EDITORIAL 1 Copyright © by Indiana State University Clinical Practice in Athletic Training All rights reserved. ISSN Online 2577-8188 Volume 5 – Issue 1 – April 2022 The State of Work in Athletic Training: A Conversation K. Ellis F. Mair, EdM, ATC*; Lindsey E. Eberman, PhD, LAT, ATC† *Go4, Philadelphia, PA; † Indiana State University, Terre Haute, IN Key Phrases Work place culture, employment, work force, employer, employee Correspondence Ellis Mair and Dr. Lindsey Eberman, 567 Nth 5th Street, Terre Haute, IN 47802. E-mail: Ellis.Mair@gmail.com Twitter: @go4ellis Full Citation Mair KEF, Eberman, LE. The state of work in athletic training: A conversation. Clin Pract Athl Train. 2022;5(1): 1-7. https://doi.org/10.31622/2021/0005.01.1. EDITORIAL Recent employment reports have suggested that 18% of healthcare workers left their respective professions since the onset of the pandemic and another 12% have been laid off.1 Although current data about the impact of the pandemic on the athletic training workforce has not been released from the Strategic Alliance, an early study indicated that 20% of athletic trainers were out of work.2 Editor-in-Chief, Lindsey Eberman, engaged in a conversation with Ellis Mair, Co- Founder and Vice President of Medicine/Community at Go4 (formerly Go4Ellis) about the state of work in athletic training. LEE: What is your current sense of work in athletic training? KEFM: Historically, I think this has always been an interesting question because the title of athletic trainer applies to many different people doing many different jobs. We have athletic trainers that work clinically with patients in traditional athletics settings but also we’ve seen a big expansion into physician practice, the performing arts, public safety and the industrial setting. We also have people working in education and research that are still athletic trainers, however their day-to-day looks much different than someone who works providing direct patient care every day. I think the definition of “work” in athletic training has changed tremendously. LEE: Do you think that it gives us an advantage in terms of retaining folks in the profession, the variety that one could explore, because of those different ways that we can define ourselves as athletic trainers? KEFM: Yes. But I think it's commonly misunderstood. I don't know if we do the best job of selling all the different skills we have and how our skills can be used in various settings. I think it is amazing that our patients can be anyone from an astronaut to an acrobat or factory worker or even a middle schooler. But I don't think that is necessarily something the general public knows. Sometimes athletic trainers put on scrubs and go into an Operating Room and sometimes you are teaching in a classroom. We all look very different from setting to setting and I think one of the harder aspects about our profession is to describe how we fit into each of these settings and understand that we have the ability to transition from one setting to another. LEE: I also think we actually struggle to communicate it within our own profession. That seems to be obvious with so many athletic trainers leaving the profession. And that's a historic trend, not just a pandemic trend. We have not taught people resilience, or what options, they have available because so much of professional preparation is in the college/university and secondary school settings cause those are clinical sites of convenience. Exposure outside of that is infrequent in professional preparation and I think an early career athletic trainer has have a lot of courage to go into a brand new setting and mailto:Ellis.Mair@gmail.com https://doi.org/10.31622/2021/0005.01.1 The State of Work in Athletic Training: A Conversation 2 Copyright © Indiana State University Clinical Practice in Athletic Training All rights reserved. ISSN Online 2577-8188 Volume 5 – Issue 1 – April 2022 explore, especially in the current financial climate and likely student debt. I think as much as we struggle to communicate it to the public, we're equally struggling to communicate it to ourselves. KEFM: I agree and experienced this first hand in the pandemic. When the pandemic hit, the Go4 platform lost a million dollars in business in a span of four days. At the time, we were largely based in youth sports and every single tournament, practice and camp in the country was cancelled. I called my colleague and said, “Half of the users on the platform are healthcare workers who are currently sidelined. This is a perfect time for them to get involved.” And we got straight to work because we had over 10,000 healthcare professionals that could be activated with the click of a button and I just had to find someone who believed me. I had some amazing conversations with athletic trainers who were reaching out to me to say, “Let me know where you need me and I will go. I know I can help and I want to be involved.” People were calling from Texas and Oklahoma offering to fly across the country to help in New York! We were working around the clock emailing every department of health trying to get someone to take our call. I ended up in meetings with the Health Commissioners, Chief Nursing Officers and Directors of HR for large urban health systems. I was having conversations with people who essentially were saying, “I have no idea who you are, what you do as a profession and why the heck should I trust you right now?” Convincing them to trust us wasn’t easy at first but when it came down to it, it was a simple conversation about skills and what we could to help them. We were able to pivot and ended up working primarily in the public health realm, whether it was in hospitals or screening and testing sites, we saw the same athletic trainers that were used to working camps excelling alongside nurses and physicians in the pandemic. I think that may changing, but I don't think that a lot of the general medical community understands how we can fit into the healthcare hierarchy and what a massive help we can be to them and their practice.I think that communication and advocacy is as important a skill for athletic trainers as many of our hard clinical skills. LEE: You mentioned having to pivot with the pandemic. Do you see currently a worker shortage in athletic training and why doesn't it feel like we're not talking about it more? KEFM: There definitely is and I believe this is partly because of how people managed their athletic trainers when the pandemic began. In early April of 2020, we ended up interfacing with the Human Resource Director of New York City Health and Hospitals. Her daughter was an athletic training student down in Florida, so while she had a nursing background understood who athletic trainers are and how they could help New York City Health and Hospitals. This organization is the largest hospital system in the country and they were utilizing athletic trainers from the very beginning. If it could happen in New York, there is no reason it shouldn’t happen everywhere. The other large healthcare organizations that are having trouble today are the ones that neglected to empower and utilize their athletic trainers. Historically they’ve employed athletic trainers as loss leaders and had never realized the actual value of athletic trainers. Whether it was a departmental decision or an administrative one they chose to furlough or lay off athletic trainers instead of utilizing our skills in another way. All over the country, athletic trainers we were setting up the facilities for safe patient flow, conducting screenings and temperature checks and even doing COVID testing and vaccinations. But these organizations chose to furlough their athletic trainers and now that sports are back, they can’t find the ATs that used to work for them. Some people faced geographic challenges where their cost of living was so high that they could not stay in their communities without employment. We also have seen large expansion of the industrial setting in the past few years. As the The State of Work in Athletic Training: A Conversation 3 Copyright © Indiana State University Clinical Practice in Athletic Training All rights reserved. ISSN Online 2577-8188 Volume 5 – Issue 1 – April 2022 pandemic raged on, the need to protect our supply chain workers became very real and demand for athletic trainers here grew. Many athletic trainers changed settings; some on a per diem basis but for many it progressed into a full time job. While there may be a worker shortage in some settings, there is growth in others. We've also seen a lot of people working per diem until they can find a job that they like. The demand for healthcare workers has grown over the last two years and therefore we've seen those pay rates go up astronomically. Per diem work has been able to keep a lot of people afloat and work a flexible schedule that works for them while they can find the right job to go back full time. Some organizations also realized how much they needed an athletic trainer. Traditional athletics, although paused, did not go away so there is still a need in college and secondary school athletics. But some athletic trainers got used to a different approach to working and are asking themselves, “Do I want a regular schedule or more control over my schedule, or do I want to go back to what I was doing before?” LEE: That really fits people with a dynamic life or those with a family. Per diem seems to have given people the opportunity to earn money but at their own will versus a traditional athletic training setting, which often makes the worker feel like they are at the will of others. LEE: How do you think the workforce itself has changed in the last two years? Demographics of the population but also individual people? How have we changed as athletic trainers within the healthcare system? KEFM: A lot of people liked the transition to work from home. Many athletic trainers were shifted into the student health or physician practice realm. They were engaged in the public health and prevention side. Anecdotally, people seemed to really like that shift. They may have been doing more healthcare administration and organizations relied on them to be decision-makers. The other leaders “at the table” were looking at athletic trainers saying, “Who are you? You see things through a completely different lens and you're great at this!” I think that that's been awesome. It has been really amazing to watch friends excel in positions of leadership that they suddenly found themselves in. We haven’t always been afforded the opportunity to be in the boardroom and this helped a lot of athletic trainers realize their range of skills too. They were put in positions that they succeeded in and going into it they didn't necessarily realize that they could do the things they ended up doing. LEE: That is an in interesting observation. Recently the BOC produced the Practice Analysis 8th edition,3 which serves as the blueprint for the certifying exam, characterizing the knowledge, skills, and abilities for entry-level practice. The weight of the Healthcare Administration and Professional Responsibility (7th ed.) domain,4 now the Health Administration and Professional Administration (8th ed.) domain, decreased from 13% to 8%.3,4 Two years of a pandemic, where people had to go work from home, build policy, implement policy, have a policy for when people broke policy, develop testing procedures, figure out to enhance safety in a facility. Where I would have thought there would be an increase, there was a 5% decrease! KEFM: That is shocking. I feel like so much of what we’ve done in the pandemic is to help develop policies and then rip them up and then create another one based on whatever change was thrown our way. LEE: How do you think employers have changed? You mentioned inviting athletic trainers to the table, so obviously there's been some openness about how athletic trainers can contribute to the bigger picture, but do you feel like employers are valuing athletic trainers more or not? KEFM: I think this is a case by case situation. We talked earlier about how many different jobs exist The State of Work in Athletic Training: A Conversation 4 Copyright © Indiana State University Clinical Practice in Athletic Training All rights reserved. ISSN Online 2577-8188 Volume 5 – Issue 1 – April 2022 that are all considered working as an athletic trainer. There are some people that were able to forge new relationships as they gained new colleagues in student health service or at their local Department of Public Health. I also think that these new colleagues will continue to seek out that athletic trainer's input because they were a reliable source of information and a creative problem solver. Some employers are realizing how much they need athletic trainers and they’re willing to pay more than they would have in the past to have them come back to work. I also think that we are starting to dig in and realize that we are not willing to come back for what we were previously earning, especially if they were mistreated prior to or during the pandemic. LEE: Retention data has taught us that there's a salary at which athletic trainers are willing to put up with the typical chaos and work-related stress attached to the sport industrial complex… I think that we have to figure out what that point is. The National Athletic Trainers’ Association just published the Executive Summary of the 2021 Salary Survey. Although the summary requires some methods clarification, the general premise is that the average salary is around $61,000 and that number has risen about $10,500 since 2011, but the gender gap is concerning (-$11,000).5 Unfortunately no data are provided for minoritized populations, at the time of this publication. What is the salary someone should be earning to also accept the unstructured work of traditional athletics? There are so many jobs available in the traditional settings without sufficient workers to fill the jobs based on popular listservs and the Career Center. I'm wondering whether we're going to hit a tipping point in these traditional settings where employers are willing to reconsider compensation models, much like we have seen in the per diem compensation. Unfortunately, we had seen trends of assistantships shifting to internships that exploit the least experienced athletic trainers, instead of converting these positions to full-time staff positions. The patient need is still there, so I think we need innovation in both compensation and healthcare delivery structure. We need to identify what our priorities are and consider how to focus our staff if we are unable to bring folks back in and compensate them accordingly. KEFM: I think candidates have the pick of the litter right now, and I think that it's very important that they know that. We've talked about this for years and it's really only addressing half of the problem, “Say no to low paying jobs!”. But that is not the solution. This blame is misdirected and cannot be solely assigned to the person taking a low paying job. We, the athletic trainers that are behind the hiring, need to stop offering low paying jobs. Employers have a responsibility to pay their employees appropriate salaries for the work that they are being asked to do. Candidates are going to be graduating soon and there are jobs everywhere. I think they have a lot of leverage to negotiate. Especially with the proliferation of legislation that requires an athletic trainer to be present if you have certain activities occurring at a facility, it is no longer a luxury to have an athletic trainer, it is a legislative necessity. When those employers are struggling to find someone to fulfill those duties, they are going to have to offer more so that they can find someone willing to do the job for an appropriate pay rate. We've seen the average rate on Go4 rise from $35/hour a few years ago to $50/hour and some rates are as high as $100/hour in some areas. It has been a long two years for the profession and if an employer wants someone to get off the couch at the end of a long hard work week, they are going to have to pay them a rate worth their valuable time. I think graduating candidates need to know that there are going to be a plethora of jobs available to them and they shouldn’t take something that they are not excited about. There are great The State of Work in Athletic Training: A Conversation 5 Copyright © Indiana State University Clinical Practice in Athletic Training All rights reserved. ISSN Online 2577-8188 Volume 5 – Issue 1 – April 2022 employers and great work experiences out there and you’ve got to do the work to find one that meets all of your needs. At the Annual Meeting in June, there will be dozens of companies who are looking to hire athletic trainers. They will be looking to recruit graduates right there on the Expo floor. For the longest time, positions were easy to fill but times have changed and these companies are having to put in the work and reconfigure these jobs if they want to find the best candidates. LEE: Employees should be able to make decisions in their best interest. I work primarily with folks who are in their early career and many of them want to go into college/university athletic training and I'll be curious to see how this setting adapts. Historically these job postings require previous college/university setting experience; often 3 to 5 years. However, we lack evidence to support that criteria as leading to retention of improved health outcomes. It seems arbitrary and I am not sure there will be enough candidates with those experiences, at least in the short-term hiring cycle. They will see far more early-career athletic trainers applying and securing those positions, but this setting does not seem to have demonstrated the same radical adaptability the other settings have when it comes to increasing compensation and adjusting workplace climate. I would not encourage any of our early-career athletic trainers to take those positions at the rate being offered. How do you think candidates can leverage themselves in the landscape? KEFM: First, they cannot be afraid to negotiate and tell the employer what you believe you are actually worth. Companies may be posting the position for $41,000 but if they interview 10 candidates who say they are worth the national average at $61,000, they are going to have to go back to Human Resources. The employer will have to advocate directly to Human Resources that great candidates are unwilling to work for their listed salary. Candidates need to know the number that works for them. Employers need that feedback and they’re going to have to reassess. LEE: Compensation has long been our problem in athletic training, but compensation is not the only indicator of job quality. I tell students that they need to weigh three things; geography, autonomy, and compensation. If the most important thing to you is the ability to have your weekends off and climb mountains. Then you should be looking for a job that geographically allows you to do that. If you want to be in control of your time and how you focus your attention, choose a job that gives you that autonomy. But sometimes these three factors are in conflict with one another, but the important thing is for a candidate to know what their priorities are. They get to decide, but they should certainly not be sacrificing all three. For me, I prioritize autonomy, and in that I sacrifice geography, living away from family. In my work with early-career athletic trainers, I have noticed they are so fearful of negotiating. I think they think the employer will take away the offer, the moment we push them a bit. They are offering the job they have. As an employee, we have a responsibility to push the employer higher, for long term professional health. I encourage folks to negotiate for at least 10% more even if the salary is a good offer. The higher your salary goes the more valuable everybody around you becomes because eventually those salaries will be raised to match yours. You mentioned people having an affinity toward work from home, some of the administration components of athletic training, and other kinds of workplace climate changes that have happened as a result of the pandemic that are an advantage to the employee. Let’s talk more about those. KEFM: We got out of the rhythm of the chaos and the overwhelming hours we typically work. We got used to a more normal schedule and I think now that athletics are back, it has been really The State of Work in Athletic Training: A Conversation 6 Copyright © Indiana State University Clinical Practice in Athletic Training All rights reserved. ISSN Online 2577-8188 Volume 5 – Issue 1 – April 2022 hard to adjust. I think it’s making departments realize they are wildly understaffed and more than they have been in the past. I'm hoping that we will see more jobs created because people are realizing the need is not matched by the workforce, in terms of total personnel. I also think people realize the importance of personal time. This is something candidates should be asking on interviews as well. “What does vacation actually mean? Can I take it when I want it? Am I allowed to engage in life events?” I think athletic trainers do not think labor laws apply to us, but the issue is practice not policy and this culture must change. People are realizing that time is theirs and asking for it back. People are being more protective over their time, and I think that's a good thing. Candidates can really advocate for paid time off in an appropriate way and use it when they need and want to, not at the convenience of the employer or team they work with. LEE: Athletic trainers have historically said, “Rain or shine, sick or not, I’m willing to come to work.” Now, I hope every human on the planet no longer feels an obligation to work sick. The ramifications are far bigger than you. What do you think employers could be doing to embrace some of these changes and ensure that workplace culture matches worker need? KEFM: Retaining personnel is less expensive. If someone is leaving, it is to their advantage to conduct an exit interview and ask why that person is leaving and how they could improve the experience of working there. Staff that stay and thrive creates an overall better experience for everybody. They should be gathering information from candidates, those leaving, and those staying. Find out what their needs are and figure out how you can meet them. We are seeing workers across all kinds of industries organizing for better work environments. Look at the Amazon workers unionizing and the nurses moving into traveling positions. People are not going to work for low wages or in abusive cultures anymore, because it is just not worth it. To create a successful workplace, you need to listen to what people want and what they need, and how you can make their lives better. We know happy healthcare providers provide better patient care. LEE: Some of this includes rethinking how we deploy staff. WE have, for far too long, provided coverage instead of healthcare and this is a turning point, if we allow it to be, to consider how to deliver athletic healthcare differently. KEFM: Absolutely. We do not always need to be focused on coverage. People find more fulfillment in working with patients one on one and seeing them improve. LEE: I think it's about identifying what the need is; what is the need and then organizing staff to meet those needs. I also am hopeful that folks will realize that we shouldn't be the only person assigned to a team, which often means the only provider available to those patients. There are many challenges within the American healthcare system, but a strength is personal choice. Our traditional approach to deploying personnel in athletic training has withheld choice from patients. KEFM: Those models also allow us to leverage specialization. We don’t have to be able to know everything and it is nice to have colleagues you can rely on for complex patient cases. It creates a collaborative environment that can improve workplace culture. LEE: Ideal athletic healthcare has generalists, advanced generalists, specialists, and sub- specialists; all of which bring important contributions to the system. I’m looking forward to this shift in how we approach athletic training. ACKNOWLEDGEMENTS Special thanks to Christine Benz and Justin Young for their transcription support. The State of Work in Athletic Training: A Conversation 7 Copyright © Indiana State University Clinical Practice in Athletic Training All rights reserved. ISSN Online 2577-8188 Volume 5 – Issue 1 – April 2022 REFERENCES 1. Galvin G. Nearly 1 in 5 health care workers have quit their jobs during the pandemic. Morning Consult. Accessed on February 9, 2022. Available at: https://morningconsult.com/2021/10/04/he alth-care-workers-series-part-2-workforce/. 2. Winkelmann ZK, Games KE. Athletic Trainers' Job Tasks and Status During the COVID-19 Pandemic: A Preliminary Analysis. J Athl Train. 2021;56(1):20-30. 3. Practice Analysis (7th ed). Board of Certification, Inc. Accessed on April 8, 2022. Available at: https://bocatc.org/candidates/exam- preparation-tools/practice- analysis/practice-analysis 4. Content Outline for Practice Analysis (8th ed). Board of Certification, Inc. Accessed on April 8, 2022. Available at: https://bocatc.org/candidates/exam- preparation-tools/practice- analysis/practice-analysis 5. NATA 2021 Salary Survey Executive Summary. National Athletic Trainers’ Association. Accessed on April 8, 2022. Available at: https://www.nata.org/career- education/career-center/salary-survey https://morningconsult.com/2021/10/04/health-care-workers-series-part-2-workforce/ https://morningconsult.com/2021/10/04/health-care-workers-series-part-2-workforce/ https://bocatc.org/candidates/exam-preparation-tools/practice-analysis/practice-analysis https://bocatc.org/candidates/exam-preparation-tools/practice-analysis/practice-analysis https://bocatc.org/candidates/exam-preparation-tools/practice-analysis/practice-analysis https://bocatc.org/candidates/exam-preparation-tools/practice-analysis/practice-analysis https://bocatc.org/candidates/exam-preparation-tools/practice-analysis/practice-analysis https://bocatc.org/candidates/exam-preparation-tools/practice-analysis/practice-analysis https://www.nata.org/career-education/career-center/salary-survey https://www.nata.org/career-education/career-center/salary-survey