


































Global Research in Higher Education 
ISSN 2576-196X (Print) ISSN 2576-1951 (Online) 

Vol. 4, No. 1, 2021 

www.scholink.org/ojs/index.php/grhe 

32 
 

Original Paper 

Implementation of Cultural Competence Education into Athletic 

Training Programs: A Qualitative Report 

Ashley M. Harris
1*

, Jennifer L. Volberding
2
, Lawrence Richardson

3
 & W. David Carr

4
 

1
 Department of Athletic Training, Aurora University, Aurora, IL, USA 

2
 Department of Athletic Training, Oklahoma State University Center for Health Sciences, Tulsa, OK, 

USA 

3
 Department of Psychology, Oklahoma State University, Stillwater, OK, USA 

4
 Department of Athletic Training, Missouri State University, Springfield, MO, USA 

*
 Ashley M. Harris, Department of Athletic Training, Aurora University, Aurora, IL, USA 

 

Received: December 15, 2020   Accepted: December 28, 2020  Online Published: February 5, 2021 

doi:10.22158/grhe.v4n1p32            URL: http://dx.doi.org/10.22158/grhe.v4n1p32 

 

Abstract 

Cultural competence education is a foundational behavior of professional practice that Athletic 

Training Programs (ATPs) have been tasked to incorporate into their curriculums. Ten ATP faculty 

were individually interviewed to determine the current methods used to teach provision of culturally 

competent care. Four major themes were identified: 1) Barriers to cultural competence education 

implementation in a didactic setting, 2) Strategies for incorporation into an existing didactic 

curriculum, 3) Barriers to cultural competence education in a clinical setting, and 4) Strategies to 

implement cultural competence education into an existing clinical model. Further research is 

necessary to determine the effectiveness of specific strategies.  

Keywords 

diversity, multicultural care, professional education, practical application 

 

1. Introduction 

Within the United States, the lack of diversity within healthcare providers has been demonstrated to 

have a negative impact on the quality of healthcare provided to a highly diverse patient population (Lie 

et al., 2011). It has been shown that cultural differences between the provider and patient may create 

barriers to providing the best possible care, often times due to a lack of understanding (Renzaho et al., 

2013; Cooper et al., 2012; Maurer-Starks, Clemons, & Whalen, 2008). In research within the field of 

health care, a link has been established between higher patient outcomes and culturally competent 



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health care professionals (Renzaho et al., 2013; Cooper et al., 2012; Lie et al., 2011; Maurer-Starks et 

al., 2008). The lack of understanding of the impact of an individual‟s culture on patient care seems 

especially problematic due to the lack of cultural competence seen in certified athletic trainers and 

athletic training students (Marra et al., 2010; Maurer-Starks et al., 2008; Volberding, 2014, 2015). 

Marra et al. (2010)
 
demonstrated that athletic trainers are operating at lower levels of cultural 

competence according to scores on the Cultural Competence Assessment (CCA), even after 

self-reported high levels of cultural competence prior to measure. Athletic training students have also 

demonstrated the trend of high confidence in providing appropriate care yet lacking in the actual ability 

(Marra et al., 2010; Volberding, 2014, 2015). In an ongoing study, athletic trainers have also 

demonstrated the lowest scores across multiple health care professions on the modified Gay 

Affirmative Practice Scale (mGAP) when providing care to individuals who identify as gay, lesbian, or 

bisexual (Madrak, Volberding, Harris, Richardson, unpublished data 2015). 

A number of approaches have been offered from researchers within the varying fields within health 

care as to how to make professionals more culturally competent (Crawford, Candlin, & Roger, 2017; 

Betancourt et al., 2016; Renzaho et al., 2013; Like, 2011). It has been suggested that the best way to 

increase the quality of healthcare provided to all patients is to attempt to increase the diversity of the 

practitioner population to be more reflective of the general patient population (Kirmayer, 2012). This 

was first suggested based on the theory that less barriers to understanding would present if there was a 

more common background between health care providers and the patients they are treating (Kirmayer, 

2012). Historical demographics have demonstrated the profession of athletic training lacks diversity in 

the practitioner population (Pacquiao, 2007). The National Athletic Trainers‟ Association (NATA) 

demographics show that in September of 2018, only 20.1% of the professional population identified as 

an ethnicity other than white non-Hispanic (NATA, 2018), yet these individuals provide care to an 

extremely diverse patient population. Looking at current trends regarding career setting within athletic 

training, the profession is seeing a departing from the traditional collegiate setting and a branching out 

into other areas of patient care (NATA, 2018). The second most populated job setting for athletic 

trainers in in the secondary school setting, hosting 19.38% of our athletic training professional 

population (NATA, 2018). Clinic settings host the third most, at 12.89% (NATA, 2018). The US 

Census Bureau estimates that by the year 2060, approximately only 44% of the US population will 

identify themselves as non-Hispanic white (US Census Bureau, 2014), showing a major disparity 

between those providing care and those receiving care, should membership trends continue as they 

have previously. Combining the changing demographics within the United States with the career 

setting changes within the athletic training profession, practitioners are going to be caring for an ever 

diversifying and changing patient population more so now than ever before. Researchers do caution 

that there is no shown relationship between diverse populations and an increase in cultural competence 

at this time, further exploration will be necessary to determine effectiveness of increased diversity on 

cultural competence levels of practitioners (Pacquiao, 2007). 



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While increasing the exposure to a more diverse patient population has been identified as the ideal 

method of improving culturally competent healthcare delivery, the most common method identified in 

the literature of improving a clinician‟s cultural competence is seen in the form of additional training.  

This training typically is in the form of continuing education after national certification has already 

been obtained (Barnes et al., 2013; Renzaho et al., 2013; Like, 2011). Though, Barnes et al. (2013) 

have demonstrated that the skills do not transfer when the clinician is placed in a work setting that does 

not support the continuing use of these skills. Within the fields of pharmacy, nursing, and medical 

education, research has demonstrated an increase in quality of health care provided once cultural 

competence education had been given (D. Kim, & S. Kim, 2013; Rowan et al., 2013; Long, 2012; Lie 

et al., 2011). Within the field of athletic training, athletic trainers with self-reported diversity training 

scored higher on the Cultural Competence Assessment (CCA), and its two subscales, the Cultural 

Awareness and Sensitivity Scale (CAS) and the Cultural Competence Behavior (CCB), than those that 

did not, suggesting that further cultural competence education is indicated for all health care 

professions to improve patient outcomes (Marra et al., 2010). 

Beyond the post-certification education, research within the health care field on cultural competence 

education has found that there needs to be more emphasis on the education provided to students in 

health care fields throughout their curricula (Calvillo et al., 2009; Lipson & Desantis, 2007; Seeleman, 

Suurmond, & Stronks, 2009). Specific to athletic training, we are seeing research that suggests that 

students want more information on this topic to allow them to be more informed clinicians with better 

relationships with their patients (Nynas, 2015). In 2011-2012, The Commission on the Accreditation of 

Athletic Training Education (CAATE) and the NATA adapted and re-wrote their educational 

competencies to reflect the need for such education (CAATE, 2012; NATA, 2011).
 
The fifth edition 

released in 2011, competencies listed in regards to cultural competence and diversity training are found 

under the foundations of professional practice (NATA, 2011). Educational programs are also being 

asked by the CAATE to provide proof of cultural competence education under the psychosocial content 

area found within the fifth edition of the competencies (NATA, 2011). When these governing bodies 

transitioned to the 2020 standards for Professional Master‟s Programs, the language changed from a 

direct statement surrounding cultural competence education to: “Communicate effectively and 

appropriately with clients/patients, family members, coaches, administrators, other health care 

professionals, consumers, payors, policy makers, and others” (CAATE, 2018). This reduction in the 

specific language was intended to be taken in the same spirit as previous versions of the content 

standards.  

While cultural competence education has been deemed a necessity within health care education 

programs, limited research exists on cultural competence education and curriculum implementation. 

This project seeks to determine the current practices in educating a population with limited diversity to 

provide culturally competent care to patients of all racial/ethnic backgrounds. Our main questions 

included: How important do academic instructors feel cultural competence education is to the 



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profession of athletic training, how competent do academic instructors feel in delivering cultural 

competence education to athletic training students?, what barriers are seen in the delivery of cultural 

competence education within an existing athletic training curriculum?, what implementation strategies 

are currently being used in the delivery of cultural competence education within athletic training 

education? These research questions include both the didactic and clinical aspects of an education 

program.  

 

2. Method 

To best understand the different approaches that Athletic Training Programs (ATPs) are utilizing to 

educate students in cultural competence, the researchers selected a qualitative approach. This method 

allowed for rich, quality discussions in individual interviews. Confidentiality was ensured to capture 

personal thoughts and candid responses by informing participants that neither they nor their institution 

would be identified. All participants reviewed and gave verbal informed consent that was approved by 

an institutional review board. Two researchers with expertise in qualitative research design conducted 

all interviews. Nine of the 10 interviews occurred over the phone, and one occurred in person and 

lasted an average of 60 minutes. Interviews were preceded by a demographic questionnaire that 

included institutional and personal demographics, as well as a question designed to allow participants 

to indicate their level of perceived confidence in the delivery of cultural competence education on a 

Likert Scale from 1-5. Semi-structured interviews were guided by the questions identified in Table 1. 

 

Table 1. Interview Questions 

Questions 

1) What is your definition of cultural competence? 

2) Do you feel that cultural competence education is an essential component of an ATP and why? 

3) What are the methods you are currently utilizing to educate your students in cultural competence 

in the classroom? 

4) What are the best methods you are currently utilizing in the clinical setting to educate your 

students in cultural competence? 

5) What in your program assists you in cultural competence education? 

6) What in your program hinders your cultural competence education? 

7) Do you feel that your current clinical instructors/ preceptors are well educated in cultural 

competence and able to demonstrate this to your students? Why or why not? 

 

Interview questions were created and agreed upon by the research team based on current literature in 

cultural competence as well as in athletic training education prior to the solicitation of participants.  

 



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2.1 Participants 

An a priori data saturation of faculty members from various athletic training programs from various 

institutional types and from across the country was set to establish geographical and institutional 

diversity. This target was met with 10 faculty members (four male, six female), representing 

institutions that spanned from undergraduate private religious to public doctoral research institutions 

and represented six of the ten NATA membership districts. Participants were not selected based on 

their cultural competence education experience, as they were meant to be representative of the larger 

population of athletic training educators. The full distribution of participants can be found in Table 2. 

The average number of years of teaching experience was 13.6±7.41.  

 

Table 2. Participant Demographics 

Pseudonym Gender Years Teaching
#
 Institution Type

**
 NATA District 

Cathy Female 6 Private UG- HBCU 3 

Jessica Female 4 Private Masters LP 5 

Mary Female 24 Public R3 2 

Patti Female 13 Public R2 5 

Ryan Male 13 Private R2 5 

Sam Male 21 Public R3 8 

Sarah Female 23 Public Masters LP 1 

Steve Male 14 Public Masters LP 2 

Theresa Female 14 Public Masters LP 5 

Tim Male 4 Public Masters MP 9 

Note. R2: Higher research activity. LP: Large program (annually awarding 200+ masters degrees). MP: 

Medium program (annually awarding 100-199 masters degrees). UG-HBCU: Undergraduate Programs- 

Historically Black College or University. 

**Based on the Carnegie Classification of Institutions of Higher Education. 

#Years teaching in athletic training education. 

 

2.2 Data Analysis 

Quantitative data was analyzed by SPSS 23.0. The data analyzed included years of teaching experience 

and the self-rated item of perceived abilities. Qualitative data were transcribed and coded by a team of 

three experts using general inductive method of analysis (Thomas, 2006). Main themes were identified, 

data were categorized, and conclusions were formed using the constant comparative analysis method is 

“based on suggested techniques to ensure trustworthiness of the study” and utilized the stages of 

analysis as dictated by Brown et al. (2014). The team of experts first familiarized themselves with 

current literature on cultural competence in athletic training education and agreed on common words 



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and statements (Brown et al., 2014). Second, they each independently read the data and coded themes. 

The team then met to discuss and reach a consensus on overall themes. Fourth, they separately read and 

categorized statements or segments into the agreed upon themes from the previous meeting. Finally, the 

team discussed and reached a consensus on the coding for each statement or segment. Member checks 

were utilized throughout the process by discussing interpretations of themes and statements with 

members of the original participant groups.  

 

3. Result 

The four major themes that were identified within the data are: 1) Barriers to academic implementation 

of cultural competence education, 2) Strategies to incorporate cultural competence education into an 

existing curriculum, 3) Barriers to clinical implementation of cultural competence education, 4) 

Strategies to effectively incorporate cultural competence education into the clinical setting. Each of 

these themes is explained below, including supporting and explanatory quotes. Pseudonyms were used 

to protect the identity of participants. 

3.1 Academic Implementation Barriers 

Overarching barriers to academic implementation accounted for 22 different comments within the data 

and included subthemes such as: lack of diversity within the staff, institution, or surrounding 

population; discomfort in addressing the topic due to lack of perceived abilities; perceived ignorance as 

to how to incorporate cultural competence education; and time within the curriculum to implement 

material. 

It was stated by multiple subjects that the diversity students encountered on their campuses was limited, 

with the academic program of athletic training often times hovering right at or below the campus wide 

percentage.  

Sarah commented: 

“I think one of the things that hinders would just be looking round at the faculty which we 

have, we‟re all white… although I‟m probably a bit more sensitive to issues because of my 

personal life, I can‟t know everything there is to know and I still carry my own stereotypes 

with me. It‟s not reflective in the people who study athletic training. We are still pretty much 

heavy white English speaking individuals who are studying it and my assumption is that we 

probably have the same reflection in the faculty who are teaching it and so knowing that the 

population is going to be shifting, we are going to be providing services and healthcare to a 

population that in some ways will be different of who we are and hence the some reason it‟s 

imperative that we reach out and make sure we understand it, not just because that‟s what‟s 

going to be happening as far as the demographics but because that‟s the right thing to do. 

Another barrier that was discussed and presented as a consistent theme throughout the interviews with 

participants was the discomfort in addressing the topic due to a perceived personal lack of abilities. 

This was seen in both the statistical analysis of the Likert scale abilities score where the average 



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response for a Likert scale 1-5 question was a 3.15±.75 and in comments made by participants. Ryan 

commented, “This isn‟t something that people, in athletic training at least right now… where no one 

talks about this out loud”. 

Jessica added: 

“I think the first step is me taking an active role in how to figure that out and then educating 

our preceptors and our other instructors on how to incorporate it as well, not necessarily 

dictate on that they do that in their classroom but encourage it... and give them tools to use on 

how to incorporate it”. 

An additional component that many stated as a barrier to implementation of cultural competence was 

having the time within the curriculum to address the topic. 

Sam stated: 

“What a lot of people would say is „Time‟, how can I fit this in and I think also, the other thing 

that has hindered is getting other people in your program to understand the importance of it 

because I think some people, you need to get the „buy in‟ and for some people they feel as 

though students will learn these things through experience, and yes they will get better through 

experience but I think they need a foundational understanding just like anything we teach 

them”. 

While barriers exist, the underlying theme to the discussion was the realization that if cultural 

competence is not addressed, it can lead to major problems down the road.  

Mary stated:   

“If we can‟t teach students to filter or be aware of the sensibilities that certain people are 

operating under, then we don‟t know what buttons might be pushed when working with them 

that can cause major damage to the professional relationship that we are trying to cultivate”. 

Tim commented: 

“[It‟s] Essential the idea of bringing in not only other cultures in your athletic training 

program, but within in the realm of athletic training in general, how to interact with other 

cultures so we can treat more effectively, treat more accordingly” 

3.2 Academic Implementation Strategies 

Academic implementation strategies encompassed a wide range of ideas totaling 38 different 

suggestions within the data; however, a major subtheme was weaving cultural competence education 

throughout the entire curriculum, which accounted for 13 of the 38 suggested implementation strategies. 

An idea expressed by multiple subjects was the option of having subscribed implementation method; 

however, it was suggested more as a way to help educators to weave cultural competence into multiple 

areas of a curriculum over time. 

Steve stated: 

“It almost seems like it‟s one of those things we need to learn some foundational information 

about but we also need to think about it through our entire curriculum. It‟s almost like the way 



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we look at writing at this point, it‟s not just something you do in an English class, it‟s 

something that goes throughout the curriculum”. 

Cathy added: 

“You have to integrate your cultural competency through everything they do. That‟s why we 

talk about it in Gen Med and eval. And we talk about it in the clinical classes. It isn‟t a 

stand-alone anything because in practice it‟s not a stand-alone anything. You have to be 

culturally competent in everything you do”. 

Actively working to vary in-class examples was discussed as a way that these educators were already 

incorporating cultural ideas into their current curricula. These ideas included such ideas as: finding 

ways to incorporate a wider range of cultural backgrounds into visuals and in-class scenario examples 

and addressing cultural issues in specific discussions to create a rich dialog.  

Theresa gave the example: 

“In all of my examples, not just present pictures of a Caucasian male when I‟m talking about a 

male, I try to show different races, different genders, different skin types in the pictures so that 

people can understand not every bruise is black and green or black and yellow or blue and 

yellow. Different skin colors show up differently, so, just hitting up on the things like that”. 

Sarah replied: 

“I have them [students] write a little reflection piece up to say what did you learn from this? 

And we learn about stereotyping and we dialogue in class, where do we get it from and how 

do we change those „tape record messages‟ that have given to use through family, church, 

media, etc. Trying to get us to, whenever we bring up examples in the classroom, try to make 

sure that we bring up specific examples that might hit on a specific population in”. 

3.3 Clinical Implementation Barriers 

Overarching barriers to implementation of cultural competence education in the clinical setting 

accounted for 23 different comments within the data and included subthemes such as: current lack of 

diversity in both preceptor and treated populations, lack of cultural competence in clinical staff, and 

lack of focus on cultural competence education as a goal within clinical education experiences.   

It was stated by multiple educators that the amount of diversity most students encountered on their 

campuses and within their clinical rotations was limited, especially due to the regional area in which 

they were housed. Institutional demographics seemed to play a large role in the diversity of the treated 

population and subsequent preceptors to which students were assigned. 

Patti commented: 

“We don‟t have a lot of diversity, we are very rural in a lot of things we do… we‟re very small 

town people compared to some of the things that people are exposed to out on the coast”. 

Theresa said: 

“We‟re not a very diverse program, college, or even the larger community is not very diverse. 

So it‟s sometimes hard to go out and find those examples because everybody is serving as a 



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mentor for students or a preceptor for our students”.   

Jessica stated: 

“Because the sites we use are highly Anglo-Saxon. We use 3-4 public high schools who serve 

a pretty affluent community and then we use two private high schools who are very affluent 

communities”. 

Cathy was able to give a unique aspect to this particular barrier to cultural competence education within 

their program housed at a Historically Black College/University (HBCU): 

“There is a private high school, high SES [socio-economic status] students in our area and 

they‟ve actually been one of the biggest supporters of our program, but it definitely means that 

my African American students on campus where they are the only African Americans, often 

times, for miles, when they cover these games”.  

The idea was expressed by many that there was a focus to attempt to diversify the clinical experiences 

of the students to allow for exposure to a wide range of patient populations and preceptors. The 

participants indicated that the challenge in this was that the demographics of the program preceptors 

matched fairly closely to the demographics of the surrounding area in the lack of diversity. 

Theresa responded: 

“They do their best, but again they are in a non-diverse setting themselves. So many of them 

came from settings that are non-diverse, so they‟ve never had the real world experience with 

differences”. 

Mary said: 

“They [students] struggle and that‟s okay because I wasn‟t them to struggle and I want them to 

know what if eels like to perhaps be uncomfortable and trying to get the frustration of, I don‟t 

speak the language of this person, how can I help them? The reality is that, in some of our 

school districts, we do have some people who are speaking languages that the athletic trainer 

doesn‟t know and the whole thing then is, how do we handle this?” 

Another barrier to cultural competence education was that many participants indicated that there was a 

lack of cultural competence in the preceptors that are used by the programs. One participant in 

particular, Mary, gave a very poignant example of this barrier. 

“None of our preceptors are fluent Spanish and some of them have been in that job for 10-12 

years now. Over that time it hasn‟t been important enough to really learn the language and as 

you know the last person to get a translator is the athletic trainer later in the afternoon, that‟s 

one of the issues and they‟re not seeing that and I try to tell them it‟s critical that you get an 

understanding of what the problems are because if you miscommunicate or things are not 

followed because there was a communication issue whether it was language or culture 

language, that‟s come back on you, you‟re gonna bear the brunt of that legal decision even if 

we don‟t talk about outcome”. 

 



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One participant, Cathy, was once again able to add a unique challenge that she is facing at a HBCU 

institution that was not seen in the challenges indicated by others. 

“I‟m really struggling to change the language, because students speak their own slang or 

whatever and they take that with them to the clinic ad so we‟ve really been working to try and 

get them to speak proper English and use the correct terminology and to them it‟s a fine line 

because they identify so much with the way they speak and you‟re trying to get themselves to 

present differently… We‟re really struggling because you don‟t want to stifle them, we‟re 

trying to be sensitive to them and yet we know hoe that medical presentation comes across. 

For us, on this side, it‟s how much do you insist on this and how much do you change 

behavior when really we‟re talking about cultural issue on their side? It‟s been an interesting 

dynamic that I haven‟t faced before”. 

The third and final barrier identified was a lack of focus on cultural competence education as a goal 

within the clinical setting. This was indicated to be both on the part of the program disseminating 

information to the preceptors and on the part of the preceptors taking the initiative to do so themselves. 

Sara offered: 

“What are their perceptions of the level of cultural competence of their preceptors? Much of 

the responses that I received was that they felt that they were fairly culturally competent and I 

said, based on what? How often do you know they do XYZ? Oh, I don‟t know that. I agree, 

there needs to be more that‟s done as far as education, so what does that mean?” 

Jessica commented: 

“I think from a professional scale, I think we‟re trying to get there but I would say 

professionally I think there are a lot of things that people are like what does that actually mean 

and I could say that probably the EBP [evidence- based practice] people think that seems silly 

and say Ok, what do you want me to do about it? But I would also feel like cultural 

competence from a professional level we are at that point. Ok, I know it‟s an important thing, I 

know I should be worried about it but I don‟t really understand what it is, how to do it, how to 

incorporate it, how does it fit into my practice. I think if you were to ask a lot of clinicians, 

they would say well, I treat everyone the same, I treat everyone medically how they need to be 

treated. I think they would feel that they feel they were culturally competent”.  

From an academic faculty perspective, many participants also addressed the lack of focus on cultural 

competence education on behalf of the program to the preceptors. 

Tim commented: 

“I can‟t necessarily say, even as the clinical coordinator, that I spend time talking with my 

preceptors about how to incorporating that into their student education”. 

Jessica responded: 

“I think there are ways to incorporate it into our clinical but again right now if you ask me 

how to do it I would say I don‟t know. I think the first step is me taking an active role in how 



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to figure that out and then educating our preceptors and our other instructors on how to 

incorporate it as well, not necessarily dictate on that they do that in their classroom but 

encourage it...and give them tools to use on how to incorporate it”.  

Theresa offered: 

“I would definitely need help and guidance on how to do that [cultural competence education 

in clinical setting], especially in a low diversity type of environment. I don‟t know how to 

achieve that, but I would embrace putting into our clinical settings if given examples on how 

to do it”. 

3.4 Clinical Implementation Strategies 

Various implementation strategies were suggested by the participants as ways to increase the amount of 

cultural competence education in the clinical experiences of their students. The most common recurring 

suggestion assumes an ideal situation where it would be possible to vary the clinical rotation location to 

include different cultural areas and patients of differing backgrounds. While previously indicated as a 

specific limitation based on the location of each institution, comments from our participants did speak 

to the effectiveness that the small amounts of exposure that programs were able to offer even within 

their given limitation. 

Mary commented: 

“We do have some sites where, as I mentioned before, we have high populations of different 

groups of kids and I‟m sure that the students are getting some of that from the preceptor. I‟m 

the clinical coordinator and one of the things that I try to do is to make sure they are getting a 

spattering of a lot of different things”. 

Tim said: 

“One big advantage is that we do have a Japanese athletic trainer and she has done a 

tremendous amount to help our students with understanding athletic trainers from other 

cultures”. 

Another implementation strategy suggested by participants is to encourage students and preceptors to 

have open and respectful discussions with patients from differing backgrounds. One participant, Ryan, 

spoke to the idea of open communication being important in interactions between patients and 

practitioners. “Five different athletes heard me say five different things, even though the words I said 

were the exact same”. 

He adds: 

“When we talk about preceptors in the rehabilitation clinic and orthopedic center, I think they 

[preceptors] probably do [address cultural competence education]. I don‟t think they use the 

terminology, but I think they model it because they work with all different types of patients in 

different situation”. 

 

 



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Sam comments: 

“It‟s important for my students to see from a clin ed perspective, when we do have African 

Americans or even Caucasians that aren‟t responding in a cultural norm way in regards to pain 

or treatment, that I talk to them about it‟s more than just looking at this person as they‟re not 

„sucking it up‟ like other people do, there is cultural influences going on in here”. 

Perhaps the most profound commentary on the importance of communication and having respectful 

conversations revealed in the data came from one participant in particular. 

Sara commented: 

“Relationship is important, that‟s an ingredient and it‟s important to have good relationships. 

That takes an appreciation of the other person, the individual. In order to appreciate that 

person, I have to appreciate their culture and their perspective on things”. 

 

4. Discussion 

The findings of this study are similar to those in other healthcare professional programs, in that there is 

very little consistency in the implementation of cultural competence education among athletic training 

programs for various reasons. Most state that time for implementation and lack of strategies or ideas on 

how to implement are the biggest barriers to providing quality cultural competency education for their 

students. This has been followed by reports of lack of diversity within both the staff and the reported 

patient populations at various institutions.  

The subjects interviewed for this study possess an average of 13.6±7.41 years of teaching experience 

within athletic training, though when asked on a scale of 1-5 how they perceive their abilities to 

incorporate cultural competence into their education programs, the average response was 3.15±.75. 

This has shown us that most educators that are required to implement cultural competence education 

into athletic training programs do not feel confident in their abilities to do so. Certain participants in 

this study have called for more prescriptive means of implementing cultural competence education, 

though it seems unlikely that this will occur in the near future given the higher need for institutional 

autonomy. 

Strategies for implementation of cultural competence education were given, mostly from those with 

higher self-reported perceived abilities, but all included the major subtheme of implementation over 

time. This idea accounted for 13 of the 38 implementation strategy suggestions given by participants, 

and the majority of the participants interviewed in this study indicated that they are currently working 

to weave cultural competence education into the overall curriculum at their respective institutions and 

not attempting to address the topic all at once. This strategy is already being used within athletic 

training education to demonstrate integration of material at multiple points in the curriculum for almost 

all other required skill content areas. Strategies given by participants include diverse examples used in 

class settings to provide a visual consideration of diverse patient populations, reflections on personal 

biases related toward different cultures, and open discussion on the subject of diversity and how it 



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might impact injury and performance outcomes.  

In both medical education programs and nursing education programs, we are able to see an approach to 

cultural competence education that is more similar to our findings within athletic training (Long, 2012; 

Betancourt & Cervantes, 2009). In an article done by Betancourt and Cervantes (2009), implementation 

strategies show integration throughout the existing medical curriculum at many different points. Their 

focus was three pronged; first by introducing concepts to change the attitudes of their students, second 

by giving more information to increase the knowledge of the student in relation to culture, and third to 

integrate that knowledge into applicable scenarios and critical thinking skills (Betancourt & Cervantes, 

2009). The approach for nursing is similar, focusing on communication and scenario based knowledge 

application (Long, 2012). The implementation strategies given by the majority of the athletic training 

participants indicate that they follow a similar approach, first by introducing the topic and allowing the 

examination of biases, second by imparting knowledge that would help to increase understanding of 

cultural norms, and third by the use of varying case studies or in class examples to include cultural 

aspects, as well as the use of cultural aspects within clinical skills assessments. However, also similar 

to our field, Betancourt and Cervantes (2009) give no measurable assessment to their implementation 

strategies. 

Within the research in the field of health care education, there is an ever-growing viewpoint that a 

clinical immersion experience within another culture as the best way to increase cultural competence in 

health care education (Long, 2012; Lipson & Desantis, 2007). It would stand to reason that greater 

exposure to a culture other than your own would increase cultural awareness and allow for adoption of 

cultural norms that would allow an individual to be fully functioning within that society. Within 

nursing programs across the country, a clinical immersion experience in a different cultural setting is 

becoming more and more common, though there is limited ability in measuring the impact this 

experience has on professional practice (Long, 2012; Lipson & Desantis, 2007). Certain athletic 

training programs are attempting to offer a similar experience to a small number of students, though the 

increasing difficulty of finding a supervising clinician outside the United States has been reported to 

greatly hinder the process.  

4.1 Limitations and Suggestions for Future Research 

Though the researchers attempted to be as varied as possible and capture the perspectives of educators 

from many different areas, backgrounds, and institutional types, this research does not encompass the 

entirety of approaches to cultural competence education within the field of athletic training. Though 

there are many similarities in barriers and implementation strategies from the participants included in 

this study, the possibility exists that unique and personal experiences within cultural competence 

education are not addressed within the content of this article. Further expansion on the research topic 

with a larger number of participants might yield different results.  

 

 



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In a similar need for additional research, the effectiveness of implementation strategies has also not 

been explored to this date. While many helpful examples are given, measurements and assessments are 

in the infancy of development within athletic training and similar health care fields (Betancourt & 

Cervantes, 2009; Lipson & Desantis, 2007). Assessment tools tend to focus on the perceptions of 

cultural competence or cultural awareness within students as measures of perceived levels of cultural 

competence (Maurer-Starks et al., 2008; Volberding, 2014, 2015). Further research is also necessary to 

measure not only the effectiveness of the implementation strategies given, but also to develop a 

measure for integration of cultural competence education concepts into clinical practice.  

 

5. Conclusions 

As the population of the United States continues to diversify, the AT profession must be prepared to 

encounter and effectively communicate with a patient population that could be much different than our 

own. As educators, particular emphasis has been placed on the need to incorporate cultural competence 

education into existing curricula, regardless of our comfort level in doing so. Limitations and barriers 

have been shown to exist in all areas of the country, with certain institutions hosting unique 

circumstances that might further complicate the ability for educators to increase cultural competence to 

the level they feel appropriate. Suggested implementation strategies have been given to help those in 

the field navigate and possible incorporate a greater level of cultural competence education into an 

existing curriculum, though further research is needed to show the effectiveness of such strategies. As 

we continue to make cultural competence education a priority in our education programs, we as a 

profession can continue to strive to provide a high quality patient care experience to every individual, 

regardless of cultural background. 

 

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