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Paul R. Geisler, MA, ATC/L, provided conception and design; analysis and interpretation of the data; and drafting, critical revision, and final approval of the article.
To introduce athletic training educators and practicing professionals to the pedagogic concept and professional benefits that multicultural education, awareness, and training might provide if implemented in athletic training education.
I reviewed textbook chapters and articles used in the course of my doctoral studies and searched the archives of Diversity Digest and Academic Medicine for the years 1998 to 2002 with the key words multiculturalism, diversity, cultural competence, education, and learning. I obtained additional information by cross-referencing pertinent articles.
I present a rational argument for the inclusion of a critical pedagogy into the field of athletic training education. I outline the infrastructure in the professional field of athletic training, review some of the literature on critical multicultural theory and pedagogy, and examine some of the potential cognitive and intellectual implications of diversity and multicultural education.
Future work in this area should focus on various and creative strategies for implementing a multicultural agenda in athletic training curricula and on the analysis of the associated benefits and outcomes of such educational strategies.
Informally, the profession of athletic training has been in existence since the ancient Olympic Games, when athletes routinely sought the advice, assistance, and wisdom of scientists and other intellectuals in attempts to improve performance and ward off injury. Formally, the profession of athletic training has been in existence in the United States since 1950, when the National Athletic Trainers' Association (NATA) was formed by a small and obscure legion of “trainers.”1 In the years since, the profession of athletic training has grown significantly in association size, disciplinary grounding, professional scope, and breadth of practice. As the profession of athletic training has steadily grown, so too has the level of knowledge and skill required to practice and teach athletic training in today's environment. In addition, the extensive proliferation of empirical research, combined with the increasing complexity and accrual of clinical experiences over the last 50 years, has produced an astonishing amount of information and knowledge pertaining to the various domains making up athletic medicine and health care. These rapidly evolving theoretic, practical, and scientific advances have presented various professional and educational challenges to the practicing athletic trainer and educator alike. In this article, I attempt to emphasize the infrastructure in both the academic and professional domains of athletic training, review some of the literature on critical multicultural theory and pedagogy, and examine some of the potential cognitive and intellectual implications of diversity and multicultural education. In doing so, I present a theoretic and rational argument for the inclusion of a critical pedagogy into the field of athletic training education. My intent is to generate an interest in the existence and significance of multicultural studies and to subsequently initiate a dialogue on the considerable relevance of multicultural studies to athletic training education and practice.
In general, athletic training education program directors are primarily responsible for following fairly rigid and complex accreditation guidelines while preparing entry-level athletic training students for their certification examination and subsequent entry-level professional experiences. At the same time, and easily overshadowed by the cumbersome processes associated with program administration, program directors and other athletic training faculty members are also relatively new members of the academy. Athletic training being a relatively new discipline and entry to the academic landscape, scholars and educators of this discipline nationwide are working diligently and earnestly to earn a respected place in the halls of academia and to become honored and venerable members of the academic tradition. As such, athletic training educators are pedagogically situated, and some may even say expected, to embrace the more historical and intellectual purposes associated with higher education and the world of academia. In this light, providing meaningful and critical learning experiences that assist in the transformation of our athletic training students into proactive and authentically democratic citizens should also be central to our larger mission.
As one might imagine, and as many program directors will attest, it has become increasingly difficult to balance the competing, yet equally important, rigors of program administration with substantive, intellectual, and transformative teaching and scholarship. On one level, a very specific, detailed, and rather inflexible curriculum strongly dictates what is taught, which learning is of value, and the direction of the end result. In strong contrast to the administrative guidelines set forth by the required standards and guidelines for athletic training education lies the more intellectual, transformative, and personal endeavors often associated with higher education. Frequently lost in this age of technocratic curriculum and specialized professional preparation associated with what Giroux2 called the “industrial model” of education are the more humanistic and critical characteristics historically associated with higher education. Athletic training education programs are certainly not to blame for this gradual and cultural metamorphosis of higher education, and they are not alone in this unfortunate endeavor. But, as the profession aggressively pursues higher levels of disciplinary competency and professional recognition through initiatives and action plans centered on educational reform, specialized and technical research, and increasing levels of administrative bureaucracy, those involved in the preparation of tomorrow's professionals must be conscious of the potential pedagogic and societal ramifications associated with the larger purpose of higher education.
If athletic training educators and mentors are not careful and mindful of the larger social and intellectual roles associated with university education, they too will become complicit in the development and production of highly skilled and specialized technocratic professionals who lack the critical mass that personifies the romantic ideals of the academy and its grander intellectual purpose. If that is allowed to happen, many future athletic training professionals may subsequently prove incapable of contributing to the larger, more critical roles required for a true democratic citizenship. For clarity, the argument presented herein does not suppose that athletic training students should not be exposed to and held accountable for measurable, objective outcomes that “define” the entry-level athletic training professional, and it is not recommended that current educational standards and medicoscientific bases of knowledge that drive our profession and practice be marginalized. Rather, all university and college educators have a mission that is parallel and equally important to the respective major program of the study mission. Remaining cognizant and respectful of the higher ideals of education and personal transformation is imperative for the just professional and personal education of all students. As members of the academy, athletic training educators must also see this academic consciousness as an obligatory requisite for legitimately fulfilling the professional membership roles associated with academia. One way for athletic training educators to effectively enhance the critical mass of their curricula and pedagogy is to actively include multicultural education and diversity awareness in all aspects of their educational programs.
In modifying the list of components deemed necessary for medical education to fit athletic training education, first put forth by Cruess and Cruess, Hannam1 highlighted 2 particular challenges for athletic training educators. She stated that athletic training education should include relevant material and interpretations drawn from sociology, philosophy, economics, political science, and medical ethics because they relate to professionalism and that the link between professional status and one's obligations to society must be recognized, promoted, and maintained by all professionals in the field. Hannam also discussed some of the current and future trends associated with the profession of athletic training and cited educational reform, working conditions, and diversification as 3 of the primary challenges the athletic training profession faces in the new millennium. If athletic training is ever to approach a meaningful state of interprofessionalism, as Hannam suggested, it must first become more aware of its professional and pedagogic strengths and weaknesses while continuing to work earnestly and diligently toward the development of means and methods that best serve the interests of the patient(s). Certainly, the NATA Code of Ethics confirms Hannam's1 contentions that higher education has a responsibility for producing intellectual, critical, moral, and ethical citizens who will become productive members of a democratic society. Witness Principle 1 of the NATA Code of Ethics, which states, “members shall respect the rights, welfare, and dignity of all individuals,” and Principle 5, which states, “members shall not engage in any form of conduct that constitutes a conflict of interest or that adversely reflects on the profession.”1
Because athletic training is now officially considered an allied health profession, and because its professionals work in myriad settings with a multitude of patients, students, and colleagues, athletic trainers cannot be just athletic trainers. Rather, athletic trainers must actively seek to become global citizens capable of communicating with and understanding a vast diversity of voices, opinions, experiences, and world views. Regardless of the particular professional setting or its associated job responsibilities, most athletic trainers are confronted with issues of race, class, sex, and cultural diversity on a daily basis. The real-world existence of various sociocultural factors in both professional and educational athletic training settings means that students must be formally prepared to embrace and manage critical issues. It is now apparent that all athletic training professionals will need to have a strong multicultural perspective that transcends professional competence and experience, one that allows a critical and empathetic perspective for the voices of “others,” one that empowers the athletic training professional to maximize the nature and delivery of health care, and educational services.1 As such, athletic training education programs must formally, experientially, and intellectually prepare their respective students for their impending interpersonal, civic, and professional responsibilities. In fact, the 1999 NATA Athletic Training Educational Competencies3 reflects the need for the implementation of cultural competence and sensitivity training in our educational programs. Specifically, at least 2 cognitive domain and 3 affective domain competencies listed under the “Psychosocial Intervention and Referral” content area clearly elucidate the professional requirements regarding sociocultural awareness and relative competence. For these reasons, among others not considered here, it is critical for present and future athletic training professionals, educators, and students to become more multiculturally intelligent, culturally competent, and socially experienced.
I will present a multifaceted argument for the exploration, implementation, and eventual acceptance of a multicultural agenda into current athletic training education curricula. To support this argument, I will present a review of the field and study of multiculturalism briefly and discuss 3 points of emphasis with the intent of developing a dialogue concerning the role, influence, and potential impact of the inclusion of a multicultural pedagogy to the curriculum. I will first illuminate the need, structure, and relevance of diversity issues for the profession of athletic training with a review of specific demographic data relative to our organization and scope of practice. Second, I will introduce potential hidden cognitive and intellectual influences of diversity training that have been reported in the literature by various scholars. Last, I will present potential strategies for implementing, or at least initiating, multicultural experiences and dialogues into athletic training curricula in an attempt to create possibilities and to explore limitations. I hope that this discourse will generate interest, criticism, and even compassion from fellow athletic training educators and that subsequent inquiry and scholarship in this area will focus on creative and realistic interdisciplinary strategies for implementing a multicultural perspective into athletic training education programs.
In 2000, the American Association of Colleges and Universities4 performed a national survey to ascertain the number of colleges and universities with diversity educational plans implemented for their respective student bodies. The results of this survey indicate that 62% of the colleges and universities that responded reported either having in place a diversity requirement or being in the process of developing one. As Humphreys of the Association stated,4 these findings “…suggest that colleges and universities now recognize that learning about diversity is a key element of a quality undergraduate education and should therefore be required of all students.” In a related article commenting on the study's impact and influence, Schneider reminded readers that “…colleges and universities require a particular study when they believe it important for their students' social functioning, both as human beings and as citizens.”5 Diversity requirements, she argued, signal the academy's conviction that citizens now need to acquire significant knowledge of other cultures as well as the struggles for recognition and equity experienced by other marginalized cultures. It is precisely this kind of knowledge, contended Schneider, that is essential if we wish to be adequately prepared to face and interact in the world around us.
Although historically reserved for a classical liberal arts education, discourses related to race, class, sex, diversity, religion, and other aspects of multiculturalism should play a pivotal role in the personal and professional metamorphosis of all university and college students across all disciplines and all majors. Schneider5 suggested that 1 or 2 courses on diversity are the “…best down payment on the kinds of knowledge citizens need both as members of a democratic society still driven by the legacies of segregation and hierarchy and as participants in an ever more connected global community.” Takaki6 commented on the potential fringe benefits that multicultural education could offer when effectively presented with an intellectual purpose. Specifically, Takaki6 echoed the claims made by scholars that multicultural experiences allow the receiver to see events from the viewpoints of different groups, thus enabling a more comprehensive understanding of American history and its subsequent sociocultural condition. Perhaps Takaki's6 sentiments on educational reform can help put this monumental task into perspective and minimize the burden placed upon educators by pointing out that a much-needed materialization of diversity courses should be “…the beginning, not the end, of an important educational reform.”
If for no reason other than the spirit of higher education, multicultural experiences that are capable of initiating such opportunities for personal awakening and self-reflection should also be available for athletic training students. Helping to expose and engage athletic training students in various dialogues and experiences concerning issues of global significance and setting personal examples for social cognition, intellectual curiosity, and personal, reflective learning are necessary to help students find a cerebral balance between their major study goals, their pending social responsibilities, and their overall intellectual maturity. Because of the time-intensive and interpersonal nature of athletic training education programs, athletic training educators may actually have more inherent potential for critical transformation and exploration than do many other academics. For example, athletic training education program directors may also serve as academic advisors, and thus, they have a particular opportunity to help integrate more meaningful educational experiences for their athletic training students when helping students choose nonmajor, elective courses. Similarly, all clinical and didactic athletic training faculty members have considerable time and opportunity to engage their students in meaningful and critical dialogue concerning sensitive phenomena related to diversity, culture, and other pertinent sociocultural issues. After all, should not academic mentorship consist of much more than technical training and measurable learning-over-time expository lessons?
Although some might argue that athletic training education programs are neither appropriate nor capable of embracing an agenda inclusive of multicultural education, precedents in the disciplines of mathematics and science as well as other allied health fields such as medicine, nursing, and physical therapy do exist.7–11 According to the reports cited, curriculum planners and educators in all these related fields are recognizing the need for such an initiative and, thus, are actively developing strategies and modifying course content to create a comprehensive multicultural curriculum that will assist in the critical transformation of their advanced students. In fact, Clark9 reported that some scholars go so far as to say that faculty in the “hard” sciences are actually pioneering the transformation in this area by leaps and bounds. Upon studying the impact of diversity courses on students' attitudes and content knowledge, Palmer12 noted that the diversity courses at her institution were having a positive impact on students on multiple levels. According to Palmer,12 students enrolled in diversity courses were gaining content knowledge, developing more tolerant attitudes, and experiencing self-exploration as a direct result of their formal classroom experiences. Furthermore, Palmer's12 investigation found that undergraduate students' experiences in diversity classes showed a direct and positive effect on how students behaved and contributed to class activities while also having an influence on how they viewed the campus and the world beyond the classroom. Surely, athletic trainers and other health care professionals have had positive classroom and practical experiences similar to those described here, and it can be surmised that current and future athletic training students will also benefit from a college experience that includes meaningful diversity exposure and exploration.
With this in mind, one cannot help but compare the conversation about this movement with the reading-across-the-curriculum movement that has existed on college campuses for years. Simply put, a positive reading-across-the-curriculum perspective implies that faculty members from all disciplines must teach and evaluate effective writing for students to become better writers. In short, educators who value quality writing must also take part in the process of writing education and not expect the English department to be solely responsible for teaching effective and critical writing skills.13 In this light, athletic training and other human science-based disciplines should not also expect the humanities and social sciences to teach students everything they need to know about communication, social and cultural understanding, diversity, and democratic responsibility. Nieto14 took this challenge one step further by pointing out that part of the school mission is to create the space and encouragement that legitimate talk about racism and discrimination to develop a critical dialogue.
Although difficult to pinpoint with concrete historical accuracy, it is generally thought that multicultural studies began in the 1950s and 1960s as a result of the civil rights movement and can be described as being many different things and possessing different purposes, agendas, and goals.15,16 Although the focus of this article is not to comprehensively contemplate the many and various opinions of multicultural theory in elaborate detail, it is necessary to briefly discuss the more common theoretic approaches to multiculturalism for the uninitiated reader. Sleeter17 has skillfully condensed the considerable wealth of material in her presentation to 5 main approaches for multicultural education, which will be summarized here for the purpose of creating an initial understanding. Teaching the culturally different attempts to “increase colored student achievement.” The human relations approach employs sensitivity training to teach students that we are all the same because we are different and, thus, we all deserve to be treated equally. Single-group studies independently focus on the various ethnic groups, their histories, and their relative conditions. The multicultural education approach focuses on the redesign of American schools and the schooling process to make them more pluralistic and just. The multicultural and social reconstructionist approach centers on factors related to political and economic oppression and the distinct discrimination dynamics that are deeply woven into our culture. This last approach, also called critical multiculturalism, is by far the most radical and political in nature because it focuses on preparing students to develop and use social action skills to be active participants in a true and transformative democracy.17 One can see the gradual and distinct progression in the amount of political and critical mass associated with each approach, and so each approach has distinct goals, strategies, and methods inherent in its particular world view and pedagogy.
Critical multiculturalism is also different from what some scholars are calling cultural competence in that cultural competence typically consists of teaching students to achieve some level of competence regarding the habits, traditions, languages, and perspectives of other cultures.11,18 Although it is a common movement in medical and physical therapy education, focusing on the “exotic other” by illuminating common cultural traits and conceptions as essentialist representations can actually lead to the perpetuation of existing stereotypes, thus preventing the development of a critical and meaningful awareness that variability is essential to all humans.8,10,11,18 When combined with critical reflective practice in relation to issues of race, class, sex, and sexuality, however, cultural competence can certainly take on a more critical multicultural flavor. This heterogeneous conceptual framework, called “cross-cultural efficacy” by Nunez,18 implies that the caregiver is effective in interactions that involve individuals of different cultures and that neither the caregiver's nor the patient's culture is the preferred or more accurate world view. In support of this movement, the Liaison Committee for Medical Education recently adopted accreditation guidelines for medical school curricula requiring the implementation of cultural diversity, also termed sociocultural medicine, as a requisite for accreditation.7,19 In many contemporary medical school curricula, young medical students commonly learn that Western science does not have exclusive insight into the ability to predict and understand illnesses and abnormalities or a monopoly on the best, most appropriate therapeutic and pharmacopeial interventions. Furthermore, medical students are also gradually becoming more aware of the various and complex social, cultural, and linguistic dynamics involved in the interpersonal aspects of health care delivery.8,9
Perhaps the definition put forth by Salili and Hoosain16 provides a good fit for the discipline of athletic training by pointing out that it “aims at teaching students to accept, understand and appreciate culture, race, social class, religion, and gender differences and instill in them during their formative years a sense of responsibility and commitment to work toward the democratic ideals of justice, equality, and democracy.” But because it mirrors both the content and spirit of Hannam's1 modified priority list for athletic training education discussed earlier, the seemingly simple definition of multiculturalism provided by Banks20 may prove to be the definition best suited for athletic training curricula. Banks defined multicultural education as “an education for functioning effectively in a pluralistic democratic society…helping students to develop knowledge, skills, and attitudes needed to participate in reflective civic action.”20 Put another way, Banks' advocacy for the main goal of a multicultural education as helping students develop decision-making and social action skills so that they learn to view events and situations from a variety of perspectives might be the best fit for athletic training education.21 Regardless of whose particular definition is embraced, the collective message of these scholars is that a critical multicultural approach values diversity and encourages critical thinking, reflection, and action while empowering students to take risks, be curious, and question existing power structures, governmental policies, and all forms of social suffering.2,14,15,17,20,22
In the sections that follow, I will use Banks' definition and purpose to argue that multicultural education should be a constitutive and a critical element for all athletic training education programs. As such, all athletic training educators should have a pedagogic and critical knowledge of the purpose and impact of a multicultural approach to education and, thus, should be actively working toward a curriculum and clinical-education plan reflective of Banks' approach. Of course, this argument does not solely apply to athletic training educators but rather to everyone involved and interested in higher education and the wellness of our society. Athletic training professionals cannot possibly undertake this significant and complicated endeavor by themselves, and I do not presume to have a simple and painless solution for improving the overall sociocultural condition of our generation. However, the unique nature of the athletic training educator-student relationship that develops gradually over the course of the typical 2- to 3-year program of study does provide athletic training educators with a tremendous opportunity not available to university educators in many other disciplines.
In 1974, the NATA membership numbered 3100, with most members working in relative obscurity within the athletic training rooms of university field houses and stadiums.23 As the membership and practice of athletic training have grown, so too has the discipline of athletic training as a formal allied health profession. No longer does athletic training consist solely of taping ankles and providing water for the athletic masses. Athletic training is now a multidisciplinary synthesis of various medical specialties and disciplines assembled into a viable health service option for physically active populations. At the close of 2001, the NATA membership had grown to 21166 members, and the professional job-setting possibilities had expanded and diversified significantly.24 Currently, only 17% of certified athletic trainers (ATCs) work in the historical college/university and junior college settings, and an even smaller number work in the various professional sports settings (3%). Most of today's athletic training professionals work outside of the historical setting: sports medicine/physical therapy clinics (16%), high school/clinic outreach programs (11%), high schools (16%), hospitals (4%), and corporate/industrial settings (3%). Of the remaining membership, 20% represent student members, whereas the remaining nonstudent members work in related medical and various other, unreported settings.24
The Ethnic Diversity Advisory Council (EDAC) of the NATA has been collecting demographic data of the NATA membership since 1997.25 The purposes of the Council and its data-collecting agenda are to (1) advocate sensitivity and understanding toward ethnic and cultural diversity, (2) show the enhancement and growth of diversity in the NATA, (3) help monitor the recruitment and retention of ethnically diverse student athletic trainers, and (4) address other issues related to our profession and its ethnically diverse interests. According to the latest EDAC report, ethnically diverse members have increased from 7% in 1998 to slightly less than 10% in 2002.26 Despite the fact that 26% of the nation's population represents ethnic minorities, less than 10% of the NATA membership represents minority populations. These numbers demonstrate that, although the NATA is slowly becoming more diverse, room for growth certainly exists. Martin and Buxton27 reported from a 1995 NATA Education Council survey that 18% of all athletic training students enrolled in accredited or approved programs were from minority populations, indicating that athletic training educators need to seek out and embrace effective and meaningful multicultural training in order to better meet the needs of their students.
As the demographic numbers reflect, athletic trainers now work in a very diverse realm of professional settings, yet white athletic trainers represent by far the ethnic majority of the membership (78%).23 This contrast presents an interesting and challenging dynamic for educators and future athletic trainers to confront in the coming years. Historically, athletic trainers working in the collegiate settings, themselves overwhelmingly white and male, interacted with mostly white, mostly male athletes until desegregation and civil rights directives took effect. At this point, African American athletes entered the athletic training rooms of America's predominantly white universities and presented new challenges to the personnel involved with their care and training. Of course, the challenges associated with racial desegregation among ATCs and athletes were probably not very different from those encountered in the general society. Today, the National Collegiate Athletic Association reports that 22.7% of all athletes and 48.9% of the athletes in the “revenue sports” (football, men's and women's basketball) in Division I are African American.28 Approximately 35% of all athletes in its 3 divisions are of color (African American, Hispanic, or Asian).
In the early 1980s, women's sports participation began to blossom and the number of participants to increase, largely due to Title IX. This signaled the second wave of diversity issues for athletic trainers who were working in colleges and universities. Suffice it to say that college ATCs were primarily confronted with issues pertaining to race and sex until they were hired to work outside the traditional setting. Consequently, the predominantly white, male profession of athletic training was shaken from its social slumber. A profession that had been rather sheltered from many of the realities of a rapidly changing society was suddenly faced with complex humanistic, political, and sociocultural issues.
How athletic training students are prepared to handle issues of racial, class, sexual, ethnic, and religious diversity may influence, or even dictate, the relative social and professional success of athletic trainers in these diverse settings.1 Technical competence aside, if athletic trainers in diverse settings handle the complex issues of diversity relations well, the professional effectiveness and social acceptance of our positions may blossom. In contrast, if athletic trainers struggle with the larger social, political, and interpersonal aspects of the job, the available employment opportunities may diminish over time. For example, many of the ATCs employed in our nation's high schools are situated in urban and suburban areas that typically hold of very diverse ethnic populations (eg, northern Virginia, metropolitan Atlanta, and Orlando). Some of these ATCs are only responsible for providing health care services to school athletes, while others are employed to formally teach, and thus interact with, a larger segment of an even more diverse student population. Young professionals unaware of the various complexities and issues associated with various ethnic groups, cultures, and religions they will inevitably encounter could be in for challenging and potentially destructive moments. On the other hand, if professionals in these situations had the benefit of a multicultural experience of meaning and exploration during their formal education years, the diversity challenges that occur in public schools could be positive for all stakeholders.
Athletic trainers working in the clinical and industrial settings have perhaps the most challenging and diverse patient population with which to work. Typically, the patient population at these settings is very diverse—socioeconomically, culturally, educationally, ethnically, and religiously and, as such, different from the young and athletic population seen by many ATCs and athletic training students in the college and university settings. In these contemporary settings, the potential is high for uninitiated athletic training professionals to encounter a sizable proportion of patients who do not speak English as the first language, are immigrants of different status with regard to citizenship, or represent various levels of cultural and linguistic illiteracy. Because of the difficult life experiences that many marginalized people and so-called blue-collar workers have encountered, many patients encountered in these settings may be disillusioned and disheartened about their social status and promise for social advancement. This feeling of resignation can often be accompanied by a strong, inherent distrust of those people in positions of authority, knowledge, and power—college-educated professionals in particular. Establishing a trusting relationship with these patients, especially for white, male ATCs, can oftentimes be difficult, painful, and nonproductive.10 Being aware of, and exposed to, the culture of whiteness and the perspectives of the marginalized others who exist in society and having the confidence to confront these issues are critical components of the daily working lives for ATCs in the clinical and industrial settings. Medical schools and physical therapy education programs have certainly realized the importance of this complex pedagogic and social phenomenon, and with the recent evolutionary trends in our profession, so too must athletic training education programs.7,10,18,29
Returning to the issues confronting the traditional ATCs in the university setting, a new challenge with educational implications is rapidly emerging. As part of the educational and curricular reform occurring in athletic training, more and more colleges and universities are seeking program accreditation to retain their athletic training student program (a major benefit for the athletic department). Presently, there are more than 130 accredited athletic training education programs and another 174 in various stages of the accreditation process.30,31 As such, many ATCs are being subtly pushed into teaching and instruction roles in order to support the academic major program. The 2001 EDAC survey found approximately 12% of the students represented members of color.25 This was an increase from 8% the previous year, a promising trend if indeed accurate and reflective of the national student body of athletic training students (not all athletic training majors have joined the NATA). This means that ATCs working at an accredited institution (or one that will soon be) will be thrust into a traditional or clinical teaching role or both. Thus, they will be challenged to deal with issues of diversity as they relate to student-teacher relationships and general student development. The supervising ATC (clinical instructor) has just as much opportunity, responsibility, and potential to enlighten and awaken students with regard to social and cultural issues of injustice, bias, and diversity as any other educator at any other level.
As allied health care providers charged with the prevention, recognition, management, treatment, and rehabilitation of injury and illness in the physically active, we must become skilled clinical practitioners. This ability includes, among other things, the possession of expert psychomotor skills and their interpretation, as well as the ability to expertly analyze and synthesize the various clinical abnormalities and dysfunctions common to active people. Development of the latter skill, the ability to recognize case-pattern presentations, requires a certain level of intellectual, clinical, and scientific maturity. Full development of this skill typically requires years of training, education, and professional development. In essence, case-pattern recognition is the medical field's version of critical thinking and is common to all expert physical medical clinicians. As such, one of the central tenets of athletic training education should be to demonstrate and foster this higher-level thinking ability in all of our students.
Kogler32 presented an interesting argument for diversifying the curriculum, one that parallels the goals and intellectual challenges of allied health education. In this unique and fascinating endorsement of diversity education, he argued that a diversified curriculum has a positive impact on students, institutions, and the society at large and that our increasingly diverse society requires our educated professionals and leaders to be critically aware of the connection between social problems and race, class, sex, and other forms of diversity. To those familiar with the benefits and purposes of multicultural education, this is nothing new, but it may be a new and enlightening perspective for athletic training educators. Combining the pedagogy and practice of multicultural education with recent developments and insights in cognitive science and the philosophy of the mind in a very coherent manner, Kogler suggested that multicultural education advances cognitive capabilities in students. This enhanced cognitive ability enables students to genuinely understand different cultural perspectives, to develop a reflexive understanding of themselves, and to represent structures shared by individuals in different experiential contexts.32
Kogler's central thesis was essentially that the actual thought processes provoked and unleashed by multicultural education can be seen as instantiations of deeper cognitive thought processes. According to this theory, the process of awakening the mind's eye and sparking the cerebral circuitry that is set in motion with multicultural exposure allows the recipients to see themselves in a very different light.32 This cognitive catharsis, in turn, enables the individual to better understand the plight and perspective of others. Like a rare and exotic orchid, if cultivated properly, this process allows the student to see and hear, with distinct clarity, the various truths and fallacies that surround our history, society, and culture. It allows the student to critically examine the past and present states of social injustice and “democratic” policy that have existed in the United States at varying levels for more than 400 years. This ever-evolving and highly plastic configuration process, which Kogler32 identified as the ability to apply a theory of mind, effectively enables and empowers the individual to think at much higher intellectual levels. Through implicit or explicit means, we can make better sense of others by simulating or by employing the notion of empathy in order to understand others by putting ourselves in their shoes. The ability to do this openly, critically, and without bias requires higher levels of cognitive understanding and processing. Kogler concluded by commenting that the most gratifying and shocking experience for the majority of white students of multicultural education is that they learn to see themselves as culturally, socially, and historically situated selves. Or, to put it bluntly, they actually begin to realize that they too have an ethnicity.32 This theoretic construct certainly has implications for all university learning, including athletic training education and the ability to develop sound, mature clinical-reasoning skills.
Experimental support for Kogler's theory can be found in the work of Guthrie et al33 on cognitive capabilities, racism, and tolerance. Building on previous research connecting educational level and tolerance for diversity, the authors have attempted to examine how education affected tolerance in college-aged students. Specifically, they intended to examine whether students' levels of intellectual development, represented by their respective levels of reflective thinking, were correlated with levels of prejudice toward African Americans and homosexuals and levels of tolerance. Tolerance (as cited in an earlier, 1993 work by Chickering and Reisser34) has been operationally defined as “the ability to accept individuals for who they are, to appreciate and respect differences, and to empathize.”33 Building upon previous research in stereotyping and prejudice, and the Reflective Judgment Model (as cited in an earlier, 1994 work by King and Kitchener35), Guthrie et al33 defined reflective thinking as “…the capacity to make defensible judgments about complex and controversial issues.” This theory of intellectual development describes a progression in reasoning skills that takes time, cognitive capacity, and careful nurturing in order to mature properly. As students move from lower to higher stages of learning and understanding, the complexity, sophistication, and comprehensiveness of the judgment process gradually increases. As experiences and varieties of perspectives mount, students progressing through the Reflective Judgment Model are increasingly faced with the complex task of evaluating their knowledge claims and defending their points of view on controversial issues.
Students operating in the early stages of this model (traditional undergraduate students) are said to be in the prereflective or quasireflective models of thinking. Typically, first-year and even second-year athletic training students exist and operate in this cognitive realm. Reason and thinking are based on the assumption that one gains knowledge through direct, personal observation or through authority figures. In effect, knowledge gained is correct and certain if it comes from an “authoritative source,” and the process by which it is gained is passive and rather “a-cognitive.” Stereotypes and the prereflective judgments that are activated by the formulated stereotypes are similar phenomena according to Guthrie et al,33 who argued that they are both based on the “…authority of society or common belief, assumed to be correct, and not questioned.” As students mature intellectually, they pass into the quasireflective mode of thinking and begin to recognize that knowledge claims about ill-structured problems contain elements of judgment. They begin to have the intuitive ability to question what they learn but do not yet have the cognitive tools and experiences to make complete sense of complex issues. Thus, they often do not have the confidence to confront their internal dilemmas, and so they can persist, perpetuate, and perplex even further. At this stage, the learner is now more likely to recognize that a stereotype is an inappropriate criterion upon which to base a judgment. Unfortunately, the learner at this stage does not yet have the cognitive tools to prevent stereotype-based reactions and behavioral patterns from manifesting themselves in discreet and even some open situations.33 Older, more intellectually mature students are usually in the true reflective-thinking stage, characterized by an ability to recognize that their understanding of the world is not “given” and that it requires active construction, critical debate, and subsequent transformation. Reflective thinkers can appreciate that knowledge needs to be understood in the context in which it is generated, that is, within and from the text of their experiences and cognitions. This critically reflective and contextual state represents a state that genuinely passionate teachers aspire to in their students and one that health care students must arrive at if they wish to develop effective clinical-reasoning and problem-solving skills.
In an attempt to study this theoretic relationship further, Guthrie et al33 hypothesized that the ability to inhibit a stereotypic response was related to the level of intellectual development in the student. After studying 48 university students ranging from freshmen undergraduates to doctoral-level students, they found that intellectual development was significantly related to levels of prejudice toward African Americans and homosexuals and overall tolerance. In contrast, higher levels of prejudice and lower levels of tolerance were found in individuals who demonstrated lower levels of intellectual development. Interestingly, all subjects who scored below the mean value on levels of tolerance demonstrated levels of thinking at or below (prereflective) the quasireflective level. It appeared that the quasireflective level of thinking was the “cutoff point” for developing a more tolerant opinion of other, diverse people and ideas.33 In their conclusion, the authors steadfastly argued that their findings offer preliminary evidence of tolerance for diversity being related to a student's level of reflective judgment. That is, a student's intellectual maturity and depth will have a profound effect on the ways he or she approaches and resolves complex, ill-structured problems, including racism, xenophobia, discrimination, and justice.
Results of these unique and fascinating studies suggest that efforts within higher education to develop and build students' reflective-thinking ability, both in and out of the classroom and across disciplines, can have a strong, positive, and corollary impact on levels of tolerance and prejudice toward other groups.32,33,36 When observed in context with Kogler's32 model, one can surmise that teaching diversity can improve intellectual development and higher-level thinking, just as teaching critical and reflective thinking through other means and methods can improve levels of tolerance and social awareness. Incidentally, similar results have also been found with advanced mathematics and science students who have been involved in comprehensive multicultural educational experiences.9 In the words of Chang,36 who found experimental support for the same phenomenon in his own work, “…enhancing students' ability to think critically about class differences, for example, will also improve one's ability to appreciate cultural pluralism and to analyze inequalities that are manifested through racial, gender, or sexual orientation differences.” If this process is done openly, patiently, and systematically, the binary goals of optimizing intellectual maturity and tolerance can be promoted and achieved in a complex, yet simple, symbiotic, and cyclic process of learning and development.
Perhaps teaching athletic training students to think critically about the complex interplay at work between subjective and objective information, between a particular abnormality and its clinical manifestation, and between the evaluation and rehabilitation processes will indirectly help them become more reflective and critical in their thinking. Perhaps this development will indirectly lead to higher levels of tolerance and lower levels of prejudice toward other ethnic groups. Alternatively, perhaps instilling and developing a genuine appreciation and mastery of critical multicultural issues will help with the development of physical and cognitive skills pertaining to the medical and human sciences. Perhaps Kogler32 was right in stating that by enhancing our students' intellectual development, we can help create a sense of simulation and thus create an opaque perspective of oneness in our students. Perhaps this “assimilability” will help them to better relate to, communicate with, and appreciate all of their respective classmates, colleagues, patients, and community comrades as they progress with their academic, professional, and social lives.
If athletic training educators are to take an active role toward a more critical and multicultural education, it goes without saying that they must be ready for the pedagogic and personal challenges that such a movement introduces. As educators continue to develop by learning more about critical pedagogy and the various approaches to multiculturalism, they have to gradually become more comfortable with taking part in the larger conversations regarding race, oppression, discrimination, and what it takes to be an active, participating member of a true and just democracy. Increasing the awareness of and comfort level with these critical issues will subsequently allow the individual to bring a humanistic and social discourse into the classroom and clinical experiences for all students. Obviously, this process is neither easy nor painless, and it can require significant work, energy, confusion, and even tension among the participants active in such a movement. From this perspective, then, it is important to realize that there exists no simple plan or recipe for implementing a multicultural initiative into the already dense undergraduate athletic training curriculum. In fact, one of the central tenets of critical multiculturalism is that there is no single recipe for success and that attempts to formulate or advocate one particular method will actually be counterproductive and damaging to the central purpose.15,20 As such, all educators will need to personally evaluate their respective knowledge bases, experiences, comfort levels, resources, and educational philosophies before deciding upon a particular action plan to address some of the directives suggested herein. Indeed, this is not an easy issue for any educator, especially one in a technical and specialized field such as athletic training, already dense with content and proficiencies. But it is an issue that demands exploration, energy, and creativity by all who are interested in the ethical and social responsibilities associated with education.
Diversity is much more than just race—it includes religion, class, sex, sexuality, and a multitude of ethnic cultures. This is the first point that must be realized and addressed by all citizens interested in meaningful change. Ironically, it is also a conceptual stumbling block that often gets in the way of real progress (assuming that diversity includes only race and, even worse, that it is only an issue of black and white). As educators wishing to endorse and promote social change and a better life for all through critical and meaningful education, they must first start by questioning and expanding the understanding of the self. In general, individuals who have never had their ideas and conceptions of “others” challenged and reformulated with critical reflection, learning, and experience cannot expect to initiate a critical transformation of their students. Critical educators must seek out new sources of knowledge, alternative ways of seeing and feeling, and deeper understandings of the real issues that confront society and its future well-being. Academic scholars from all disciplines must continue to read related scholarship from the pedagogic and social sciences, and they must subsequently engage in meaningful dialogue with students, themselves, and colleagues and reflect on and experience all the factors that combine to make this issue complex and wide open. Athletic training education must promote the ability to create and carry on meaningful discourses that cause each person to reflect, reformulate, and transform our respective ways of seeing, hearing, and thinking. Once the reflective seed is planted, the road toward a better understanding and conversation may become easier and less traumatic for everyone. Being afraid to offend may be considerate and polite for the intended object of concern, but ultimately it is detrimental to the development of meaningful relationships and ways of understanding. Being afraid to bring up questions and concerns that one carries causes one to eventually develop assumptions and misconceptions that rankle in the mind and make it increasingly difficult to initiate genuine and honest conversation.
So, how do concerned and interested educators begin this arduous journey? In short, we must begin by looking at what is excluded from our curricula and perhaps even at what should be added or returned to the curriculum—the humanistic and sociocultural aspects of education and health care delivery. For many people, this requires improving self-awareness and challenging the self to identify with their personal history, race, ethnicity, and culture first. Critically reflective educators must start talking, exploring, and allowing their individual and collective positions to be challenged and flexible to reformation and enhanced clarity. In effect, an educator must begin this internal process of critical discourse with the self before he or she is able to externalize perspectives and initiate like conversations with others. Once the internal process is under way, the educator will likely feel more able and confident about externalizing critical discourses with others, where the outcomes and directions are unpredictable and complex.
Simple class activities that promote student dialogue, exploration, and sharing in and among the group can help to loosen up lines of discourse, whereas more explorative exercises that allow students to identify and elaborate upon their personal ethnic and cultural backgrounds will provide a grounded sense of interest, importance, and perhaps even relevance to the larger learning objectives. Once personal boundaries and viewpoints have been laid out and explored, diversity issues relative to the practice and provision of athletic training services can then be incorporated into the curriculum at appropriate moments. Questions such as “How might your personal cultural perspective affect your practice as an athletic training student?” and “How might patients from different cultural backgrounds interpret your language, comments, and behavioral patterns?” can thus become recurring and central themes in all didactic and clinical learning experiences. As part of the educational reform currently under way, the competencies regarding the evaluation and management of specific abnormalities and diseases in active populations have been expanded. Underlying these new competencies are additional opportunities for athletic training educators to embrace and incorporate specific elements of sociocultural medicine. Specifically, assignments and presentations regarding diseases, such as sickle cell anemia, can be expanded to include cultural, social, and racial factors that are part of the disease's manifestation.7,19
Having students write an autobiographical paper including pertinent issues relative to diversity, race, culture, discrimination, etc, serves multiple purposes: it can help the educator to better know individual students; it introduces an additional informal writing exercise into the curriculum and may, therefore, help improve students' writing skills; and most importantly, it provides the students an opportunity to be heard without prejudice or grade concerns, and it lets the students know there is an interest in their stories. In my experience, autobiographical essays are extremely enlightening, liberating, and exciting for the reasons mentioned above, and they have provided numerous openings for conversation and inquiry with particular students and for class discussions. An additional resource for athletic training education program directors involves the experiences and perspectives of ATCs who have themselves worked in clinical, industrial, and high school settings and thus have significant life experiences with diversity and other critical elements of multiculturalism. Professionals such as these are often invited on campus to share the various responsibilities, highlights, and pitfalls of their respective professional settings, but how often are nontechnical issues pertaining to multicultural awareness and practice the focus of the presentation?
Perhaps the easiest and most accessible way for educators interested in such an approach is to simply peruse their respective university course catalogues in search of classes that may help promote deeper, more critical levels of thinking and introspection. Although the list is certainly not meant to be all-inclusive, courses in cultural anthropology, women's studies, African American issues, philosophy, religious studies, and many other subjects that are universally offered will help to give students a critical and transformative intellectual start. Some of us will have to go back into the classroom or visit sections of the library with which we are unfamiliar. We may be obliged to engage more critically with colleagues from other academic departments on campus. In some programs, the opportunity may exist for program directors to develop or adapt a seminar-type class specifically for their student majors, which formally brings issues of identity, race, sex, culture, philosophy, sociology, and anthropology into the didactic setting for athletic training majors. If this opportunity does not exist in practice, then in-services, seminars, and workshops can be developed and presented for all students, staff, and instructional faculty, with or without help from other, more experienced scholars from other departments on campus. Initially, this progressive and forward-thinking process may require the expertise and cooperation of more experienced and diverse scholars from the humanities, but the athletic training professional can help to center the class experiences and conversations on pertinent issues relating to science, medicine, and health care. In fact, it may actually prove to be more productive for athletic training students to undertake such a journey with someone from within the field (ie, an ATC) so they can see the intellectual, nontechnical, and personal elements of athletic training, which traditionally embodies other academic specialties.
The humanities and social science classes are not the only place where these conversations and explorations can occur; the natural and hard sciences are rapidly and progressively being seen as appropriate and important venues for multicultural transformation. For example, Clark9 highlighted the effectiveness of a learning interest culture initiative employed at the University of California at Berkeley by advanced mathematics professors. This creative pedagogic tool was developed through workshops in which each student's evaluation was based upon the collective results of a problem-solving project involving a group of diverse students. In effect, students from different backgrounds and cultural perspectives were put together, assigned a complex problem, and confronted with the prospect of learning how to overcome communication and interpretation barriers that often interfere with group learning. According to those involved with the learning interest culture project at Berkeley, this creative initiative has had the effect of reducing racial tensions at the university and other places where it has been employed.9 Surely creative, willing, and energetic athletic training educators could develop similar learning interest culture projects around clinical case-pattern presentation problems, injury and pathophysiology case studies, and rehabilitation protocols.
Over the last few years, our field has witnessed some remarkable educational and professional reform efforts, all designed with honest intentions to redefine and advance the profession of athletic training. The restructuring of educational practices and guidelines in both the classroom and clinical settings, eliminating the internship route to certification in order to increase quality control over entry-level education, adding new clinical proficiencies to reflect the diverse work settings and role delineation of athletic trainers, and the implementation of a clinical-instructor training program certainly have their honorable intentions and pedagogic merits. Many of the reforms currently in place or scheduled for future implementation are welcome and long-overdue additions to the educational and professional process, but concern among educators and program directors regarding the additional administrative responsibilities associated with the current educational culture shift is growing. As well intended as these changes appear on paper, the current strong emphases on technical expertise and measurable outcomes by ongoing reform activities and the new paradigm being realized for entry-level athletic training education should arouse legitimate concern over the potential hyperspecialization of our future professionals. If left unchecked and if those empowered to legislate and regulate the educational processes fail to critically evaluate the bigger scope of the educational mission, athletic training educators potentially face the risk of becoming even further isolated from the traditional mission of the academy. It is conceivable (and more than likely already in effect in some places) that athletic training educators and students alike will become so engrossed in the pedantic aspects of the athletic training education process (and with passing the certification examination) that they might just forget, ignore, underestimate, or simply not be cognizant of the significance and excitement of becoming an educated citizen for a true democratic society. The fact that athletic training is now considered to be a highly specialized and evolved subdiscipline of medicine is not a creditable excuse; this transformative reality does not allow athletic training educators to cleanse their hands of the larger responsibility associated with higher education. Rather, it should serve as a strong motivation to show other, more traditional academic disciplines that the discipline of athletic training rightfully belongs in the academy and that athletic training professionals do have a critical substance and possess some semblance of worldly intellectualism.
If this educational oversight is allowed to fester and grow into an inescapable trend with unstoppable momentum, athletic training educators may well be implicated in the failure to produce reflective, socially conscious, intellectually curious, and globally minded students ready to embrace the civic responsibilities of the present and future worlds. Do we, as higher educators, mentors, and intellectual scholars want to be complicit (either actively or passively) with the large number of educators who ignore or perpetuate the significance of multicultural education and its potential impact on the society that we all live in? Are we really doing our jobs as college and university educators if 100% of our students graduate with a bachelor's degree and pass the certification examination, yet cannot even begin to comprehend the experiences and social realities of diverse populations? Are we deemed successful if all of our students become gainfully employed upon matriculation, yet are unable to engage in a meaningful dialogue with a member of another racial, ethnic, or cultural group about a complex and sensitive issue, or if they are unable to effectively communicate and understand the historical and social plight of their colleagues and patients? Is it all right if most of our athletic training students have no working knowledge of critical sociopolitical issues concerning race, discrimination, identity, or diversity and how these issues are deeply interconnected with their professional identities? In short, is it desirable for our students to leave the clutches of our control and influence without undergoing some small semblance of intellectual transformation that equips them for life beyond the walls of athletic training and sports medicine? I, for one, would like to think not.
As eloquently stated in The Commitment to Quality as a Nation Goes to College by the Association of American Colleges and Universities, “Academia has long described its highest quality education as liberal education, preparation for a life as well as a living; education for civic engagement as well as workplace intelligence.”4 Perhaps it is by this simple, yet significant, statement that all educators should measure their respective worth, progress, and more importantly, their meaningful and lasting contributions to society. Using definitions of multicultural education put forth by various multicultural scholars in our interpersonal, didactic, and clinical experiences with our students will go a long way toward educating athletic training students to become critical and active agents in a democratic and rapidly evolving social landscape—a landscape that definitively includes athletic training professionals.14,16,20,21 It is quite clear that athletic training educators cannot do it alone and that this is indeed a tall order to fill, but it needs to start somewhere and somehow. Because of the intense and formal nature of our educational programs, athletic training educators arguably spend more interpersonal and class time with their students over the course of their program of study than many, if not most, other academic majors. This unique environment provides program directors and other athletic training educators with an unbridled opportunity to explore, discuss, probe, and transform their students in innumerable, immeasurable, and unpredictable ways. Some of that valuable time needs to be spent developing and educating the whole person to be a critical and reflective citizen. If the process is performed effectively, the rewards will be numerous and significant, including but not limited to enabling future health care professionals to deal with cross-cultural experiences, to improving their critical thinking and clinical-reasoning skills, and to inspiring students to be critical agents in a world that benefits all, athletic trainers included.
Future work in this area should focus on various and creative strategies for implementing a multicultural agenda to athletic training education program curricula and on the analysis of the associated benefits and outcomes of such educational strategies. In this light, athletic training educators must seek out, understand, embrace, and effectively implement a critical multicultural perspective to the current athletic training curriculum. The future is now, the future is in our hands, and as Hannam1 so clearly pointed out, we are ethically and professionally responsible for preparing competent athletic trainers who are also socially conscious, civic minded, and critically aware of their roles in this ever-changing, democratic society. Perhaps multicultural education is one door that may help to open these pathways.