Portability of United States Athletic Training Education in an International Setting

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1 ATHLETIC TRAINING EDUCATION JOURNAL Q National Athletic Trainers Association ISSN: X DOI: / ORIGINAL RESEARCH Portability of United States Athletic Training Education in an International Setting Hideyuki Izumi, PhD*; Masaaki Tsuruike, PhD, ATC *Tokyo Ariake University of Medical and Health Sciences, Japan; San José State University, CA Context: United States-educated athletic trainers (ATs) are expected to have more opportunities in the international environment as the number of mutual recognition agreements grows. However, no information is available from existing studies regarding the portability of current US athletic training education in an international environment. Objective: To determine if there are differences in the practices and perceptions of ATs tasks between US-educated Japanese ATs and Japan-educated Japanese ATs. Design: Cross-sectional study. Setting: Analysis of secondary datasets from the Global Practice Analysis Survey. Patients or Other Participants: Two hundred seventeen Japanese ATs in Japan, of whom 34 were educated in the United States and 183 completed the required coursework to be certified by Japan Sports Association. Main Outcome Measure(s): Fisher exact tests were used (P,.05) to determine the difference in each of 24 task ratings in terms of the criticality, importance, and frequency dimensions between the 2 groups. Further, Spearman s ranked correlation, in which rankings were based on the average score of 4-point Likert scales (P,.05), were used to compare priorities regarding the 24 tasks between the 2 groups. Results: Differences were identified for only 2 tasks among 72 (24 tasks for 3 dimensions) in task-level evaluations. The correlation coefficients were as follows: criticality ¼ 0.92 (P,.01), importance ¼ 0.93 (P,.01), and frequency ¼ 0.92 (P,.01). Conclusions: There were negligible differences in the practice patterns and perceptions between those trained in Japan and those who were US trained, indicating that US athletic training education prepares Japanese students well to work in Japan and may be portable internationally. Key Words: Athletic training and therapy (ATT), Global Practice Analysis (GPA), mutual recognition agreement (MRA) Dr Izumi is currently Associate Professor of Tokyo Ariake University of Medical and Health Sciences. Please address all correspondence to Hideyuki Izumi, PhD, Tokyo Ariake University of Medical and Health Sciences, Ariake, Koto-ku, Tokyo , Japan. h-izumi@tau.ac.jp. Full Citation: Izumi H, Tsuruike M. Portability of United States athletic training education in an international setting. Athl Train Educ J. 2018;13(1): Athletic Training Education Journal j Volume 13 j Issue 1 j January March

2 Portability of United States Athletic Training Education in an International Setting Hideyuki Izumi, PhD; Masaaki Tsuruike, PhD, ATC KEY POINTS There are minimal differences in the practice patterns and perception of Japanese athletic trainer educated in Japan and those educated in the United States. The result indicated that US athletic training education prepares Japanese students well to work in the Japanese environment. This result suggests US athletic training education model may be portable internationally and play a key role in global standardization of athletic training education. INTRODUCTION As athletic training and therapy (ATT) is becoming more global, US-educated athletic trainers (ATs) are expected to have more opportunities in the international environment. However, it is necessary to examine whether current US athletic training education is portable. Further, does it prepare students to experience international opportunities to meet the health care needs of athletes and physically active populations in different countries? In 2005, under initiatives of the World Federation of Athletic Training and Therapy (WFATT), for further expansion of knowledge and understanding of the ATT profession, a mutual recognition agreement (MRA) was signed by the Board of Certification, Inc (BOC) and Canadian Athletic Therapists Association. 1 On September 4, 2014, Athletic Rehabilitation Therapy Ireland also officially signed the MRA with BOC and Canadian Athletic Therapists Association in Dublin, Ireland. 2 The MRA has now become a trilateral agreement regarding athletic training credentials across the United States, Canada, and Ireland. This trend is expected to continue to grow in the future. 3,4 The MRA has recognized international credentials for ATT professionals, granting them eligibility to challenge national certification exams in each partner jurisdiction. United States-educated ATs are expected to have more international opportunities; however, US athletic training education is designed based on information from a practice analysis conducted domestically, rather than internationally. 5,6 Consequently, in their programs, students are not required to complete any specific courses as preparation for work in an international environment. To date, no research has been conducted to assess the portability of US athletic training education programs to prepare students for working in another country. For many years, international students have had the opportunity to enroll in US athletic training education programs, which are currently known as Commission on Accreditation of Athletic Training Education accredited programs. Many graduates of these programs have since returned to their home countries to work as ATs. Since the 1970s, many former Japanese students have studied in the United States, and Japan has the largest number of US-certified ATs living there. 7 In fact, more than 250 Japanese certified ATs now work in their home country. 8 However, no prior study has compared the practices and perceptions of US-educated Japanese ATs with those of Japan-educated ATs to identify the international portability of US athletic training education. Therefore, the purpose of the study was to determine if any differences existed between the 2 groups in terms of their practices and perceptions of ATT tasks. A hypothesis of this study is that the practices and perceptions of both groups would be comparable, and US athletic training education would be portable for an international environment. METHODS Participants This study used existing data from the Japanese version of the Global Practice Analysis (GPA) Survey, which was originally conducted by the BOC/WFATT and 2 other WFATT member organizations in Japan Japan Sports Association (JASA) and Japan Athletic Trainers Organization (JATO). Japan Sports Association was founded in 1911 and has been recognized as the national organization for integrating national sports in Japan. Since 1996, it has provided an accredited athletic training education program and, since 1994, has issued a certified AT (JASA-AT) credential in Japan. 9 Japan Athletic Trainers Organization is a professional organization of Japanese BOC-certified ATs with membership in the National Athletic Trainers Association; further, it is a formal affiliate organization of the National Athletic Trainers Association in Japan. 7 Japan Sports Association conducted the GPA Survey among 1606 registered JASA-ATs. Responses from 497 of these (31.0%) were received between November 24, 2011, and January 31, Japan Athletic Trainers Organization disseminated the survey to 142 US-educated Japanese ATs who were regular members (BOC-certified Japanese ATs) and who had not participated in the WFATT/BOC or JASA surveys. Subsequently, 52 responses (36.6%) were received between November 11 and December 11, Japan Sports Association and JATO approved use of data obtained from the GPA Survey for this study. Further, the purpose of this study was approved by the university s institutional review board. Instruments The GPA was developed by the BOC in cooperation with several delegates from WFATT member organizations. The GPA questionnaire was developed with the method used to create the Role Delineation Study, 5th edition, for which validity and reliability have been confirmed. 5 Initially, the BOC invited ATT professionals throughout the world to a meeting held in Chicago, Illinois, in January The following 8 ATT organizations sent delegates to this meeting: 1. The Board of Certification, Inc (US) Athletic Training Education Journal j Volume 13 j Issue 1 j January March

3 2. The National Athletic Trainers Association (US) 3. The Spanish Association of Sports Nurses (Spain) 4. The Canadian Athletic Therapists Association (Canada) 5. The Japan Sports Association (Japan) 6. The Japan Athletic Trainers Organization (Japan) 7. The Biokinetics Association of South Africa (South Africa) 8. The Taiwan Athletic Trainers Society (Taiwan ROC) A panel of experts was assembled by the delegates from these participating organizations to discuss the practices of ATT professionals in their respective countries. The panel identified common areas of practice and major responsibilities performed by ATT professionals in their respective countries and described the essential ATT tasks for each domain. The GPA Survey consists of 2 parts: the first part contains questions regarding demographics (ie, sex, age) and personal background (ie, 11 items including years of experience, profession, and skill level of the athletes with whom a professional works). The second part of the survey analyzes 24 ATT tasks from 4 performance domains: assessment with 5 tasks, intervention with 11 tasks, administration with 5 tasks, and education with 3 tasks. The tasks were determined by the panel of experts representing ATT organizations from 6 countries. (See Appendix for descriptions of the tasks.) Each of the 24 tasks was assessed according to 3 dimensions: criticality, importance, and frequency. Participants were asked to rate each of the 24 tasks based on these dimensions using a 4-point Likert scale. The operational definition of criticality was the degree to which adverse effects could result if a health care professional is not competent in a performance domain. A 4-point scale (0 ¼ causing minimal harm, 1 ¼ causing moderate harm, 2 ¼ causing substantial harm, 3 ¼ causing extreme harm) was used to rate this dimension. Regarding importance, described as the degree to which knowledge in the performance domain is essential to the job performance of a minimally competent health care professional, the 4-point scale included the following assessments: 0 ¼ of little importance, 1 ¼ moderately important, 2 ¼ very important, and 3 ¼ extremely important). For frequency, the 4- point scale (0 ¼ rarely, 1 ¼ infrequently, 2 ¼ frequently, 3 ¼ repetitively) was used to describe how frequently ATT professionals performed each task. The operational definition of frequency was represented by the question, How much time does a health care professional (ie, a certified AT or athletic therapist, sports physiotherapist, sports nurse) spend performing duties or using the principles associated with each performance domain? For the GPA, all data were collected anonymously. Global Practice Analysis Survey (Japanese Version) The Japanese version of the GPA Survey was developed by JASA. The original version was translated into Japanese by a bilingual AT with both US- and Japan-issued certifications. To confirm that the translation accurately reflected the original contents, the draft of the translated survey was reviewed and edited by a person with both US and Japanese athletic training credentials who had participated in the development of the original GPA Survey at the Chicago meeting. Furthermore, JASA added 9 items to the demographic and background sections, including years of certification, other credentials, activity types, and salaries, so that it would be comparable to the survey for ATs that they had conducted prior to the GPA Survey. Additionally, some questions in the background section were modified, such as the question regarding practice requirements, since athletic training is not regulated in Japan. No modifications were made to the explanation of the GPA Survey, including the definitions of each dimension and survey questions in the practice analysis (second part). A statistical analysis was conducted to examine the internal reliability of the Japanese version of the GPA Survey. We used Cronbach a coefficient and set it a priori at Cronbach a coefficient for the Japanese version was This result showed that the internal reliability of the Japanese version of the GPA Survey was acceptable. PROCEDURES Regarding the JASA dataset, information for this study was extracted only from those respondents who indicated that they had trained and practiced in Japan. Regarding the JATO dataset, this study used the data of regular members who had received athletic training education in the United States and chose to practice in Japan. Only data from those who identified their profession as athletic trainer or athletic therapist were extracted. Ultimately, 217 individuals responded to the GPA Survey and met all of our inclusion criteria (ie, 34 US-educated Japanese ATs [US-JAT] and 183 Japancertified ATs [JAT]). For this study, each participating organization was asked to provide members demographic data, including gender and age, to test the representativeness of the data. Japan Sports Association provided age and gender information for their registered JASA-ATs, but JATO only provided gender information for its members. The representativeness of each sample was tested using a v 2 test (a,.05). Regarding the representativeness of the data, no differences were observed for US-JATs. However, there was a significant difference among male participants who were JATs compared to the general membership (JAT: v 2 ¼ 4.70, P ¼.03). Regarding age, no differences were observed for JATs. Since the ages of US-JATs were not provided, we could not compare age information (see Table 1). DATA ANALYSIS Descriptive statistics were calculated to report demographic and background information. In this study, calculations performed using descriptive data were based on the number of responses per question since responses to some of the questions were missing. In this study, frequency data for practices and criticality and importance data related to perceptions of ATT tasks performed by US-JATs and JATs were analyzed. The first calculation was the sum of the ratings when more than 80% of the tasks were rated by individuals. For comparison, according to dimension and domain, the total score by dimension and the total score by domain in each dimension were tested using the Kruskal-Wallis test (a,.05) to measure differences between the 2 groups. Fisher exact test was used to compare each of the task ratings between the 2 groups (a,.05). Because data from each of the Athletic Training Education Journal j Volume 13 j Issue 1 j January March

4 Table 1. Group Sex and Age Information of Participants and Population With v 2 Test Results for Representativeness Athletic Trainers Educated in the United States (n ¼ 34) Athletic Trainers Certified in Japan (n ¼ 183) Sample Population Sample Population Sex, No. (%) Male 23 (67.7) 101 (71.1) 157 (85.8) 1477 (79.0) Female 11 (32.4) 41 (28.9) 26 (14.2) 392 (21.0) v 2 (P value).16 (.69) 4.70 (.03) Age, No. (%) Under 25 0 (0.0) 18 (9.8) 145 (7.8) (23.5) 88 (48.1) 899 (48.2) (67.7) 42 (23.0) 447 (23.9) (5.9) 30 (16.4) 303 (16.2).55 1 (2.9) 5 (2.7) 73 (3.9) v 2 (P value) 1.58 (.81) task ratings included 4-point ordinal data and some of the cell counts were less than 5, the v 2 test was less accurate. Tasks were ranked from first (highest priority) to 24th (lowest priority) in each dimension based on mean scores. The highest- and lowest-ranked tasks for each group were compared, and relationships of the rankings between groups were also examined using a Spearman s ranked correlation; the a level was set at.05. For our analysis, the JMP Pro (version 9.02; SAS Institute, Cary, NC) statistical software package was used. RESULTS Demographic and Background Information Regarding gender, both groups were male dominated; however, the JATs had a greater percentage of males than the US-JATs (85.8% versus 67.7%). Regarding age, more than three-fourths of US-JATs (76.5%) were at least 36 years old, whereas more than half of JATs were 35 years old or younger (57.9%). Regarding the highest level of education, more than 40% of JATs selected other, whereas none of the US-JATs chose this category. Furthermore, half of the US-JATs selected master s degree in response to this question. Regarding sports levels and job titles, there were fewer differences between the groups, although some unique characteristics were noted. Approximately one-third of US- JATs selected collegiate (37.5%) as their sports level; in contrast, high school/secondary was identified predominantly for JATs (27.2%). More than 10% of the participants of both groups were working with elite athletes (pro/pro club/olympic; US-JAT: 20.8%; JAT: 16.0%). In terms of job title, US-JATs had the highest percentage of participants listed as head athletic trainer/therapist (41.2%). Athletic trainer/therapist represented the largest group of JATs (33.9%). Table 2 summarizes participants demographic and background information. Comparisons by Dimension and Domain Table 3 shows the results of the comparisons for summed rating scores in the 3 dimensions of criticality, importance, and frequency. The Kruskal-Wallis test indicated that there were no significant differences in ratings in any of the 3 dimensions of criticality [v 2 ¼ 0.12, P ¼.719], importance [v 2 ¼ 0.24, P ¼.624], and frequency [v 2 ¼ 0.95, P ¼.331]. Table 4 demonstrates the results for group comparisons in terms of differences by domain in each dimension (based on the Kruskal-Wallis test). The results showed no differences by domain. Comparisons of Task Rating Further comparisons of task ratings with Fisher exact test revealed that there were significant differences between groups in 2 tasks (2.8%, 2 out of 72 tasks [24 tasks over 3 dimensions]) for all 3 dimensions. One task differed in criticality, and the other task differed in importance. In terms of criticality, Task No. 20, Execute communication responsibilities to the patient and other professionals to ensure quality health care, was identified as having a significant difference in ratings. For this task, more US-JATs chose either causing extreme harm (41.2% [14/34]) or causing substantial harm (35.3% [12/34]) than JATs: causing extreme harm (50.8% [93/183]), causing substantial harm (17.5% [32/ 183]). Therefore, the task of communicating with patients and other professionals was more critical for US-JATs than JATs. Regarding importance, Task No. 13, Use standard techniques to prevent or minimize risk of injury using taping, bracing, immobilizing/splinting, and/or protective equipment, was identified as having a significant difference in ratings. More US-JATs considered this task to be either extremely important (55.9% [19/34]) or very important (44.1% [15/34]) than JATs: extremely important (61.2% [112/183]) or very important (25.1% [46/183]). These results indicate that the application of taping/bracing for injury prevention was more important for US-JATs than for JATs. Please refer to Table 5 for descriptive data associated with task rating comparisons. Comparisons of Highest- and Lowest-Ranked Task Rank for Criticality, Importance, and Frequency Criticality. Concerning criticality, the top-ranked task differed for the 2 groups of participants, whereas the lowestranked task was common for the 2 groups. Task No. 16, Athletic Training Education Journal j Volume 13 j Issue 1 j January March

5 Table 2. Demographic and Background Information of Participants Group ATs Educated in the United States (n ¼ 34) a ATs Certified in Japan (n ¼ 183) a Experience, No. (%),3 y 1 (2.9) 29 (15.9) 3 6 y 5 (14.7) 47 (25.7) 7 10 y 13 (38.2) 34 (18.6) y 13 (38.2) 49 (26.8) y 2 (5.9) 12 (6.6).25 y 0 (0.0) 12 (6.6) Level of sport, No. (%) Pro/pro club/olympic 5 (20.8) 27 (16.0) Semiprofessional 4 (16.7) 38 (22.5) Amateur club 0 (0.0) 7 (4.1) Collegiate 9 (37.5) 34 (20.1) High school/secondary 1 (4.2) 46 (27.2) Other 1 (4.2) 3 (1.8) Highest level of education, No. (%) Bachelor s degree 16 (47.1) 88 (48.1) Master s degree 17 (50.0) 18 (9.8) Doctoral degree (PhD, 1 (2.9) 1 (0.6) EdD) Other 0 (0.0) 76 (41.5) Job title, No. (%) Administrator/program 1 (2.9) 8 (4.4) director AT/therapist 11 (32.4) 62 (33.9) Educator 0 (0.0) 7 (3.8) Head AT/therapist 14 (41.2) 44 (24.0) Staff AT/therapist 3 (8.8) 39 (21.3) Physician extenders 1 (2.9) 20 (10.9) Not practicing 2 (5.9) 1 (0.6) Other 2 (5.9) 2 (1.1) Abbreviation: AT, athletic trainer. a Missing is not counted. Table 3. Comparisons of Sum of the Ratings by Dimensions (Criticality, Importance, and Frequency) Between Athletic Trainers Educated in the United States (US-JAT) and Athletic Trainers Certified in Japan (JATs) Dimension Mean Rank Kruskal Wallis Test Result (a,.05) v 2 df P Value Criticality US-JATs JATs Importance US-JATs JATs Frequency US-JATs JATs 99.4 Table 4. Comparisons of Sum of the Ratings by Domain (Assessment, Intervention, Administration, and Education) in Each Dimension Between Athletic Trainers Educated in the United States (US-JAT) and Athletic Trainers Certified in Japan (JATs) Dimension Score Mean Kruskal Wallis Test Result (a,.05) v 2 df P Value Criticality Assessment US-JATs JATs Intervention US-JATs JATs Administration US-JATs JATs Education US-JATs JATs Importance Assessment US-JATs JATs Intervention US-JATs JATs Administration US-JATs JATs Education US-JATs JATs Frequency Assessment US-JATs 97.1 JATs Intervention US-JATs JATs Administration US-JATs JATs Education US-JATs JATs Execute emergency action plans to facilitate efficient patient care in catastrophic situations, was ranked first by US-JATs, but third by JATs. Task No. 24, Educate appropriate individual(s) about risks associated with participation and specific activities using effective communication techniques to minimize the risk of injury and illness, was ranked first by JATs, but ninth by US-JATs. On the other hand, Task No. 18, Use a human resource and fiscal management system to manage personnel and execute budgeting, accounting, and billing responsibilities, was the lowest-ranked task for both groups. The Spearman s ranked correlation between US-JATs and JATs was r ¼.92 (P,.01) for criticality rankings. Athletic Training Education Journal j Volume 13 j Issue 1 j January March

6 Table 5. Descriptive Statistics of Ratings of Tasks with Statistical Significance (a,.05) Athletic Trainers Educated in the United States, % Athletic Trainers Certified in Japan, % Criticality Task 20. Execute communication responsibilities to the patient and other professionals to ensure quality health care. Causing extreme harm 41.2 (14/34) 50.8 (93/183) Causing substantial harm 35.3 (12/34) 17.5 (32/183) Causing moderate harm 2.9 (1/34) 14.2 (26/183) Causing minimal harm 20.6 (7/34) 17.5 (32/183) (P ¼.044) Importance Task 13. Use standard techniques to prevent or minimize risk of injury using taping, bracing, immobilization/splinting and/or protective equipment. Extremely important 55.9 (19/34) 61.2 (112/183) Very important 44.1 (15/34) 25.1 (46/183) Moderately important 0.0 (0/34) 11.5 (21/183) Of little importance 0.0 (0/34) 2.2 (4/183) (P ¼.034) Importance. In terms of importance, the top-ranked tasks were the same for both groups, although the lowest-ranked task differed. Task No. 8, Employ lifesaving techniques through US standard emergency care procedures to reduce morbidity and the incidence of mortality, and Task No. 16, Execute emergency action plans to facilitate efficient patient care in catastrophic situations, were ranked first (with the same mean among US-JATs) and second for both groups, respectively. The lowest-ranked task for US-JATs was Task No. 19, Design and use a facility management plan to control environmental injury risk, waste disposal, biohazardous waste removal, and equipment maintenance, whereas Task No. 18, Use a human resource and fiscal management system to manage personnel and execute budgeting, accounting, and billing responsibilities, was ranked the lowest by JATs. The Spearman s ranked correlation between the 2 groups for importance was r ¼.93 (P,.01). Frequency. Regarding frequency, the lowest-ranked task was common to both groups, but the top-ranked task differed. The common lowest-ranked task was Task No. 8 (stated previously). The top-ranked task for JATs was No. 5, Palpate the involved area(s) using standard techniques to assess the injury, illness, or condition, whereas Task No. 7, Administer conditioning, prehabilitation, rehabilitation, and functional exercise using appropriate methods and techniques to facilitate recovery, function, and/or physical performance, was ranked highest by US-JATs, but second by JATs. The Spearman s ranked correlation for frequency was r ¼.92 (P,.01). Table 6 provides a summary of the means and task rankings for each dimension. Spearman s ranked correlation coefficients for criticality, importance, and frequency are summarized in Table 7. DISCUSSION This was the first study to compare practices and perceptions of ATT tasks by US-JAT and JAT groups using standardized research methodology. Using the GPA as the basis for country comparisons, it was remarkable that the practice frequency and perceptions of ATT tasks between the 2 groups were minimally different. Of the 3 dimensions examined criticality, importance, and frequency no differences were found. The results of comparison of the various dimensions demonstrated that there were no country-specific response patterns to the GPA Survey. Previous research has shown that there was a country-specific pattern of responses based on country bias when cross-cultural comparison studies were conducted using the Likert scale. 11 However, the results of this study indicated that there were no effects of country-specific ratings in the comparison of the 2 groups that shared the same culture or ethnicity. This finding suggests that educational experience did not change the style of response of the US-JAT group compared to the JAT group. This study demonstrated no differences in the practices or perceptions in domain-level comparisons and a few differences in each dimension s task-level comparisons. Correlation studies indicated that task rankings in practices and perceptions were very similar. Comparisons of task rankings revealed some commonalities in each dimension. These results indicate that there were minimal differences in frequency and perceptions of ATT tasks between the 2 groups. Although most results in this study showed few differences between the 2 groups, it is plausible that the uniqueness identified in task rankings by US-JATs was possibly influenced by their US education. The largest difference between highest- and lowest-ranked tasks was found in the dimension of criticality. Patient education and education of appropriate individuals were much less critical for US-JATs (ninth ranked) than for JATs (first ranked). Emergency care was more critical for US-JATs than JATs. Most of the initial Japanese ATs were licensed therapists, such as massage and acupuncture therapists, and their education did not require emergency care. Their primary role was therapy in a therapy room rather than emergency care on the field of play. 12 On the other hand, the traditional job setting in the United States is college, high school, or professional sports, and ATs are the first responders for emergency care on the field of play or practice. 13 These varying histories of the developing roles of ATT professionals in Japan and the United States Athletic Training Education Journal j Volume 13 j Issue 1 j January March

7 Table 6. Means and Rank (1 24) of Each Athletic Training/Therapy Task Rating in Criticality, Importance, and Frequency Between Athletic Trainers Educated in the United States (US-JATs) and Athletic Trainers Certified in Japan (JATs) Task No. Criticality Importance Frequency US-JATs JATs US-JATs JATs US-JATs JATs Mean Rank Mean Rank Mean Rank Mean Rank Mean Rank Mean Rank a a a a b b a b b b b a a The highest-ranked task. b The lowest-ranked task. might have influenced the perception of emergency care tasks. Another task with differences among the highest- and lowestranked tasks was clinical evaluation, ranked fourth by US- JATs and first by JATs. This finding suggests that the evaluation task has higher priority and is more frequently performed by JATs than US-JATs. One reason may be the regulations related to athletic training practice in Japan. United States-educated ATs may face obstacles in performing certain ATT tasks in foreign countries; in fact, they may need to have a legal background to practice clinical tasks. In Japan, ATs are not recognized as health care professionals and are not regulated. Practicing ATT is often regarded as a gray zone in the Japanese health care system. Under these Table 7. Spearman s Ranked Correlation Coefficients for Criticality, Importance, and Frequency Between Athletic Trainers Educated in the United States and Athletic Trainers Certified in Japan Dimension Correlation Coefficient (P Value) Criticality 0.92 (,.01) Importance 0.93 (,.01) Frequency 0.92 (,.01) circumstances, those who wish to work as ATs often seek licenses in related health care professions such as physical therapists, massage therapists, or acupuncture therapists. 14 In fact, 72% of full-time ATs certified in Japan have licenses in other health care professions. 15 Education for other health care professionals does not require a bachelor s degree. Instead, they complete a 3-year noncollege degree professional school in Japan. Our demographic data indicate that many JATs chose other to describe their highest level of education, which was consistent with this analysis. There are still a limited number of countries with credentialing systems for ATT professionals and other licensed health care professionals, such as physical therapists and nurses. In the countries where athletic training is not recognized and not regulated by the government, individuals with other health care professional licenses may be practicing as ATT professionals. This situation can be confirmed by member organizations of WFATT that include various health care professionals. 16 A US-educated AT without a license in a related health care area may practice in strength and conditioning, injury prevention, or first aid, which are unregulated areas in Japan. Therefore, US-educated ATs may not have the same priorities, particularly in clinical tasks, as JATs. LIMITATIONS This study has many limitations that might have affected the analyses. The first limitation relates to the influence of the Athletic Training Education Journal j Volume 13 j Issue 1 j January March

8 sample s nationality on the results. This study involved a comparison of JATs with US-JATs returning to Japan, their home country. However, there was no comparison of these groups with ATs of other nationalities, such as American ATs who were practicing in Japan, because of an unavailability of samples. The native origins of the subjects, rather than their educational differences, might have influenced their rating patterns in the GPA Survey results, although having the same nationality helped to avoid a countryspecific rating bias in our study. In addition, there is the possibility that the comparisons observed between the 2 groups might only be applicable to the Japanese. Thus, a further study is needed with a sample of ATs who practice in nonnative countries for generalizable findings applicable to ATT professionals from other countries. The second limitation relates to the influence of the experience in Japan on perceptions and practices of US-JATs, who are more experienced than JATs. As a result, there is a possibility that their perceptions may be influenced by their experience. This study did not include a postanalysis using years of experience. Furthermore, US-JATs with more years of experience might have already adapted to the environment in Japan. Even with these limitations, this study was unique in its examination of the portability of US athletic training education to an international setting. The study findings are encouraging for US athletic training educators and athletic training students who study in the United States and wish to collaborate with ATT professionals in other countries or work in an international setting. CONCLUSIONS To sum up, the findings of the current study point to negligible differences in the practice patterns and perceptions of those trained in Japan and those trained in the US, indicating that US athletic training education prepares Japanese students well to work in the Japanese environment and may be portable internationally. This conclusion will encourage the global application of the US model of education and play a key role in global standardization of athletic training education. REFERENCES 1. Ferrara MS. Globalization of the athletic training profession. J Athl Train. 2006;41(2): Athletic therapists expand their international reach. Athletic Rehabilitation Therapy Ireland Web site. 09/athletic-therapists-expand-their-international-reach/. Accessed October 28, Ferrara MS. Ortega C. That was then and this is now! Int J Athl Ther Train. 2011;16(1): Kanazawa TJ. JASA-AT Qualification. Jpn J Athl Train. 2017; 2(2): Board of Certification Inc. Role Delineation Study for the Entry- Level Certified Athletic Trainer. 5th ed. Omaha, NE: Board of Certification; National Athletic Trainers Association. Athletic Training Education Competencies. 5th ed. Dallas, TX: National Athletic Trainers Association; 2011: Takahashi T, Izumi H, Shikakura J. The past, present and future of Japanese Athletic Trainers Association. Jpn J Athl Train. 2017;2(2): Basic online verification. Board of Certification, Inc Web site. Accessed June 16, Japan Sports Association. Role of Athletic Trainer. Bunkyu-ku, Tokyo, Japan: Bunkodo; Global practice analysis 2012 report. Japan Sports Association Web site. doc/jasa_gpa_report.pdf. Accessed June 9, Heine SJ, Lehman DR, Peng K, Greenholtz J. What s wrong with cross-cultural comparisons of subjective Likert scales? The reference-group effect. J Pers Soc Psychol. 2002;82(6): Mizoguchi H, Izumi H, Koyama K, Sasaki S. History and evolution of trainers in Japan. J Tokyo Ariake Univ Med Health Sci. 2010;2: Ebel RG. Far beyond the shoe box. Fifty years of the National Athletic Trainers Association. New York, NY: Forbes Custom Publishing; Izumi H, Koyama K, Sasaki S, Mizoguchi H. Athletic trainers in Japan part-3: Additional credential JASA-ATs hold and work style as an AT. Presented at the 5th Japan Athletic Trainers Society Scientific Meeting; July 9, 2016; Ariake, Tokyo, Japan. 15. Izumi H, Koyama K, Sasaki S, Mizoguchi H. Athletic trainers in Japan part-1: Characteristics of full-time JASA-ATs. Presented at the 5th Japan Athletic Trainers Society Scientific Meeting; July 9, 2016; Ariake, Tokyo, Japan. 16. Member associations. World Federation of Athletic Training and Therapy Web site. Accessed April 27, Appendix. Athletic Training Tasks in Global Practice Analysis Survey Task Number and Description a 1. Perform preparticipation and other relevant screening (eg, dietary, physical, psychological) in accordance with accepted guidelines to determine preparedness for activity and minimize the risk of injury and illness. 2. Formulate a clinical impression by interpreting the history, signs, symptoms, severity and predisposing factors of the injury, illness, or condition and determine the appropriate course of action (eg, treatment, return to play). 3. Identify safety hazards associated with physical activities, facilities, and protective equipment by following accepted procedures and guidelines to make appropriate recommendations and to minimize the risk of injury and illness. 4. Monitor participants and environmental conditions by following accepted guidelines to promote safe participation. 5. Palpate the involved area(s) using standard techniques to assess the injury, illness, or condition. 6. Understand the concepts of tissue healing and the administration of therapeutic modalities to facilitate recovery, function, and/or physical performance. 7. Administer conditioning, prehabilitation, rehabilitation, and functional exercise using appropriate methods and techniques to facilitate recovery, function, and/or physical performance. Athletic Training Education Journal j Volume 13 j Issue 1 j January March

9 8. Employ life-saving techniques through the use of standard emergency care procedures to reduce morbidity and the incidence of mortality. 9. Use standard accepted procedures for the transport, ambulation, stabilization, and/or immobilization to minimize for the injury or structural damage to an injured person. 10. Use standard accepted techniques to triage patients with medical emergencies. 11. Ensure compliance with World Anti-Doping Agency guidelines of pharmaceutical and nutraceutical (supplements, ergogenics, herbal remedies) products to facilitate recovery, function and performance. 12. Facilitate and/or conduct doping control programs in compliance with World Anti-Doping Agency or domestic doping control agencies to protect the athlete s health and to ensure fair play. 13. Use standard techniques to prevent or minimize risk of injury using taping, bracing, immobilization/splinting and/or protective equipment. 14. Facilitate appropriate medical referral and consultation of injuries and illnesses. 15. Facilitate the withdrawal of participants from the field of play to prevent or reduce injury or illness. 16. Execute emergency action plans to facilitate efficient patient care in catastrophic situations. 17. Utilize an information management system to maintain medical records and ensure compliance with accepted best practice guidelines. 18. Utilize a human resource and fiscal management system to manage personnel and execute budgeting, accounting, and billing responsibilities. 19. Design and use a facility management plan to control environmental injury risk, waste disposal, biohazardous waste removal, and equipment maintenance. 20. Execute communication responsibilities to the patient and other professionals to ensure quality health care. 21. Develop emergency action plans to facilitate efficient patient care in catastrophic situations. 22. Educate the patient to improve their physical condition and lifestyle. 23. Engage in continuing clinical education activities to maintain competence. 24. Educate appropriate individual(s) about risks associated with participation and specific activities using effective communication techniques to minimize the risk of injury and illness. a Assessment (#1 #5), Intervention (#6 #16), Administration (#17 #21), Education (#22 #24). Athletic Training Education Journal j Volume 13 j Issue 1 j January March