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

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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.