Understanding Patient Trust in the Athletic Setting through Interviews

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Dedicated to allied health professional practice and education

Vol. 16 No. 2 ISSN 1540-580X

Understanding Patient Trust in the Collegiate Athletic Training Setting: Findings

from Interviews with Patients and Athletic Trainers

Shannon L. David, PhD, ATC

John H. Hitchcock, PhD

1. North Dakota State University

2. Indiana University – Bloomington

United States

ABSTRACT

Background: Trust is a vital component of the patient-clinician relationship, yet little is known about trust in the athletic training

(AT) profession. Purpose: The purpose of this qualitative study was to define and understand trust in a collegiate athletic training

setting. Methods: Interviews with Division I student-athlete patients (n=9) and athletic trainers (n=3) were conducted to collect

data about participant views and definitions of trust. Data were analyzed using classical and constant comparison techniques; the

trustworthiness of findings were assessed via peer debriefing, member checks, and reflexive journaling. Results: The analyses

yielded 21 codes and four themes described to promote trust: 1) athletic trainers’ attributes, 2) interactions between athletic trainers

and athletes, 3) the quality of this relationship, and 4) the overall experience. Conclusion: A working definition of trust in the

collegiate athletic training setting was developed via this work. Athletic trainers and patients agreed that trust is a complex construct

but is vital to developing a productive therapeutic relationship.

INTRODUCTION

Several studies have established that patient adherence to treatment plans tends to increase as the quality of their relationship

with health care providers improves.

1-5

Health care providers can promote the quality of these relationships by following a patient-

centered approach. This approach requires health-care providers to account for patients’ feelings and perceived needs.

6,7

There

are five components to the patient-centered approach: 1) explore patient treatment preferences, 2) attempt to understand patients

in a holistic manner (e.g., considering their mind, body, and spirit), 3) include a prevention component into each visit, 4) purposefully

focus on improving or maintaining a positive relationship with patients, and 5) make intervention approaches as realistic as possible

while helping patients see obtainable outcomes.

Overall, the combination of these components should promote trust between

health care providers and patients.

The connection between relationship quality, trust, and treatment adherence is also considered via the Primary Provider Theory

(PPT).

Supporters of PPT argue that trust is associated with patient adherence.

1,8

Finally, the connection between trust and

treatment adherence has been established in multiple physician-based settings.

9-11

Indeed, trust has been evaluated in other health

professions including nursing, psychotherapy, and emergency medicine.

14-17

Trust, or lack thereof, can be a critical factor in

treatment delivery and participation, and further study of this connection is warranted.

12,13

Trust and its relationship to treatment

adherence (and treatment outcomes) have not, to date, been empirically studied in athletic training (AT) even though others have

suggested that the link is worth investigating.

The purpose of this study was, therefore, to develop an initial, working definition of

trust in AT, as well as to explore factors that appear to be related to developing a trusting relationship. It is reasonable to expect

that the basic connection between trust and the quality of an AT relationship will influence treatment fidelity, just as it does in other

healthcare professions.

7,17,18

Understanding Patient Trust in the Collegiate Athletic Training Setting: Findings from Interviews with Patients and Athletic Trainers 2

METHODS

A flexible and emergent data collection approach that allowed the researcher to follow the respondent’s lead was utilized because

of the expectation that patient viewpoints about trust would not be easily elicited or readily reduced to a few quantifiable variables.

A series of semi-structured interviews regarding trust were conducted, and analyses were guided by Grounded Theory techniques

specifically using classical and constant comparative analyses.

19-21

Participants

Twelve participants engaged in semi-structured interviews (n=9 patients; n=3 athletic trainers). Patients were recruited through a

university listserv, while athletic trainers were recruited through a random sample of emails provided by the National Athletic

Trainers’ Association. The goal of including both types of study participants was to cross-reference the AT’s perceptions of trust

with those of patients. For a patient to be included, they were required to be a Division I collegiate athlete and had to have received

services from an athletic trainer. Athletic trainers were selected if they provided AT services in a collegiate setting. Respondents

were recruited and interviewed until qualitative data saturation—the point at which new information was likely to be redundant—

could reasonably be claimed.

23,24

Guest et al suggest a sample size of 12 is typically adequate for understanding the perceptions

of a group in a given context and this general guidance was deemed appropriate for the study.

Procedures

Interview questions were developed by the first author who has eight years of AT experience, professional licensure and

certification, a graduate degree in the field, and who has already completed pilot work on the subject. The first author also had a

history of being a collegiate student-athlete who received AT services. The interview questions were developed following general

information from Patton

including: ask open-ended questions, use jargon that demonstrates experience in the field, distinguish

between behaviors, experiences, opinions, values, feelings and emotions, knowledge, and sensory information.

The questions

were vetted with a research methodologist who had expertise in interview protocol development and three other experienced,

university-affiliated athletic trainers. Probing was used during interviews to develop full explanations of trust and how it influences

participants’ behavior in AT settings.

Participants, both ATs and patients, were also asked to think out loud about treatment

scenarios and their experiences in the past. Interviews were conducted in a private office, were recorded using a digital recorder,

and were later transcribed verbatim for analyses in a two-month timeframe. This study was approved by the university institutional

review board.

Credibility Techniques

Five credibility techniques were used in this study.

27,28

First, level one member checks were used, in which participants reviewed

the accuracy of raw transcript data to verify information accuracy.

Three patients and two athletic trainers who completed the

interviews were randomly sampled from the participant pool and reviewed their interview transcripts for overall accuracy. No serious

errors were noted. Second, two researchers independently analyzed the transcriptions to assess the reliability of thematic

development. They demonstrated a high agreement rate. In cases where a minor inconsistency was noted (across approximately

20% of the themes), reconciliation was easily achieved. Third, findings were shared with other AT experts who were asked to

comment on whether statements about trust matched their understanding of theory and if the findings offered reasonable

extensions to AT practice. These experts did not question the validity of the findings and saw useful application in promoting a

better understanding of AT trust. Fourth, reflexive journaling was conducted by the primary investigator to help account for potential

researcher bias, which could yield inaccurate interpretations of interview data. Reflexive journaling is the process through which

the primary investigator documents personal thoughts and feelings about specific aspects of the research.

Such reflection is

thought to promote the identification and handling of a priori assumptions in an open manner while considering the presented

results. Finally, a negative case analyses, which entails a specific search for and accounting of any data that are not consistent

with overall results was conducted.

No specific examples of contrary data were found, so this technique was not formally applied.

Data Analyses

Each interview was transcribed verbatim and analyzed using both classical content (focusing on identifying codes and the number

of times they were used in analyses) and constant comparison analyses.

The latter analytic style is a systematic approach used

in Grounded Theory, in which open coding is used to collate data into segments and the researcher provides a descriptor

(sometimes referred to as “chunks”).

19,21

This was followed by axial coding that groups these segments into larger themes. Finally,

these segments were selectively coded to generate a framework for a theoretical analysis of trust.

19,30

As applied to the current

study, such refinement focused on developing a definition of trust. Coding of the transcripts, using the Atlas.ti software (Atlas.ti

Americas, Corvallis, OR), was completed by the primary and secondary investigators through label assignment of specific units of

data, organizing data into codes, and then into themes. Analyses were interpreted from theory and prior literature, such as literature

describing the patient-centered approach.

Understanding Patient Trust in the Collegiate Athletic Training Setting: Findings from Interviews with Patients and Athletic Trainers 3

RESULTS

Nine Division I collegiate athletes (n=4 females; 5 males; age: 21.89 ± 2.57) who participated in football, cheerleading, soccer,

cross country, basketball, and track and field at the same university were included in the study (Table 1). Three athletic trainers

(n=2 males; n=1 female; ages: 24, 27, 47) from the private clinic, collegiate, and high school settings were also interviewed.

Table 1. Demographics of Interview Participants

Participant

Minimum

Maximum

Mean ± SD

Patients

Number of years playing collegiate

athletics

3.11± 1.36

Total number of Injuries

3.27 ± 2.77

Most severe pain from an Injury

7.78 ± 1.5

Longest time spent with an AT on

treatment

1 week

1 year

0.311 ± 2.89

Athletic Trainers

Years of Experience

10.0 ± 12.16

Age

32.67 ± 12.5

Components of a Trusting Relationship

A total of four themes were summarized from codes and interview data: attributes, relationship, experience, and effort. These

themes relate to characteristics the AT either has (e.g., experience) or can control (e.g., effort) when building patient trust. The

themes are based on 21 codes with 14 that were a priori in nature, having already been established in other health care professional

literature. Seven codes were exploratory having been identified spontaneously during analyses. Table 2 summarizes the themes

and codes derived from this study, presents a frequency count of the times a code was identified in the data, sample quotes, and

references to associated literature on trust in clinical relationships. For an example, a code that fell within the attributes theme is

the athletic trainer’s clinical competence, which was used the most often (n=34) during coding, and defined by the researchers

during coding as a “belief that the therapist is current (with respect to AT practice) and knowledgeable.” Quotes from study

participants are provided in the next column (e.g., “…they always know like the names of everything [muscles, tendons, bones],

knows what areas and can like describe it …”). The example supporting the notion that clinical competence is a facet of trust that

has been identified by other studies published in the broad medical literature are cited in the last column. A priori codes are denoted

with a superscript “a” while exploratory codes are denoted with a superscript “b.”

Understanding Patient Trust in the Collegiate Athletic Training Setting: Findings from Interviews with Patients and Athletic Trainers 4

Table 2. Themes and Codes representing AT Trust

Theme

Code

Frequency

Explanation

Sample Quotes

Associated

Literature

Attributes

Clinically

Competent

Belief that the

therapist is

current and

knowledgeable

“…they always know like the

names of everything, knows what

areas and can like point it out and

everything.”

“I think um, ya know, the first step

to building a relationship is I would

have to say first and foremost [is]

they have to know what they’re

doing.”

Aragon et al

; Hall

et al

; Hupcey &

Miller

Attributes

Attentive

The AT was

described as

being attentive

to needs

“She was attentive to what I

needed and make sure I was

getting it as soon as I could..”

Thom et al

Attributes

Individualized

Care

Applying

individualized

professional

knowledge to

develop an

effective

treatment plan

“She would always make sure

everyone was good and like would

go to each and every person in

the training room…just to make

sure no one has anything.”

Bova

; Thom &

Campbell

Attributes

AT Confidence

ATs appear to

be certain about

his or her

actions

“You could tell they just weren’t,

well I guess that goes with

confidence, they weren’t really

sure, or you can tell that they

haven’t dealt with it before.”

Anderson &

Dedrick

; Radwin

et al

Attributes

Patience

The AT was

described as

patient when

providing

services

“I think she has a good sense of

patience when working with us.”

Thom et al

Attributes

Professionalism

Manner in which

the AT conducts

themselves in a

work setting

“I would say there is a level of

professionalism that must be met.”

Attributes

Knowledge of

Sport

Information and

skills directly

related to the

activity

“..if they know a little about the

sport that helps.”

“I would say that they should know

the sport cause then they’ll have a

better idea of what injuries are

most common and what is

happening on a daily routine [sic].”

Attributes

Education

Degree

completed and

status

I know I just needed to be

stretched one time and one of the

umm, undergrad trainers I don’t

know what their title is but they

didn’t know what to do [because

they are still learning] so level of

education is important.”

Understanding Patient Trust in the Collegiate Athletic Training Setting: Findings from Interviews with Patients and Athletic Trainers 5

Theme

Code

Frequency

Explanation

Sample Quotes

Associated

Literature

Relationship

Communication

An effective

exchange of

information

between the

patient and AT

“You can be really good at

diagnosing things and treating

things but if you’re not not very

communicative and you don’t

have that relationship, I think, you

could be good at what you do, but

we wouldn’t know [sic].”

Aragon et al

;

Bova, 2006

Safran et al

Relationship

Patient

Education

Providing the

patient with

systematic and

informative

information

“It [educating the patient] eases

you when they explain what they

[athletic trainer] are doing and

why.”

Bozimowski

“Someone would explain your

injury and explain your body like

why it happened and how it’s

going to heal [sic].”

Relationship

Nonverbal

Communication

Process of

receiving

information

through

wordless

message (i.e.

body language)

“It just made sense to me, having

good eye contact and really

listening.”

Henry, Fuhrel-

Forbis, Rogers, &

Eggly,

Relationship

Feedback

Encouraging

and targeted

reinforcement

“Positive and encouraging and I

like when they do exercises with

me.”

Relationship

Approachability

Being easy to

talk to and greet

“I think just the fact that they’re out

going. I mean they’re down to

earth people, they like to joke

around and stuff while you’re

getting treatment.”

“Be personable with you ya know.

They make it seem like their

people too not just doctors and

their working on you like you’re a

piece of machinery or something

[sic].”

Relationship

Reputation

Beliefs and

opinions held

about the AT

“Sometimes you get like uh locker

room lawyer type guys, that try

and they’re like oh they [AT] don’t

know what they’re doing.”

Mechanic &

Meyer

Relationship

Personal

Connection

Having a private

and individual

rapport with

each other

“Sometimes it’s nice when a

trainer talks to you like [you are]

not just talking to you about

injuries and everything. It’s nice to

have normal conversation so it

gives you like a feeling you’re still

human.”

Alexander &

Luborsky

; Thom

et al

Understanding Patient Trust in the Collegiate Athletic Training Setting: Findings from Interviews with Patients and Athletic Trainers 6

Theme

Code

Frequency

Explanation

Sample Quotes

Associated

Literature

Relationship

Team Work

Working

together to

reach goals

“I think it’s great when the AT can

communicate and work with coach

and tell him that he can’t go or

whatever.”

“I think anytime I need something,

my mother, sometimes she calls

and sometimes my mom has

questions and I can count on her

[athletic trainer] to work with her.”

Anderson & Kaye,

2009

Relationship

Fidelity

Having the

patient’s best

interest in mind

“…that they would actually care

and like get me healthy with my

best interest in mind.”

“I think if they show interest and

real care about me and

understanding what I’m going

through out there on the court.”

Hall et al

;

Mechanic &

Schlesinger

Relationship

Environment

Atmosphere &

Resources

“When you walk in there [athletic

training room] the equipment is

new and like the atmosphere is

better than before. It makes me

feel better about coming.”

“I really like coming into a clean

[athletic] training room because

like it seems more welcoming or

comforting.”

Experience

Access

Availability of AT

“Over break if I had something I

could like text her or call her and

she would like response back to

me pretty fast.”

“I definitely see a difference in the

AT being available there

throughout the whole day versus

only for a few hours.”

Anderson &

Dedrick

; Kao et

; Langley &

Klopper

Experience

Experiences

Observation

from an event

that happen

before

“..if I had an injury prior, like if a

trainer diagnosed that to me prior

and how we handled it.”

Mechanic &

Meyer

Effort

Patient’s Effort

Patient’s attempt

with the

treatment

“I think my willingness and effort to

work with my trainer is based on

how much I trust what he is

saying.”

a priori code

Exploratory code

Understanding Patient Trust in the Collegiate Athletic Training Setting: Findings from Interviews with Patients and Athletic Trainers 7

The AT data are also represented in Table 2 because they had similar ideas about how trust could be developed in a clinical

relationship. For example, one athletic trainer stated: “I’ll initiate communication with them more because good communication

skills [and] affective listening I think is number one. You have to be a really good listener.” Another athletic trainer discussed the

idea of communication but with parents stating, “I feel like good communication with the parents is important because the parents

trust you. I had a mom… we were talking about her son who just recently sprained his ankle and… if he was going to be able to

play in the game, and she’s like I completely trust your decision… even though we had never met… I let her know that [I am] here

for the best interest of her child I’m not going to push him further than he needs to be pushed, but at the same time, if he’s okay to

go, I want him to be able to participate and do that and just kinda[sic] explaining what was going on.” These statements were coded

as communication, which informed the relationship theme.

Personal connection was cited the most (39 times), followed by clinical competence (34 times), communication (31times), and

fidelity (23 times). The codes and their frequency of occurrence are depicted in Table 2. Interestingly, multiple codes also aligned

with the five main components of patient centeredness used by physicians. In fact, most of the codes are associated with just one

patient-centered component: improving or maintaining a positive relationship with patients.

To have a good trust relationship, the

AT must be approachable. The patient must feel comfortable enough to ask for help. As one might expect from theory and common

sense, if patients are not able to ask for help because they are uncomfortable or otherwise perceive clinicians as not listening to

them, then they are less likely to follow intervention plans.

Other components of the patient centered approach reappeared throughout the codes. As expected, communication often came

up on a professional level. However, what was more interesting was personal communication. One participant stated, “You wanna

[sic] be able to talk to your [athletic] trainer comfortably whether it’s about the injury or not.” Personal conversation is a key factor

in facilitating a personal connection. Another patient stated, “You can be really good at diagnosing things and treating things but if

you’re not, ya know, if you’re not very communicative and you don’t have that relationship I think, I think there’s not really a (pause),

I don’t know, you don’t, I think you’d still be good at what you do, but she [the athletic trainer] wouldn’t be as trusted [sic].” It appears

that a good personal connection can help with approachability as well.

The codes were reasonably mutually exclusive as data captured by one code did not fall easily within another code although there

was some overlap. For example, communication and personal connection tend to go hand in hand; it is difficult to build a personal

connection without having an effective line of communication. Patients did, however, discuss these issues separately; that is, these

were described as distinct components. Communication was described as an exchange of information whereas personal

connection was the rapport built in the relationship. One participants stated, “You wanna be able to talk to your [athletic] trainer

whether it’s about the injury or not (pause) and... if they were like really admit [sic] about not listening to my specific injury that

would definitely throw me off.” Another participant described personal connection as, “Ya know in the [athletic] training room it’s

like it’s all sport related when I’m in there for the most part and then when I’d see him uptown not so much so it’s kinda building

that friendship but still being professional about it.” Personal communication appeared to be an important characteristic of the

patient-clinician relationship.

Exploratory Codes

While a majority of codes fit well within researcher expectations, existing theory, and literature, there are a few that do not appear

to have been previously discussed in the literature. The exploratory codes that did occur were knowledge of sport (5), nonverbal

communication (20), feedback (6), approachability (22), patient effort (11), access (31), and environment (10).

An athletic trainer having sport-specific knowledge was important to the patients. One participant also stated, “I would say that they

should know the sport cause [sic] then they’ll have a better idea of what injuries are most common and what is happening on a

daily routine.” Having knowledge of the sport allows athletic trainers to make their rehabilitation program sport-specific. Following

an injury, it is vital as an athletic trainer to educate patients on their status.

In terms of nonverbal communication, the athletic trainer’s body language can influence trust. One athletic trainer stated, “Just

having a smile on your face, good body language, um, not having your arms crossed and things like that improved my feeling

towards the athletic trainer.” Another stated, “I still remember reading it [about body language] and it just resonated so much, it just

made sense to me, um good eye contact, uh I think those things tell them that you’re listening to them.” All three athletic trainers

mentioned nonverbal communication.

Feedback during intervention is also important to patients. Providing the patient with positive and informative feedback helps them

know what they are doing is correct. One participant mentioned, “I like feedback. To know how I am doing or what I can be doing

Understanding Patient Trust in the Collegiate Athletic Training Setting: Findings from Interviews with Patients and Athletic Trainers 8

better.” One athletic trainer stated, “A lot of positive feedback and encouragement and goals to work towards are very helpful [to

provide motivation].” Another wrote, “I always try to be positive or encouraging.”

The athletic trainer’s approachability emerged as another important factor in establishing trust. Approachability can be described

as “easy going” and “friendly.” One participant wrote, “I think just the fact that they’re outgoing. I mean they’re down to earth people.

They like to joke around and stuff while you’re getting treatment.” Being approachable can influence a patient’s sense of trust. One

participant described a time when she felt the athletic trainers were not approachable, “Sometimes, you’ll go in there to get your

ankles taped or something or they’ll just like throw a brace at you and tell you to leave. They don’t make an effort with me.”

Patient effort was described by the participants as being important. Patients discussed the idea that they need to trust the athletic

trainer’s advice for them to put in the most effort to their intervention. One patient said, “Ya know whether I trust them will decide

whether or not I feel that it’s something that I will put all my effort into [sic].” Trust appears to play an important factor into how well

the patient adheres to the intervention.

Another exploratory code was athletic trainer access. Access refers to how often athletic trainers are available for their patients. A

participant stated, “I definitely see a difference in the athletic trainer being available throughout the whole day versus only for a few

hours.” The idea of access does not simply mean being in the AT room every minute of the day, but whether or not the patient is

able to be in contact with the athletic trainer. For example, one participant said, “Over break, if I had something I could like text her

[athletic trainer] or call her and she would like respond back to me pretty fast.”

The last exploratory code from the interviews was environment. When the participants discussed environment they referred to

having a clean and comfortable AT room. On participant mentioned, “I really like coming into a clean [athletic] training room because

like it seems more welcoming or comforting.” Patients also discussed atmosphere and resources having an impact on a trusting

relationship. A basketball player said, “When you walk in there [AT room] there is brand new equipment this year, and the

atmosphere is better than before.”

Themes

Codes were summarized into overall themes. The Attribute theme refers to the education, attentiveness, ability to provide

individualized care, patience, and confidence of the AT. Education was an exploratory code within attributes. The athletic trainer’s

level of education was deemed to be important by the patient. Patients preferred athletic trainers who had a Master’s degree over

a Bachelor’s degree. Patients who did not know that an athletic trainer needs a minimum of a Bachelor’s degree and professional

certification and licensure were less likely to trust the athletic trainer. Clinicians with more education should have more knowledge,

however, the impact of experience was not considered.

The relationship theme addresses how the athletic trainer interacts and works with the patients. Codes that fell within this theme

were communication, reputation, and personal connection. An example of a quote describing communication is, “You can be really

good at diagnosing things and treating things, but if you’re not very communicative and you don’t have that relationship, I think you

could be good at what you do, but we wouldn’t know. Being able to talk to me is really important for me to build my trust.” Another

example of a relationship pattern was personal connection. One patient stated, “Sometimes it’s nice when an [athletic] trainer talks

to you not just about injuries. It’s nice to have normal conversation so it gives you like [sic] a feeling you’re still human.”

The experience theme encompasses the familiarity the patient had with the athletic trainer. Two codes represent this theme: 1)

access and 2) previous experience. A quote from a patient related to access was, “I definitely see a difference in the athletic trainer

being available there, at practice or in the AT room, throughout the whole day versus only for a few hours. That way I knew I could

get their help if I needed it.” Another quote to explain previous experience was, “...if I had the same injury prior, like if the [athletic]

trainer diagnosed that to me [sic] prior and how we handled it.”

The final theme that emerged was effort. Effort can be described as the patient’s effort towards the prescribed treatment. An

example of this theme is as follows “I think my willingness and effort to work with my [athletic] trainer is based on how much I trust

what he is saying.”

Athletic Trainer Patients’ Definition of Trust

Participants had difficulty defining and discussing trust which, in part, justified the methodological approach and analyses used in

this study. Participant 6, for example, stated, “And I would say trust in general is like (pause), um (pause) oh man (pause), I don’t

even know how to define trust honestly.” Other respondents hesitated, were vague, and sometimes used platitudes, suggesting

they have not previously thought about the topic. One participant further illustrated this point because he went to extremes to

Understanding Patient Trust in the Collegiate Athletic Training Setting: Findings from Interviews with Patients and Athletic Trainers 9

describe trust, and yet another participant was unable to define trust but rather stated some of its components (Table 3). This is

evidence that respondents did not come to the interview with ready-made answers and used stark or extreme phrasing when trying

to communicate the abstract idea. Unfortunately, an inability to define the construct as applied to AT in this study may undermine

a capacity to account for it in future studies. What could be gleaned from the data was patients referenced the notion that trust

entails a sense of confidence in an AT, which was viewed as a type of feeling. Other terms that were used to describe trust were:

understanding, communication, reliability, and knowledge of the athletic trainer.

Table 3. Trust Described During Interviews

Participant

Description

“Well I think in this situation it’s (pause) knowing that what you’re doing is going to get you back on

the field and at least to the point where you were before if not better.”

“I would say it just means um the ability to know that their gunna [sic] give you the best treatment

to get you healthy again. It kinda [sic] goes with knowledge in this context. (pause) That they’re

going to give you the best treatment.”

“ [I] guess kinda [sic] like believing (pause) what their telling you what you to do and putting like

you’re state of well-being in their hands.”

“Um, I would say it would just be uhh like being able to like follow what someone says and like

understanding what their saying and um, trying to think of a good word to use. Uh, it’s just like

(pause) having a connection I guess like even a connection with them so you can um, (long pause)

just under, just understanding [sic].”

“It deals with like believing in them. Kind of trust like you know based on what they’ve done in the

past to you or other athletes like maybe like their past history like that will cause you to trust

someone a lot more than if you just meet someone out of nowhere and don’t really know what

they’ve been doing or if they’re new.”

“I would say well person to person I would say having a general understanding of each other,

knowing where things are and um (pause), being able knowing that uhh, the opposite person has

your back regardless of whatever is going on. Oh yeah I think um,(pause) I definitely think it’s a

belief… it’s a belief and attitude, but I’m not sure what kind of belief or attitude it is.”

“I feel like she knows what she’s talking about and she’s gunna [sic] make my injury go away.”

“I think it’s knowing that no matter what somebody says to you to believe in that and obviously if

somebody tells you to go jump off a bridge that’s I mean there’s some reasoning in that.”

“In the in the relation just I mean in the uh, believing in what they’re saying, believe in the message

that they convey to you, how’s that not what they say the message because you have to believe in

the facial experiences um, and gosh that’s so hard.”

“Just reliability and um knowing that I can count on them to get the job done right and to.”

“I think it’s a feeling um or the ability to unconsciously rely on an individual for really any particular

reason.”

“Umm, you know I don’t know if I can explain it…Gosh that really is a tough one. Is it a feeling or a

belief? I’m not entirely sure. I guess it could mean being reliable but umm, it’s more than that. I

don’t know.”

*Note that participant 12 was unable to clearly describe or define trust. He made suggestions of components but was unable to

articulate a definition.

Understanding Patient Trust in the Collegiate Athletic Training Setting: Findings from Interviews with Patients and Athletic Trainers 10

From this information, in the context of athletic training, trust was defined as a belief (and/or a feeling) that an athletic trainer has

the patient’s best interest in mind and that treatment and any associated information provided during treatment, will help the patient

return to activity. Patient trust is informed in part by their perception of their athletic trainer’s attributes (e.g., education, patience,

confidence), level of effort, experience, and relationship skills.

DISCUSSION

A key contribution of this work to the AT literature is predicated on the idea that constructs that are difficult to define and describe

are likely to be difficult to measure and ultimately influence. This is true of the trust construct, yet there is merit in understanding it

better within AT given its role in clinician-athlete relationships and likely connection to later treatment fidelity. The current study’s

results revealed that trust has both an emotional component (approachability, fidelity, etc.) as well as a cognitive component

(providing feedback, patient education, etc.). The two components have been described before to explain the patient-clinician

relationship.

However, it appears that both are also components critical to first establish trust and then to further develop the

patient-clinician relationship. It is important to recognize that the emotional and cognitive components are not mutually exclusive

and can affect each other. For example, consider the codes communication and personal connection. Although participants

described them as separate ideas, they overlap, and when considered together, may have a synergistic effect on improving AT-

patient relationships. Kelley et al

describe a similar idea after a detailed systematic review and meta-analysis of randomized

controlled trials that examine the connection between this type of relationship and health outcomes. This meta-analysis revealed

a small, but statistically significant, result suggesting that the patient-clinician relationship does influence patient outcomes.

This

finding has bearing on the current study because it demonstrates a connection between trust and AT-patient relationships.

This qualitative study also revealed facets of trust not previously described in the AT literature. The level of AT education may be

an important factor. Interview responses suggest that athletic trainers should communicate their overall and sport-specific

experiences with patients to build trust. Providing unique qualities or experiences can show patients that the athletic trainer’s

knowledge has prepared them for the particular job. A good time to describe qualifications or related previous experience could be

during the initial meeting session with teams. In addition, athletic trainers need to be conscious of their nonverbal communication

and its effect on the patient-clinician relationship; a positive body language can help facilitate a good patient-clinician relationship.

Examples of positive body language include making eye contact, facing the patient, and nodding in agreement at the appropriate

times.

Although communication is a well-known facet of trust, this work serves as a reminder of the need for athletic trainers to educate

patients on their status. Not only is this useful to help patients understand their conditions, but it also reveals that the athletic trainer

is knowledgeable. Providing a description of the injury and purpose of the treatment plan shows that the athletic trainer has carefully

thought about the individual.

Access was another important aspect to establish trust and has been discussed previously in other health care professions.

17,32,33

Because AT has its own unique attributes, there are a variety of tasks the athletic trainers can do to improve access. Providing the

patients with a phone number to text or email address provides easier and faster access to their care. This will allow immediate

access and help build the relationship.

Environment also appeared as an important aspect to build a trusting relationship. Environment has been discussed previously by

Norkfolk et al but to establish empathy rather than promote trust.

Environmental factors considered previously have been waiting

room size, lighting, and layout, whereas in this study, it was also considered equipment and cleanliness.

Having a clean AT room

with newer equipment appears to provide a sense of comfort and a good atmosphere that can influence the amount of trust a

patient has for their athletic trainer. This may or may not be an aspect of trust that the athletic trainer has any control over, but it

may impact the relationship. However, an athletic trainer can have control over equipment organization and cleanliness.

Providing quality feedback was another important aspect. Although not specifically related to trust, positive feedback has been

shown to increase levels of performance when completing a given task.

To continue to improve the patient-clinician relationship,

it is key to provide positive and informative feedback during treatment. For example, during rehabilitation rather than simply saying

“Good job,” the athletic trainer can say, “Good job, your technique during that exercise is spot on.”

This work has helped to highlight the importance of trust in the athletic trainer-patient relationship and has provided constructs

AT’s should consider when promoting a sense of trust in their practice.

Understanding Patient Trust in the Collegiate Athletic Training Setting: Findings from Interviews with Patients and Athletic Trainers 11

Delimitations and Limitations

This study was delimited to Division I collegiate-aged participants; therefore, findings from this study cannot be readily applied

outside of this population. In terms of limitations, the authors worked under the assumption that data saturation was achieved.

However, it is possible that there is additional information that may have been missed. This study is also limited by its small sample

size, which is often a byproduct of managing transcribed interview data and imposing a data collection burden on participants.

Future research examining the construct of trust and the related codes and themes in other age groups as well as other AT settings

(e.g., secondary setting, industrial setting, etc.) would be beneficial as it is unclear how this information generalizes to other age

groups and AT settings.

Conclusion

The purpose of this study was to develop a definition of trust in AT and explore factors that appear to be related to developing a

trusting relationship. Four themes, attributes, relationship, experience, and effort, emerged to help understand how trust influences

the relationship between the athletic trainer and patient. Additionally, a working definition of trust between athletic trainers and

patient was developed. Athletic trainers can use this information to help improve their relationships and potentially improve patient

adherence.

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