proficiencies as previously outlined. The NATA Professional Education Council has determined 191 different competencies in athletic training, surrounding six performance domains. Forty-one of those competencies are related to the psychological aspect of athletic injuries. Most entry-level athletic trainers should have spent approximately 22% of their professional preparation in the area of psychological considerations in sport.6 Because of the amount of research that has been recently completed on the psychological aspect of athletic injuries and the support for the use of psychological intervention skills in the treatment of athletic injuries may explain the importance of information suggested to be taught in the competency-based program specific to this area of athletic training.5,7 Several professionals including researchers in the AT field, and sport psychology field have indicated the ideal position of athletic trainers in dealing with the psychological aspect of athletic injuries. However, the question remains as to whether students believe they are receiving nearly one quarter of their education in this area and whether they feel comfortable with this area. 49 Psychosocial Interventions and Referral Specifically the area of Psychosocial Interventional and Referral is comprised of cognitive, psychomotor and affective domains.1,5 The cognitive domain teaches ATS how to think about and comprehend that particular injury. The psychomotor domain, encompass the performance that is going to be taught and learned while the affective domain teaches the feelings the ATS/AT should have towards that area. The cognitive domain focuses on teaching the athletic training student to learn how to analyze and think about the processes one should use should a psychological concept occur with an athlete either prior to or post injury. The psychomotor domain focuses on the student being able to carry out a particular task based on the academic and theoretical knowledge. The affective domain concentrates on the ability to carry out the feelings or the emotional concepts of Psychosocial Interventional and Referral.5-6 The cognitive domain of Psychosocial Interventional and Referral competencies (Appendix C2) consists of 25 individual areas, additionally the affective and the psychomotor domain consists of six and ten individual areas, respectively.5 50 Not only should the students understand all 41 competencies under Psychosocial Interventional and Referral, but the ATS should be able to demonstrate two clinical proficiencies as well. The two proficiencies students should know include: 1) the ability to intervene and make referral to appropriate medical or allied medical professional, and 2) integrate motivational techniques into the rehabilitation program for an athlete.5 Psychological Problems in Rehabilitation During any participation in sport, injury is likely to happen to an athlete.6-9 Every year approximately as many as 17 million sports injuries arise amongst American athletes.9 Of those 17 million, 8 out of the 10 are athletes that have been injured during some point of their high school and college career.10 In addition to physical injury athletes, risk medical and psychological “injuries” as a result of competition.9 Entry-level athletic trainers spend approximately 74% of their time preventing, evaluating, managing and rehabilitating athletic injured.6 A serious injury during any point in someone’s career can have a significant emotional effect.9 An injury may make an athlete feel terrified and helpless when injured. An 51 athlete may feel the need to turn to someone other than family, friends, teammates, coaches, and an AT during this dreadful time in their life. It is the job of the AT to be able to determine when the athlete may need or desire additional assistance. The AT job responsibility is also knowing when to make a proper referral to the appropriate medical professionals whether it is to physician, psychologist or counselor when it is beyond the scope of practice by the AT.2 Athletic injury causes a great deal of stress to an athlete of any age.11 During the injury recovery process an athlete might go through many different mood changes. Examples of mood changes would be depression, anger, tension, confusion, hostility, loneliness, fear, irritability and anxiety.10-12 Athletes might also feel some sign of isolation and/or estrangement from their teammates and their sports.14 As time goes on they might drift into depression.15 This is due to the fact they feel they are personally responsible for their injury. Quite a few athletes feel guilty concerning letting everyone down, this includes family and friends.16 This is a result due to injury. An injury not only affects the athletes’ physical well-being, but also their self-image experience, selfesteem, belief system, values and commitments in addition 52 to emotional equlibrium.16 Furthermore, an athlete suffering from an increased mood disturbances is more likely to have heightened pain reports and slower recovery.17-22 Psychological distress can have an impact on the injured athletes’ life outside rehabilitation. 13 As an outcome of psychological distress, school or work performance can decline due to a harmful preoccupation with the injury.14,23 Mainly with injured athletes participating in team sports, decline of some important social relationships and withdrawal from reinforcing social activities can occur as a result. The result is a negative spiral of psychological distress that creates difficulties within and outside of rehabilitation that, in turn, can lead to more psychological distress without proper intervention.23 The first step in the education process is to recognize the significance of psychological disturbance in population in which rehabilitation personnel commonly work. Psychology disturbance, or distress is the most universally reported clinical responses in injury rehabilitation.22 Brewer et al.23 reported that a 19% occurrence rate of selfreported clinically related levels of psychological distress in a sample of 200 orthopedic patients of which 53 58% were either recreational or competitive athletes. Physical therapist or athletic trainers reported that 31% showed signs of anxiety and 20% showed signed of depression. Anxiety and depression were the most commonly reported psychological disturbances.23 Also, up to 33% of the sample size were injured football players that may perhaps be categorized as depressed individuals.23 Psychological distress is best described as a depressing reaction to an event that can impair an athlete’s functioning at several levels. It can have negative impact on an injured athlete response to rehabilitation. Psychological distress of a low to moderate degree is expected during rehabilitation. It should disappear as rehabilitation continues. McDonald and Hardy24 reported an adaptation process in a sample of seriously injured athletes. The researchers found that the injured athletes experienced considerable psychological distress during the first 2 weeks of rehabilitation. After the passing of the two weeks, the athletes exhibited a progressively more positive response to the injury and rehabilitation.24 Young athletes as well as older athletes are also at risk for psychological distress when return from an injury. A study completed by Newcomer and Perna25,they evaluated the 54 psychological involvement of children and adolescence since so little is known about their psychology stress with injuries. Athletes with a recent injury history exhibited a greater frequency of disturbing thoughts and avoidance behaviors compared to those without a recent injury history. This suggests that the athlete is still somewhat bothered by the injury after it happens and may persist even after physical rehabilitation.25 Newcomer and Perna25 suggested that adolescent athletes experience injury-related distress despite having physically recovered from their injuries which is comparable to findings with adult athletes and other medical populations.25-30 Adolescents may be at increased risk for developing psychological distress, particularly posttraumatic distress. If injured athlete’s experience psychological distress and adjustment does not occur, then clinical problems are likely to occur. Clinical reactions are usually considered to be pessimistic responses that significantly impair specific and general functioning.24 One of the biggest challenge for an AT after talking to their athlete may be the development of the referral process in finding a mental health professional.25 However, it is recommended that symptoms must be present outside of 55 the athletic training room and persist for several days.25 There are many mental health professionals, but few have proper training and understanding of an injured athlete’s mind set.24 Ultimately a sport psychologist would be the best trained individual. However, psychologists or counselors are better trained to facilitate individuals to cope with psychological disturbances than an ATS or an AT. Yet, there is ample evidence that AT are in the best position to make an assessment and make the appropriate referral when necessary.26 An ATS must understand that through the educational approach they must be aware of the importance of developing a referral procedure and a professional rapport with the mental health professional. Prior to a referral, it is imperative that as an ATS or an AT must properly evaluate and recognize psychological difficulties and the degree of the distress.27 Additionally, AT can make referrals directly to a mental health professional in the area that is in private practice, hired through a local hospital or high school, or at the college counseling center. In a study concluded by Moulton et al26, athletic trainers received an open-ended survey pertaining to questions on counseling of college athletes. This study showed that an AT experiences many different roles than one 56 pertaining to preventing and caring for injuries. The survey discovered that 86% of the athletic trainers thought that they were experienced enough to discuss personal issues with athletes if they were approached by an athlete. However, this study revealed that only 36% believed they received adequate training and counseling techniques to aid athletes with their personal issues. Athletic trainers are sometimes placed into situations where they try to meet job expectations, but struggle with feeling that they are not ready to adequately fulfill the task of counseling of an athlete that might need it.26 Numerous people in sports medicine staff and sport psychology researchers have suggested that there is relationship present between numbers of psychological variables. In a survey completed by Wiese et al.28, the researchers found that psychological skills, were influencing factors in facilitating an athlete’s ability to cope with injury rehabilitation. The results reported as the most important factors in helping injured athletes with their athletic injury and recovery knowledge were positive communication style, encouraging positive communication style, setting realistic goals, encouraging positive selfthought, and understanding individual motivation. Medical 57 staff has also been reported to be an important source of support during an athlete’s recovery.31 Social support is something that is a multidimensional structure and it consists of emotional and informational support.26 An AT can give emotional support as well as information, by listening to the athlete, and educating the athlete about the injury. An AT also should also understand and know through experience what the athlete is going through during the injury process. Through this the athlete should trust an AT that he or she will properly return them back to play as soon as possible.31 The social support component was a key emotional factor in dealing with injury and recovery from that injury.30 Social support is something that every athlete should have, whether or not it is the self-belief in an athletic trainer or in a coach. Education and Training Suggestions for Athletic Training Students The BOC makes it mandatory that all ATCs have continuing education units (CEU). Continuing education units help ATCs acquire new and maintaining knowledge through workshops, course work, or conventions.32-37 ATs are 58 currently required to earn 75 CEUs in a 3-year time span. It has been suggested that .55 CEU, which is about 1% compared to 22% required in the competency based curriculum can be committed to the Psychosocial Interventional and Referral aspect of athletic training.7,32-36 Gordon et al36 projected a 3-year psychoeducational curriculum for sport injury rehabilitation workforce. Under this curriculum, didactic teaching and practicum seminar instruction would be given. This would be a great curriculum to integrate into the current entry-level athletic training program but, it would be complicated. It would require the hire of new specific faculty, who specialized in this area.36 Roh et al35 recommended that ATs increase their knowledge of psychology and counseling. This should also be implemented for the entry-level athletic training students who are preparing to sit for the BOC examination. Roh et al34 also stated that skills such as counseling, active listening and emotional support should be offered to the athlete and little additional invested time with the proper training in the psychology and counseling area. The outcome of spending addition time could be therapeutic to the athlete in the long run and may prevent an athlete from 59 experiencing unnecessary emotional disturbance or seeking additional medical support.37-39 As research has indicated, individuals that have undergone emotional stress can delay healing as much as 40% in tissue.18-20 Additionally, individuals with emotional stress have been known to have increased pain reports, decreased strength, and altered immune functions.18-20,37 Thus, delaying or prolonging recovery from injury/illness. Summary Athletic training education programs are accredited by Commission on Accreditation of Allied Health Education Program (CAAHEP) through the Joint Review Committee Athletic Training (JRC-AT) and can lead to a bachelors or masters degree in athletic training through a competencybased education program.40 Through this education students can learn the proper competencies and proficiencies of becoming an ATC. After completion of an educational program and mastery of the competency and proficiencies, then an ATS is eligible to sit for the BOC exam. This study plans to evaluated entry-level athletic training education with the emphasis on psychosocial interventions and referral competencies. The researcher 60 examined whether students perceive to be competent in their educational program with regards to the psychosocial interventions and referral area of competency and proficiency. All 41 competencies should be taught and learned by an ATS prior to taking the BOC exam. Researchers have focused on explaining why the referral process is important if an athlete exhibits psychological distress and why it is important that entry-level athletic training students have competent knowledge in the area of Psychosocial Interventional and Referral. During certain situations where an athlete might need to be referred to a mental health professional, that decision is to be made by the athletic trainer themselves. This decision depends on the type of distress the athlete is having due to the mental anguish from the injury. Do ATS learn how to give this type of support to an athlete through the rehabilitation process? Athletes who have experienced a high level of distress may be at greater risk for seeing a mental health professional. With help from an ATC, who has received education from qualified personnel, the athlete may receive social support and/or assistance for referral to a mental health professional if necessary. 61 Athletes may go through varying degrees psychological distress. This may be due to the feeling of being held responsible for the injury. The athletes may not only have distress but also may be feeling pressure from their team to return to play as soon as possible. Athletes may not want the help from an athletic trainer because the athlete may feel that the AT may think they are a head case to deal with in the rehabilitation setting. It is important as entry-level athletic training students enter the world of sports medicine that they must recognize the possible signs of psychological distress associated with an athletic injury in order to assist the athlete with the best overall care. The athletic trainer should be able to provide the support the athlete needs and refer the athlete to the proper care if the care is beyond the ATs knowledge and competence level. If presently, only 36% of the AT believe they have the knowledge to handle psychological concerns of athletes, and they are our educators for our ATS, then how confident will the ATS be when they become certified? 62 APPENDIX B The Problem 63 THE PROBLEM Statement of the Problem The purposes of this study are to determine the comfort level of Athletic Training Education Program (ATEP) students and how students are receiving information in relation to the Psychosocial Intervention and Referral competencies. These students are enrolled in Commission on Accreditation of Allied Health Education Program (CAAHEP) and ATEP. Certified Athletic Trainers (ATs) are the first to respond to an athlete’s physical injury. However, there are times when an athlete may suffer from psychological anguish associated with an injury, but not often consulted with their feelings. An AT not only has to assist with athletes during the physical rehabilitation but with the mental health. physical injury. This could be just as serious as the However, an athletic training student (ATS), who prepares to sit for the Board of Certification (BOC) exam, is expected to understand and have the knowledge and skills of the psychological components associated with a sports injury and rehabilitation. The National Athletic Trainers’ Association (NATA) has a list of 191 different competencies that fit under the 12 64 subsections for each domain of athletic training and span across all six domains. Nearly 22% of the 121 competencies are related to Psychosocial Intervention and Referral competencies. Yet, there is not a specific course required to teach these competencies. To date, the comfort level of ATS in the Psychosocial Intervention and Referral competencies has not been researched. However, it has not been researched as to whether an ATS thinks they are competent in area based on the instruction that is received. Definition of Terms The following is a list of terms that are defined to better understand this study: 1) Athletic Training Student (ATS) – Any student who is enrolled in a university or college and CAAHEP approved entry-level athletic training program within the 10 National Athletic Trainers’ Association districts and who are entry-level athletic training students eligible to sit for the Board of Certification examination. 2) Board of Certification (BOC)- An organization that grants the certification for athletic trainers upon 65 passage of their examination upon graduation from a CAAHEP accredited program. 3) Athletic Trainer (AT)- A BOC certified professional who specializes in athletic training. 4) Commission on Accreditation of Allied Health Education Program (CAAHEP) – accredits more than 2000 educational program in 21 health science occupations across the United States and Canada. It accredits universities and colleges with an entry-level athletic training program (ATEP). 33 5) Competencies - Twelve Specific content areas that are covered under each domain. There are 191 total competencies that comprised of cognitive, psychomotor, and affective domains. 6) Domains - Six areas of athletic training that must be covered in any entry-level athletic training program. They are Prevention, Recognition, Evaluation and Assessment, Immediate Care, Treatment, Rehabilitation and Reconditioning, Organization, and Administration, Professional Development and Responsibility. 7) National Athletic Trainers’ Association (NATA)- An organization that is made up of ATs and ATs that is dedicated to the health and well-being of athletes1. 66 8) Psychosocial Intervention and Referral Competency Topics - one of 12 specific content areas of athletic training education that is subdivided into cognitive, psychomotor, and affective areas. Basic Assumptions The following is a list of the basic assumptions used in this study. 1) It is assumed that all entry-level athletic training CAAHEP approved athletic training programs are teaching all 41 psychosocial interventions and referral competencies. 2) It is assumed that all ATs, who are eligible to sit for the BOC exam, are familiar with the 41 psychosocial interventions and referral competencies and have been given the proper instruction in that area. 3) It is assumed that all surveys sent out will be returned and answered correctly and honestly. Limitations of the Study 1) A limitation to this study is the number of correctly completed surveys returned in a timely manner. 67 2) Survey is intended to measure a student’s perception, rather than knowledge. 3) The survey is measuring only the entry-level ATS perceptions of competence and not the knowledge of the personnel designated by the Athletic Training Educational Programs (ATEP) to teach 41 Psychosocial Intervention and Referral competencies. Significance of the Study This study will determine the comfort level of each competency that the entry-level athletic students perceive they are receiving specifically for the psychological and referral competency section outlined by the NATA. From this study, ATEP program directors will have an objective report of how competent their students are aware of in relation to the Psychosocial Intervention and Referral area. Since nearly almost a quarter, (22%) of the competencies are specific to this area one would think that each ATEP would require a specific course to cover this topic area. However, there is not a specific course mandated to instruct ATS about all of competencies and proficiencies specific to Psychosocial Intervention and Referral. If ATS do not have the knowledge of psychological concerns, then this can be overlooked and athletes may not 68 be getting complete care, which means rehabilitation may be prolonged. This study is primarily investigating entry- level students and their comfort levels with the intent to inform program directors across the country how these students rate the comfort level specific in the Psychosocial Intervention and Referral domain. 69 APPENDIX C Additional Methods 70 APPENDIX C1 Psychosocial Intervention and Referral Survey for EntryLevel Athletic Training Students 71 Psychosocial Intervention and Referral Survey for Entry-Level Athletic Training Students Please answer the following 41 competencies on whether it was taught or not, and where it was taught by circling the answer. Please answer comfort level based upon the following scale: 5-Very Comfortable 4- Quite Comfortable 3- Neutral 2- Somewhat Comfortable 1- Not Comfortable at All After Completing Part A please continue to Part B Part A Please answer the following demographic questions. Gender: Female or Male Year: Undergraduate or Graduate Lifetime experience: Part B- Comfort Level of Psychosocial Interventions and Referral Competency Competency Cognitive Domain - Understanding knowledge of certain Was it Where was competency. Taught? it Taught? 1. Describes the current psychosocial and sociocultural Yes Psych. Of issues and problems confronting athletic training and Sport sports medicine and identifies their effects on athletes No Injury and others involved in physical activity. Sport Not Sure Psych. 2. Compares the psychosocial requirements of various sports activities to the readiness of the injured or ill individual to resume physical participation. Yes No Not Sure Clinical Field Other Psych. Of Sport Injury Sport Psych. Comfort Level 5 4 3 2 1 5 4 3 2 1 72 3. Understands the psychological and emotional responses (motivations, anxiety, and apprehension) to trauma and forced physical inactivity as they relate to rehabilitation and reconditioning process. Yes No Not Sure 4. Describe the basic principles of mental preparation, relaxation, and visualization techniques, general personality traits, associated trait anxiety, locus of control, and athlete and social environmental interactions. Yes No Not Sure 5. Provides health care information to patients, parents/guardians, athletic personal and others regarding the psychological and emotional well being of athletes and others involved in psychical activity. Yes No Not Sure Clinical Field Other Psych. Of Sport Injury Sport Psych. Clinical Field Other Psych. Of Sport Injury Sport Psych. Clinical Field Other Psych. Of Sport Injury Sport Psych. Clinical Field Other 5 4 3 2 1 5 4 3 2 1 5 4 3 2 1 73 6. Disseminates information regarding the roles and functions of various community-based health care providers (sport psychologist, counselors, social workers). Yes No Not Sure 7. Describes the accepted protocols that govern the referral of athletes and other physically active individuals to psychological, community health, or social workers. Yes No Not Sure 8. Describes the theories and techniques of interpersonal and cross-cultural communication among certified athletic trainers, athletes, athletic personnel, patients, administrators, health care professionals, parents/guardians, and others. 9. Employs the basic principles of counseling, including discussion, active listening and resolution. Yes No Not Sure Yes No Not Sure Psych. Of Sport Injury Sport Psych. Clinical Field Other Psych. Of Sport Injury Sport Psych. Clinical Field Other Psych. Of Sport Injury Sport Psych. Clinical Field Other Psych. Of Sport Injury Sport 5 4 3 2 1 5 4 3 2 1 5 4 3 2 1 5 4 3 2 1 74 10.Describes the various strategies that certified athletic trainers may employ to avoid and resolve conflicts among superiors, peers, and subordinates. Yes No Not Sure 11. Identifies the symptoms and clinical signs of common disordered eating (anorexia nervous, bulimia) and the psychological and sociocultural factors associated with these disorders. Yes No Not Sure 12. Identifies the psychological issues that relate to physically active women of childbearing years. Yes No Not Sure Psych. Clinical Field Other Psych. Of Sport Injury Sport Psych. Clinical Field Other Psych. Of Sport Injury Sport Psych. Clinical Field Other Psych. Of Sport Injury Sport Psych. Clinical Field Other 5 4 3 2 1 5 4 3 2 1 5 4 3 2 1 75 13. Identifies the medical and community-based resources that disseminate information regarding safe sexual activity and the health risk factors associated with sexually transmitted diseases. Yes No Not Sure 14. Describes commonly abuse substances (e.g., alcohol, tobacco, stimulants, nutritional supplements, steroids, marijuana, and narcotics) and their impact on an individual’s health and physical performance. Yes No Not Sure 15. Recognizes the signs and symptoms of drug abuse and the use of ergogenic aids and other substances. Yes No Sport Psych. Clinical Field Other Psych. Of Sport Injury Sport Psych. Clinical Field Other Psych. Of Sport Injury No Sport Psych. Clinical Field Other Psych. Of Sport Injury Not Sure Sport Psych. Not Sure 16. Identifies the societal influences toward substance abuse in the athletic and physically active population. Psych. Of Sport Injury Yes 5 4 3 2 1 5 4 3 2 1 5 4 3 2 1 5 4 3 2 1 76 17. Contrasts psychological and physical dependence, tolerance, and withdrawal syndromes that may be seen in individuals addicted to alcohol, prescription or nonprescription medications and/or “street” drugs. Yes No Not Sure 18. Describes the basic signs and symptoms of mental disorders (psychoses), emotional disorders (neuroses, depression) or personal/social conflict (family problems, academic or emotional stress, personal assault or abuse, sexual assault, sexual harassment) and the appropriate referral. 19.Identifies contemporary personal, school, and community health services management, such as community-based psychological and social support services Yes No Not Sure Yes No Not Sure Clinical Field Other Psych. Of Sport Injury Sport Psych. Clinical Field Other Psych. Of Sport Injury Sport Psych. Clinical Field Other Psych. Of Sport Injury Sport Psych. Clinical Field Other 5 4 3 2 1 5 4 3 2 1 5 4 3 2 1 77 20. Formulates a plan for appropriate psychological intervention and referral with all involved parties when confronted with a catastrophic event. 21. Describe the acceptance and grieving process that follow a catastrophic event. 22. Identifies the stress-response model and how it may parallel to an injury. Yes No Not Sure Psych. Of Sport Injury Yes No Not Sure Sport Psych. Clinical Field Other Psych. Of Sport Injury Yes No Not Sure 23. Defines seasonal affective disorder (SAD). Yes No Not Sure Sport Psych. Clinical Field Other Psych. Of Sport Injury Sport Psych. Clinical Field Other Psych. Of Sport Injury Sport 5 4 3 2 1 5 4 3 2 1 5 4 3 2 1 5 4 3 2 1 78 24. Cites the potential for psychosocial interventional and referral when dealing with population requiring special consideration (e.g., those with exercise-induced asthma, diabetes, seizure disorders, drug allergies and interactions, or unilateral organs). 25. Describe the motivational techniques that certified athletic trainer must use during injury rehabilitation and reconditioning Yes No Not Sure Yes No Not Sure Psychomotor Domain- The following 5 competencies (questions) are associated with the relating to skills utilizing in Psychosocial Intervention and Referral 26. Intervenes, when appropriate, with an individual with a suspected substance abuse problem. Yes No Not Sure Psych. Clinical Field Other Psych. Of Sport Injury Sport Psych. Clinical Field Other Psych. Of Sport Injury Sport Psych. Clinical Field Other Psych. Of Sport Injury Sport Psych. Clinical Field 5 4 3 2 1 5 4 3 2 1 5 4 3 2 1 79 27. Communicates with appropriate health care professionals in a confidential manner. Yes No Not Sure 28. Uses appropriate community-based resources for psychosocial intervention. Yes No 30. Develops and implements stress reduction techniques for athletes and others involved in physical activity Sport Psych. Clinical Field Other Psych. Of Sport Injury Yes No Not Sure Sport Psych. Clinical Field Other Psych. Of Sport Injury Yes No Not Sure Sport Psych. Clinical Field Other Psych. Of Sport Injury Not Sure 29. Uses motivational techniques with athletes and others involved in physical activity. Other Psych. Of Sport Injury Sport 5 4 3 2 1 5 4 3 2 1 5 4 3 2 1 5 4 3 2 1 80 Psych. Clinical Field Other Affective Domain- influencing feelings or emotions on Psychosocial Intervention and Referral competency 31. Develops and implements mental imagery techniques for athletes and others involved in physical activity. Yes No Not Sure Psych. Of Sport Injury Sport Psych. Clinical Field Other 32. Accepts the professional, ethical, and legal parameters that define the proper role of the certified athletic trainer in providing health care information, intervention, and referral. Yes No Not Sure Psych. Of Sport Injury 33. Accepts the responsibility to provide health care information, intervention, and referral consistent with the certified athletic trainer’s professional training. Yes No Not Sure Sport Psych. Clinical Field Other Psych. Of Sport Injury Sport Psych. Clinical 5 4 3 2 1 5 4 3 2 1 5 4 3 2 1 81 34. Recognizes the certified athletic trainer’s role as a liaison between all of the parties involved with athletes and others involved in physical activity. 35. Accepts the need for appropriate interpersonal relationships between all of the parties involved with athletes and other involved in physical activity. 36. Accepts the moral and ethical responsibility to intervene in situations of suspected or known use and/or personal/social conflict. Yes No Not Sure Field Other Psych. Of Sport Injury Yes No Not Sure Sport Psych. Clinical Field Other Psych. Of Sport Injury Yes No Not Sure 37. Accepts the moral and ethical responsibility to intervene in situations of mental, emotional, and/or personal/social conflict. Yes No Sport Psych. Clinical Field Other Psych. Of Sport Injury Sport Psych. Clinical Field Other Psych. Of Sport Injury 5 4 3 2 1 5 4 3 2 1 5 4 3 2 1 5 4 3 2 82 Not Sure 38. Recognizes athletes and other physically active individuals as deserving of quality professional health care. Yes No Not Sure 39. Accepts the individual’s physical complaint(s) without personal bias or prejudice. Yes No Not Sure 40. Respects the various social and cultural attitudes, beliefs, and values regarding health care practices when caring for patients. Yes No Not Sure Sport Psych. Clinical Field Other Psych. Of Sport Injury Sport Psych. Clinical Field Other Psych. Of Sport Injury Sport Psych. Clinical Field Other Psych. Of Sport Injury Sport Psych. Clinical Field Other 1 5 4 3 2 1 5 4 3 2 1 5 4 3 2 1 83 41. Accepts the role of social support during the injury rehabilitation process. Yes Psych. Of Sport Injury No Sport Psych. Clinical Field Other Not Sure Part C Comfort Level for 12 Athletic Training Competencies Competency 1. Risk Management and Injury/ Illness Prevention 2. Pathology of Injury/Illness Comfort Level 5 4 3 2 1 5 4 3 2 1 5 4 3 2 1 5 4 3 2 1 5 4 3 2 1 5 4 3 2 1 5 4 3 2 1 5 4 3 2 1 3. Assessment of Injury/Illness 4. General Medical Conditions and Disabilities 5. Therapeutic Exercise 6. Rehabilitative Techniques 7. Health Care Administration 8. Weight Management and Body Composition 5 4 3 2 1 84 9. Psychosocial Interventions and Referral 5 4 3 2 1 5 4 3 2 1 5 4 3 2 1 5 4 3 2 1 10. Medical Ethics and Legal Issues 11. Pharmacology 12. Professional Development and Responsibilities APPENDIX C2 Psychosocial Intervention and Referral Competencies 86 Cognitive 1) Describes the current psychosocial and sociocultural issues and problems confronting athletic training and sports medicine and identifies their effects on athletes and others involved. 2) Compares the psychosocial requirements of various sports activities to the readiness of the injured or ill individual. 3) Understands the psychological and emotional responses (motivations, anxiety, apprehension) to trauma and forced physical inactivity as they relate to rehabilitation and reconditioning process. 4) Describe the basic principles of mental preparation, relaxation, and visualization techniques, general personality traits, associated trait anxiety, locus of control, and athlete and social environmental interactions. 5) Provides health care information to patients, parents/guardians, athletic personal and others regarding the psychological and emotional well being of athletes and others involved in psychical activity. 87 6) Disseminates information regarding the roles and functions of various community-based health care providers (sport psychologist, counselors, social workers). 7) Describes the accepted protocols that govern the referral of athletes and other physically active individuals to psychological, community health, or social workers. 8) Describes the theories and techniques of interpersonal and cross-cultural communication among certified athletic trainers, athletes, athletic personnel, patients, administrators, health care professionals, parents/guardians, and others. 9) Employs the basic principles of counseling, including discussion, active listening and resolution. 10) Describes the various strategies that certified athletic trainers may employ to avoid and resolve conflicts among superiors, peers, and subordinates. 11) Identifies the symptoms and clinical signs of common disordered eating (anorexia nervous, 88 bulimia) and the psychological and sociocultural factors associated with these disorders. 12) Identifies the psychological issues that relate to physically active women of childbearing years. 13) Identifies the medical and community-based resources that disseminate information regarding safe sexual activity and the health risk factors associated with sexually transmitted diseases. 14) Describes commonly abuse substances (e.g., alcohol, tobacco, stimulants, nutritional supplements, steroids, marijuana, and narcotics) and their impact on an individual’s health and physical performance. 15) Recognizes the signs and symptoms of drug abuse and the use of ergogenic aids and other substances 16) Identifies the societal influences toward substance abuse in the athletic and physically active population. 17) Contrasts psychological and physical dependence, tolerance, and withdrawal syndromes that may be seen in individuals addicted to alcohol, prescription or nonprescription medications and/or “street” drugs. 89 18) Describes the basic signs and symptoms of mental disorders (psychoses), emotional disorders (neuroses, depression) or personal/social conflict (family problems, academic or emotional stress, personal assault or abuse, sexual assault, sexual harassment) and the appropriate referral. 19) Identifies contemporary personal, school, and community health services management, such as community-based psychological and social support services. 20) Formulates a plan for appropriate psychological intervention and referral with all involved parties when confronted with a catastrophic event. 21) Describe the acceptance and grieving process that follow a catastrophic event. 22) Identifies the stress-response model and how it may parallel to an injury. 23) Defines seasonal affective disorder (SAD). 24) Cites the potential for psychosocial interventional and referral when dealing with population requiring special consideration (e.g., those with exercise-induced asthma, diabetes, 90 seizure disorders, drug allergies and interactions, or unilateral organs). 25) Describe the motivational techniques that certified athletic trainer must use during injury rehabilitation and reconditioning. Affective 1) Accepts the professional, ethical, and legal parameters that define the proper role of the certified athletic trainer in providing health care information, intervention, and referral. 2) Accepts the responsibility to provide health care information, intervention, and referral consistent with the certified athletic trainer’s professional training. 3) Recognizes the certified athletic trainer’s role as a liaison between all of the parties involved with athletes and others involved in physical activity. 4) Accepts the need for appropriate interpersonal relationships between all of the parties involved with athletes and other involved in physical activity. 91 5) Accepts the moral and ethical responsibility to intervene in situations of suspected or known use and/or personal/social conflict. 6) Accepts the moral and ethical responsibility to intervene in situations of mental, emotional, and/or personal/social conflict. 7) Recognizes athletes and other physically active individuals as deserving of quality professional health care. 8) Accepts the individual’s physical complaint(s) without personal bias or prejudice. 9) Respects the various social and cultural attitudes, beliefs, and values regarding health care practices when caring for patients. 10) Accepts the role of social support during the injury rehabilitation process. Psychomotor 1) Intervenes, when appropriate, with an individual with a suspected substance abuse problem. 2) Communicates with appropriate health care professionals in a confidential manner. 92 3) Uses appropriate community-based resources for psychosocial intervention. 4) Uses motivational techniques with athletes and others involved in physical activity. 5) Develops and implements stress reduction techniques for athletes and others involved in physical activity. 6) Develops and implements mental imagery techniques for athletes and others involved in physical activity. 93 APPENDIX C3 Approval from the National Athletic Trainers’ Association Educational Council 94 ----- Original Message ----From: Knight, Ken To: Palermo, Gina Sent: Tuesday, April 26, 2005 You have my permission to use the competencies in your survey. -kk Kenneth L Knight, PhD, ATC, FACSM Jesse Knight Professor of Exercise Sciences Chair, National Athletic Trainers Association Education Council Editor, Athletic Training Education Journal www.nataec.org nataec@byu.edu atej@byu.edu Ed Council matters Ed Journal matters 801-422-3181 fax 801-422-0555 95 APPENDIX C4 Institutional Review Board 96 Proposal Number PROTOCOL for Research Involving Human Subjects Institutional Review Board (IRB) approval is required before beginning any research and/or data collection involving human subjects Request for Exempt Review Request for Expedited Review Request for Full Board Review (Reference IRB Policies and Procedures for clarification) Project Title Evaluating Entry-Level Athletic Training Students Perceptions on Psychosocial Intervention and Referral Researcher/Project Director Gina R. Palermo Phone #724-938-6249 E-mail Address pal0303@cup.edu Faculty Sponsor (if you are a student) Dr. Joni Cramer Roh Department Health Science and Sport Studies Project Dates Spring 2005 to Summer 2005 Sponsoring Agent (if applicable) Project to be Conducted at California University of PA Purpose of the Project Thesis Class Project Research Other 97 (All Proposals Must be Typed) 1. Give a brief overview of your project/proposal with research hypothesis. The purpose of this study is to evaluate entry-level athletic training students and their comfort level of psychosocial interventions and referral competencies enrolled in CAAHEP accredited ATEP. 2. Give a brief description of the subjects you plan to use, and check the appropriate box(es) below. Adult Volunteers Mentally Ill Minor Volunteers Elderly Children Under 18 Mentally Retarded CAL University Students Physically Handicapped Minorities Prisoners Disadvantaged 3. Pregnant Women Is remuneration involved in your project? Yes or No If yes, Explain below. 4. How do you plan to select subjects? participation required? Did they volunteer? Is Required IRB Training The training requirement can be satisfied by completing the online training session at http://cme.nci.nih.gov/ . A copy of your certification of training must be attached to this IRB Protocol. If you have completed the training at an earlier date and have already provided documentation to the California University of Pennsylvania Grants Office, please provide the following: Previous Project Title Date of Previous IRB Protocol 98 Explain below. I plan to get a list of all senior and graduate athletic training students who are entry-level athletic training students who are preparing to sit for the Board of Certification (BOC) Exam from the National Athletic Trainers Association (NATA). 5. Does your project involve use of a consent form? Yes or No If yes, attach the form. 6. What instruments or devices will be used to gather data? Provide a copy of documentation pertaining to the data collection, such as but not limited to: Cover letter, survey, consent form, interview/focus group sheets. I will be using a survey that was created by and my research advisor. A cover letter will also be included in the mailing of my survey explaining the purpose of the survey and what its intensions are for this study. 7. Is this project part of a grant? provide the following information: Yes or No If yes, Title of the Grant Proposal Name of the Funding Agency ______________ Dates of the Project Period 8. Does your project involve the debriefing of those who participated? Yes or No If yes, explain the debriefing procedure. 9. The Federal Regulations require that the protocol meet certain criteria before IRB approval can be obtained. Describe in detain how the following requirements will be satisfied: A. Insure that the risks of the subject are minimized. There are no risks involved with this study. B. Justify the degree of risk involved (if any) in relationship to the potential of the project to the subject matter. There are no risks involved with this study. C. Insure that the selection of the subjects is equitable. 99 All subjects will be equitable. A list will be obtained from the National Athletic Trainers Association Board of Certification. D. Guarantee that informed consent will be obtained for each prospective subject or the subject’s legally authorized representative and that consent forms will be adequately documented. Informed consent will be implied by anonymous response to this survey. E. Monitor the data collected to ensure the safety of the subject. The data will be collected through United States Postal Service. The survey will be used for only the researcher and the advisor to record all results. All data will be kept in safe storage experience area at the researcher request. F. Protect the privacy of subjects and maintain the confidentiality of data. Informed consent will be implied by anonymous response to this survey. G. Provide for extra safeguards to protect the rights and welfare of “vulnerable” subjects (e.g., children, prisoners, pregnant women, mentally disabled persons or economically or educationally disadvantage experienced persons). The researcher will not knowingly be using any of the abovedescribed people in her study. 100 101 APPENDIX C5 Cover Letter to Athletic Training Students 102 Dear Athletic Training Student: I am a master’s degree candidate at California University of Pennsylvania, requesting your help to complete part of my degree requirements. Please follow complete the survey that is included in this letter to the best of your ability. The survey is titled Psychosocial Interventions and Referral Survey for Entry-Level Athletic Training Students. The purpose of this study that I am conducting is to see if students like you, are getting the proper education in the area of psychosocial interventions and referral competencies. The survey consists of 3 demographic questions, and 41 questions on the psychosocial interventions and referral competencies. This should only take about five to seven minutes to complete. One thousand, three hundred students were selected from a list from the Board of Certification office who are eligible to take the BOC examination upon approval and graduation. The California University of Pennsylvania Institution Review Board has approved this study for the Protection of Human Subjects. This is a completely anonymous survey and upon submission, neither your name nor mailing address will be attached to your answers. Your information will be kept strictly confidential. Your knowledge and opinions regarding this topic makes your input very useful. Please take a few minutes to fill out the anonymous survey that is attached. Thank you for your time and consideration. Sincerely, Ms. Gina R. Palermo California University of Pennsylvania 250 University Ave California, PA 15419 Pal0303@cup.edu 103 REFERENCES 1) National Athletic Trainers Association. The National Education Council. Available at: http://www.nataec.org/index.html. Accessed September 8, 2004. 2) Houglum PA. Therapeutic exercise for athletic trainers. 2nd edition. Champaign, IL: Human Kinetics 2001. 3) Prentice W. Arnhiem’s principles of athletic training: A competency-based approach. 11th edition McGraw-Hill 2003. 4) Weidner T, Henning J. Historical Perspective of Athletic Training Clinical Education. JAT. 2002:222228. 5) National Athletic Trainer’s Association. Athletic Training Educational Competencies. 3rd ed. Dallas, TX: National Athletic Trainers’ Association; 1999. 6) National Athletic Trainers’ Association, Inc. 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Available at: http://www.caahep.org/caahep/default.asp?doc=what Accessed October 5, 2004. 107 ABSTRACT TITLE: Evaluating Entry-Level Athletic Training Students Comfort Level on Psychosocial Intervention and Referral Competencies RESEARCHER: Gina R. Palermo ADVISOR: Dr. Joni Cramer Roh DATE: 2010 PURPOSE: The purpose of this study was to determined comfort level of entry level ATS with Psychosocial Intervention and Referral competencies. The second purpose was to examine whether ATS received the proper academic curriculum-based content in relation to psychosocial interventions and referral competencies. METHOD: There were over 1,000 entry-level student athletic trainers eligible for the Board of Certification Exam for the year 2005. Four hundred and three students responded to a completed survey. The survey consisted of 3 demographic questions, 41 questions pertaining to Psychosocial Intervention and Referral Competencies and twelve questions specific to content areas in athletic training. FINDINGS: There was no significant difference found between females and males comfort level in psychosocial interventional and referral competencies. A significant negative relationship was not found between age and comfort-level of entry-level athletic training students on psychosocial intervention and referral competency. Psychosocial Interventional and Referral 108 competencies ranked forth lowest amongst the 12 athletic training competencies. CONCLUSIONS: Although there were no significant findings, undergraduate students and males indicated greater comfort levels. Overall, students feel somewhat comfortable with the Psychosocial Intervention and Referral competencies.