- Report Published -
|Study of the Regulation of Athletic Trainers|
|Department of Health Professions|
|SJR 122 (Regular Session, 1998)|
Senate Joint Resolution 122 of the 1998 Legislative Session of the Virginia General Assembly requested the Board of Health Professions to conduct a study to determine whether athletic trainers should be regulated and, as part of the study, to determine the fiscal impact of such regulation.
SJR 122(1998) was patroned by the Honorable R. Edward Houck at the request of the Virginia Athletic Trainers Association. The chief concern prompting the study was that the role of the athletic trainer has become increasingly significant to the safety and well-being of an expanding number of physically active individuals, including minors. Although private credentialing exists, such certification is not mandatory, and athletic trainers who are not nationally certified may have no particular education or training qualifications. This lack of regulation may pose a threat to the public in that athletic trainers are often the first responders to injuries at sporting and training events and must often make immediate, independent judgments as to the severity of those injuries.
To govern the conduct of the study, the Board employed the formal criteria and policies referenced in its publication Policies and Procedures for the Evaluation of the Need to Regulate Health Occupations and Professions, 1998. The methodology used included a review of the policy literature, of the current federal and state laws and regulations, of other states’ disciplinary experiences, and of public comment. Also, it has been the Board's experience that anecdotal information is often plentiful, however, usually little objective information exists concerning the risk of harm posed by professions which are not state regulated. Given this, the Board has sought a more objective way to assess the potential for harm posed by the practice of athletic training. A newly developed research technique for sunrise review -- criticality scaling -- was instituted in this study. The criticality scaling methods employed assessed the risk of harm posed by incompetent performance of the tasks that an entry level nationally certified athletic trainer should be competent to perform. Also reviewed to evaluate potential risk was the available information concerning medical malpractice cases involving athletic trainers and the available information used by major malpractice insurance carriers to assess the risk of harm posed by a profession.
The literature review was divided into five areas: (1) What is an Athletic Trainer?, (2) States’ Regulation, (3) Other Professional Groups, (4) Previous Board of Health Profession’s Sunrise Reviews on Athletic Trainers, and (5) Current Issues.
The professional credentialing association of athletic trainers is the National Athletic Trainers Association (NATA). They define the role of the athletic trainer as “preventing, recognizing, managing and rehabilitating sports injuries.” (NATA 1997, 1998). To obtain NATA certification, athletic trainers must fulfill requirements established by the National Athletic Trainers Association Board of Certification, Inc. (NATABOC) including its national credentialing examination.
The examination is comprised of five practice areas (i.e., content domains) resulting from the latest role delineation study conducted in 1995. The content domains are as follows: (1) prevention of athletic injuries, (2) recognition, evaluation and immediate care of athletic injuries, (3) rehabilitation and reconditioning of athletic injuries, (4) health care administration, and (5) education and counseling. Each of these content domains is broken down further into constituent tasks.*
Prior to being allowed to sit for the examination, national certification standards require that graduates of accredited programs complete their program within two years, complete at least 800 hours of athletic training experience, and receive their bachelors degree from the college or university where they completed their program. Those who have not completed an accredited program must complete additional supervised experience and meet specific course work requirements as detailed on page 5 of the report. Accredited programs exist at Old Dominion University, University of Virginia, and James Madison University.
Of particular note is that of the estimated 900 athletic trainers in Virginia, over 500 are NATA certified. However, there are no reliable statistics on the geographic distribution or practice type distribution for athletic trainers in Virginia.
Currently 37 states regulate athletic trainers to some degree. Each regulating state defines athletic trainers or athletic training in statute. Appendix 6 provides details.
Other professional groups exist which are related to but distinct from athletic trainers. They include professional trainers, fitness professionals, and special populations’ trainers. Such complementary groups were excluded from the current study.
Athletic trainers have actively sought state regulation during the past fourteen years, and the Board of Health Professions conducted sunrise studies on three occasions, in 1984, 1986, and 1990. Each time, the Board determined that there was insufficient need for State regulation.
Since the 1990 Board study, certain issues have emerged regarding the environment in which athletic trainers practice which was considered by the current Board. For the general population overall participation in sports and other strenuous activity has increased substantially. This is true particularly for minors, women, seniors, and special needs athletes.
Children and adolescents posed a particular concern for the Board because of their vulnerability due to their minor status. Currently, it is estimated that 35 million minors (6 to 21 years) participate in sports in the United States. This figure is up from 20 million in 1991. Sports injuries account for the second largest health care expenditure for injuries in this age group. Injury rates for girls are estimated between 20 to 22% for girls and 39% for boys per season. The growing involvement of children in organized sports and fitness activities has been accompanied by not only increased numbers but by new types of injuries, particularly musculoskeletal in training situations.
The empirical evidence examined by the Board included disciplinary data from other states that regulate athletic trainers, criticality rating results, malpractice insurance information, and actuarial prediction data sources.
Disciplinary data for 1996 and 1997 was gleaned from 36 of the 37 regulating states. North Carolina was excluded because it has just begun to regulate athletic trainers this year. Page 10 details the results of the Board's survey. Twenty-three states (63.8%) responded. Twelve states (52.1% of responders) indicated that they had taken no disciplinary action during the two years surveyed. However, Illinois, Ohio, and New Mexico reported double-digit complaints and disciplinary action. Across states, the prevailing cause for action was unlicensed activity. However, New Jersey reported discipline for a case of substance abuse.
From several analyses of the criticality ratings, several consistent findings resulted.** A panel of experts judged the likelihood of various types of injuries resulting from the practice of athletic training practice to be significantly higher for the “incompetent”(i.e., uncertified) vs. “competent” (i.e., nationally certified) athletic trainer. For example, when the results for all content domains were combined, the probability of a severe injury resulting from an “incompetent” athletic trainer’s practice was judged to be 8 times more likely than that resulting from a “competent” trainer. When examining the results of individual Domains, the panel judged the largest probability for harm to occur in Domain 2 – Recognition and Evaluation of Immediate Care Tasks. Here the “incompetent” trainer is viewed as being 7 times more likely to inflict minor injury (54% vs. 8%), 9 times more likely to inflict severe injury (27% vs. 3%), and 8 times more likely to inflict serious injury or death (8% vs. 1%) than the “competent” trainer. When examining individual tasks within Domain 2, it was clear that tasks which require the application of judgment, life threatening situations or death were judged to be 10 to 20 times more likely for the “incompetent” vs. “competent” athletic trainer.
Under current law there is no requirement for athletic trainers to carry liability insurance. However, athletic trainers may obtain individual liability coverage; some may obtain limited group coverage for a limited scope of duties. Actual data on specific claims in Virginia from 1990 forward was sought but was deemed to be proprietary by the insurance carriers. However, the Virginia Athletic Trainers’ Association was able to obtain national claims status data from injuries incurred from 1990 forward. OF 39 claims, 11 resulted in payment. The largest disbursement was for $45,717 while the smallest was for $622. Also included in the data obtained by the Virginia Athletic Trainers’ Association is a sample description of loss for open claims.
Part of the current study’s requirement is a discussion of the fiscal impact that regulation of this group may pose. Absent reliable information on the geographical and employment type distribution of athletic trainers in Virginia, a straightforward empirical assessment of fiscal impact was not deemed practical.
However, in an attempt to afford the Board with an actuary’s insight into how to economically quantify risk of harm to the consumer posed by a particular profession, the Board secured the services of an actuary. For the current study, the most salient excerpts from his report are provided in Appendix 10. It is clear from his analysis that the available data on risk assessment are not tailored to specific professions, but must be expertly extrapolated from a variety of sources to obtain a useful picture of the risk landscape relevant to the profession in question. Further exploration of this method of assessment was advocated.
Both oral and written public comment was received. Appendix 11 contains the written comment and a summary of speakers’ comments.
The Board’s Regulatory Research Committee met on September 14, 1998 and considered a broad range of policy options resulting from its analysis of the research presented. The options discussed included required licensure, mandatory certification, registration, and no change in the status quo. The following recommendations of the Regulatory Research Committee were adopted by the full Board of September 15, 1998, with the Board’s bolded modifications:
To ensure that the public is not misled by titling, the title “Athletic Trainer,” “Athletic Trainer Assistant,” or “Trainer” should be restricted through statutory certification to those who are certified by the National Athletic Trainers Association. No restriction should be placed on the scope of practice of other state regulated health care providers. The title “Athletic Trainer” is to be reserved to those adequately trained.
Certification should be mandatory for those individuals who engage in the tasks in Domain #2 – Recognition, Evaluation and Immediate Care of Athletic Injuries (see Appendix 5), who do not have immediate, direct, on-site supervision of a licensed health care provider, and who provide athletic training to minors 21 years of age and younger. No restrictions should be placed on the practice of other regulated health care providers provided that they are practicing within the scope of their professional license.
The Board of Medicine should be considered as the appropriate Board to regulate athletic trainers.
The regulating Board should have the discretion to vary from NATA or NATABOC in setting educational, examination, and experience requirements for entry.
A modified grandfather clause should provide a period of one year for individuals who are not currently nationally certified to meet the national certification requirements. Such persons must first have a bachelors degree in athletic training from a NATA accredited program. The modified grandfather provision should incorporate the requirements for educational experience explained in the report section “What is an athletic trainer?” on pages 4 and 5. Further, the determination of what constitutes meeting those requirements should be a matter for the regulating Board to resolve.
*It is these content areas and specific tasks that were rated for potential for harm. See the report section entitled, Criticality Rating Methods and Results for further information.
**The use of criticality scaling to provide empirical evidence for sunrise review is groundbreaking in this study. Because of this, the report goes into some detail regarding the specific methodology employed and a critique of the same. The detailed findings are outlined on pages 11 through 15 of the report and in Appendix 8.