Female Athletic Training Students' Perceptions of Motherhood and Retention in Athletic Training

Context:

Motherhood appears to be a catalyst in job turnover for female athletic trainers, especially those employed at the National Collegiate Athletic Association Division I level. However, most researchers examining this topic have investigated the perspectives of those who are currently employed rather than those who are preparing to enter the profession.

Objective:

To evaluate female athletic training students'' perceptions of motherhood and retention.

Design:

Qualitative study.

Setting:

Athletic training education program.

Patients or Other Participants:

A total of 18 female athletic training students volunteered to participate. They were enrolled in 1 Commission on Accrediting Athletic Training Education–accredited athletic training program and represented 3 levels of academic study.

Data Collection and Analysis:

The participants responded to a series of questions related to work–life balance and retention in athletic training. Analysis of the data followed a general inductive process. Credibility was established by interpretive member checks and peer review.

Results:

The first theme, clinical setting, speaks to the belief that work–life balance and retention in athletic training require an employment setting that fosters a family-friendly atmosphere and a work schedule (including travel) that allows for time at home. The second theme, mentorship, reflects the acknowledgment that a female mentor who is successful in balancing the roles of mother and athletic trainer can serve as a role model. The final theme, work–life balance strategies, illustrates the need to have a plan in place to meet the demands of both home and work life.

Conclusions:

A female athletic trainer who is successfully balancing her career and family responsibilities may be the most helpful factor in retention, especially for female athletic training students. Young professionals need to be educated on the importance of developing successful work–life balance strategies, which can be helpful in reducing attrition from the profession.Key Words: athletic training careers, work–life balance, mentors

Key Points

• Balancing the demands of a career, parenthood, and life can be difficult for all professionals, including female athletic trainers, and may affect their choice of work setting and their decision to remain in or leave the profession.
• Among the factors that can help female athletic trainers in the collegiate setting attain work–life balance are supportive work and home environments, flexible schedules, and good time-management skills.
• Female athletic trainers who have learned to balance their career and family responsibilities can serve as role models for students and young professionals.

Comparable with other occupational settings,¹ the athletic training profession has seen a steady increase in the employment of female athletic trainers, who now constitute 52% of the National Athletic Trainers'' Association membership.² These demographic data are somewhat deceiving in not reflecting age or employment setting, which reveal attrition from the profession and collegiate setting once a woman begins a family.³ The reasons for departure from the college or university clinical setting appear to be multifaceted, including irregular work hours, inflexible work schedules, and travel.^3,4 Mazerolle et al⁴ found that only 22 women with children were employed in the collegiate setting, a statistic supported by Milazzo et al⁵ and Kahanov et al.⁶ Similar to Mazerolle et al,³ Milazzo et al⁵ reported a small number of women with children in the collegiate setting, and Kahanov et al⁶ noted that only about one-fourth of all athletic trainers (ATs) in the collegiate setting are women. Furthermore, Kahanov and Eberman⁷ found that at about age 28, female ATs tend to leave the athletic training profession and postulated that work–life balance concerns have the greatest influence on occupation change.Work–life balance issues and time for parenting influence the decision to persist at the collegiate and professional levels, where job responsibilities include long hours (>40 hours per week) and travel, which can limit time spent at home with family.^3,4,6–8 Employment as an AT within the secondary school setting does not completely mitigate these concerns,⁹ but this setting appears to be seen as more helpful in allowing a woman to manage her parenting obligations.⁶ The literature regarding career planning complements findings that employment policies are important when a female AT selects an employment setting.¹⁰In general, women with or without children appear to experience greater conflicts between work and home than their husbands and men do.¹¹ Gender differences regarding work–life balance conflicts have not been reported within athletic training,³ despite the concerns raised by female ATs about the difficulties associated with parenting due to working long hours.^3,4,6,8,12 Female ATs have opted to leave the profession of athletic training because of work–life balancing problems,^3,8 and this concern seems to filter down to athletic training students (ATSs) because the extensive time commitment and reduced time available for parenting and spousal duties appear to influence retention in athletic training education programs.¹³ The role of the AT is demanding; however, emerging data indicate that work–life balance is possible, regardless of the clinical setting,^9,12,14–16 but it requires personal and professional work–life balance strategies. Furthermore, even after starting a family, female ATs can find success as ATs, including at the collegiate level.¹⁶Mazerolle and Goodman¹⁶ suggested the need for mentorship between mothers who are ATs and future professionals to increase retention. The purpose of our investigation was to explore the perceptions of female ATSs and the viability of a career in athletic training after starting a family. Particular emphasis was placed on their opinions regarding ways to establish work–life balance while managing the roles of AT and mother.     

Physical Activity Participation and Constraints Among Athletic Training Students

Context:Researchers have examined the physical activity (PA) habits of certified athletic trainers; however, none have looked specifically at athletic training students.Objective:To assess PA participation and constraints to participation among athletic training students.Design:Cross-sectional study.Setting:Entry-level athletic training education programs (undergraduate and graduate) across the United States.Results:Only 22.8% (252/1105) of athletic training students were meeting the American College of Sports Medicine recommendations for PA through moderate-intensity cardiorespiratory exercise. Although 52.3% (580/1105) were meeting the recommendations through vigorous-intensity cardiorespiratory exercise, 60.5% (681/1125) were meeting the recommendations based on the combined total of moderate or vigorous cardiorespiratory exercise. In addition, 57.2% (643/1125) of respondents met the recommendations for resistance exercise. Exercise habits of athletic training students appear to be better than the national average and similar to those of practicing athletic trainers. Students reported structural constraints such as lack of time due to work or studies as the most significant barrier to exercise participation.Conclusions:Athletic training students experienced similar constraints to PA participation as practicing athletic trainers, and these constraints appeared to influence their exercise participation during their entry-level education. Athletic training students may benefit from a greater emphasis on work-life balance during their entry-level education to promote better health and fitness habits.Key Words: exercise, leisure constraints, leisure-time exercise questionnaire, work-life balance

Key Points

• Athletic training students experienced similar constraints to physical activity participation as practicing athletic trainers.
• Structural constraints, such as lack of time due to work or studies, were the most significant barriers to exercise participation.
• Emphasizing work-life balance to athletic training students may promote greater opportunities for physical activity participation as both students and future professionals.

Increased emphasis continues to be placed on physical activity (PA) in society as the rates of various preventable diseases have risen as a result of the obesity epidemic.^1–4 Health care professionals are often asked to lead the initiative to promote PA participation. Many health care professionals are educated in the intricacies of PA, and research⁵ has shown that they are more likely to educate patients in the importance of PA if they engage in healthy lifestyle habits themselves. Athletic trainers (ATs) are especially versed in the many aspects of physical fitness, such as exercise program creation, flexibility, muscular strength, cardiorespiratory endurance, fitness testing, and conditioning principles.⁶Athletic trainers typically work in settings where they are sought out for fitness advice and often serve as role models for good PA habits. However, Cuppett and Latin⁷ showed that 16% of ATs participated in no PA. They also demonstrated that despite an AT''s additional knowledge, male ATs did not participate in PA any more frequently than the general population, whereas female ATs exercised more than the general population.⁸ A similar and more recent study⁹ showed that ATs as a whole are more physically active than the general population but still fall short of the American College of Sports Medicine (ACSM)–recommended guidelines.¹⁰ Although investigators have looked at the PA habits of practicing ATs, the PA habits of undergraduate athletic training students (ATSs) are unknown. However, nursing students, like ATSs, complete required clinical education hours. Only 17.4% of first-year nursing students, compared with 25.5% of first-year students in other disciplines, met the ACSM recommendations for PA.⁵ Factors associated with the nursing major, such as the extensive theoretical and practical class schedules, were identified as potential barriers affecting PA participation.⁵ It is possible that these same factors affect ATSs.Among the many perceived barriers to PA participation for ATs are irregular hours, travel, availability, amount of leisure time, and burnout.^9,11,12 Although these barriers have been cited by practicing ATs, it is unclear whether the same barriers affect undergraduate ATSs. Previous researchers¹³ have examined the work-life conflict of National Collegiate Athletic Association Division I ATs and found that ATs needed to “take time for themselves by being involved with outside interests.” The inability to find a successful balance between work and home has contributed to attrition in working professionals.^14,15Undergraduate ATSs are often subjected to similar constraints as certified ATs, with the addition of class work. The accumulation of clinical education hours, along with class load and possibly a job, could present many barriers to PA participation. Therefore, the purposes of our study were to answer the following research questions: (1) What are the ideal and actual PA participation rates for ATSs? (2) Are ATSs meeting the ACSM–recommended levels of PA? (3) What are the perceived barriers to PA for ATSs? and (4) How do the PA habits of ATSs compare with those of practicing ATs?     

Exploring the Athletic Trainer's Role in Assisting Student-Athletes Presenting With Alcohol-Related Unintentional Injuries

Compared with their nonathlete peers, collegiate athletes consume higher quantities of alcohol, drink with greater frequency, and exhibit an increased propensity to engage in heavy episodic drinking (ie, binge drinking), which often may result in alcohol-related consequences. Moreover, collegiate athletes are also more likely to engage in other maladaptive lifestyle behaviors, such as participating in physical fights and riding with an intoxicated driver, and less likely to engage in protective behaviors, such as wearing a helmet while operating a motorcycle, moped, or bicycle. Taken together, these behaviors clearly pose a health risk for student-athletes and increase the likelihood that they will experience an alcohol-related unintentional injury (ARUI). An ARUI represents a risk not only to the health and well-being of collegiate athletes but also to their athletic performances, collegiate careers, and potential professional opportunities. Therefore, athletic trainers need to be equipped with the knowledge and skills to provide face-to-face brief interventions to student-athletes presenting with ARUIs and to evaluate the effect of their involvement. We address potential action items for implementation by athletic trainers.Key Words: collegiate athletes, alcohol use, alcohol-related consequences, interventionsCompared with their nonathlete peers, collegiate athletes consume higher quantities of alcohol, drink with greater frequency, and exhibit increased propensities to engage in heavy episodic drinking (ie, binge drinking).^1–3 Given their high-risk drinking behaviors, student-athletes are more likely to experience alcohol-related consequences.^4,5 Compared with nonathletes, collegiate athletes also are more likely to engage in other maladaptive lifestyle behaviors, such as participating in physical fights and riding with an intoxicated driver, and less likely to engage in protective behaviors, such as wearing a helmet while operating a motorcycle, moped, or bicycle.⁶ Taken together, these behaviors clearly pose a health risk for student-athletes and increase the likelihood that they will experience alcohol-related unintentional injuries (ARUIs). An ARUI represents a risk not only to the health and well-being of collegiate athletes but also to their athletic performances, collegiate careers, and potential professional opportunities. Head athletic trainers (ATs) contend that alcohol abuse during and after athletic and social events continues to be an important concern for the health and safety of student-athletes.⁷In a recent cross-sectional study, Brenner et al⁸ observed that, overall, approximately 18% of collegiate athletes experienced ARUIs and most of these occurred during the athletes'' first and second years in school. Furthermore, they noted that 38% of collegiate athletes identified ARUI as a serious issue facing them.⁸ Moreover, approximately 56% of ATs recently reported that during the 2010–2011 academic year, they evaluated, treated, or referred an average of 3 ARUIs, most of which (63%) were classified as either moderate or severe.⁹Not surprisingly, Brenner et al⁹ observed that most ATs (73.4%) assert that ARUIs are a serious problem affecting the health of collegiate athletes, with 65.7% believing that they should be involved in the alcohol-related screening process for student-athletes. In addition, Brenner et al reported that most ATs contend that more training is necessary to help them (1) identify student-athletes with ARUIs (79%), (2) confront student-athletes with alcohol-related problems (79.7%), and (3) involve themselves in the referral process (92%).⁹ Furthermore, most head ATs have also expressed interest in becoming more involved with alcohol intervention programs.⁷ Considering that most university ATs already are substantially involved with regularly evaluating and treating non–alcohol-related injuries among student-athletes, ATs can and should play important roles in recognizing and evaluating ARUIs among student-athletes, especially given their expressed desire for more training in the intervention, prevention, and referral of ARUIs. Furthermore, ATs view themselves as “safe, approachable, care-taking individuals with whom athletes felt comfortable disclosing personal information,”¹⁰(p150) placing them in a unique position to provide appropriate intervention when necessary.     

Achieving Work-Life Balance in the National Collegiate Athletic Association Division I Setting,Part II: Perspectives From Head Athletic Trainers

Context:Work-life balance has been examined at the collegiate level from multiple perspectives except for the athletic trainer (AT) serving in a managerial or leadership role.Objective:To investigate challenges and strategies used in achieving work-life balance from the perspective of the head AT at a National Collegiate Athletic Association Division I university.Design:Qualitative study.Setting:Web-based management system.Results:Two higher-order themes emerged from our analysis of the data: organizational challenges and work-life balance strategies. The organizational challenges theme contained 2 lower-order themes: lack of autonomy and role demands. The work-life balance strategies theme contained 3 lower-order themes: prioritization of commitments, strategic boundary setting, and work-family integration.Conclusions:Head ATs are susceptible to experiencing work-life imbalance just as ATs in nonsupervisory roles are. Although not avoidable, the causes are manageable. Head ATs are encouraged to prioritize their personal time, make efforts to spend time away from their demanding positions, and reduce the number of additional responsibilities that can impede time available to spend away from work.Key Words: quality of life, supervisory role, retention

Key Points

• Work-life imbalance is inevitable, particularly in the collegiate setting, but is manageable.
• As do athletic trainers in nonsupervisory roles, head athletic trainers can experience work-life imbalance due to role overload and a lack of autonomy over work schedules.
• Head athletic trainers are encouraged to prioritize their personal time, try to spend time away from work, and reduce additional responsibilities that prevent spending time away from work.
• Expectations of the athletes and coaches for medical care during out-of-season training can limit the athletic trainer''s time away, particularly because many are responsible for more than 1 team.

Work-life balance (WLB) is a complex, overarching concept that encompasses the extent to which individuals are equally engaged or satisfied with their work and family or life roles.¹ Achievement of WLB includes the time necessary to meet each role, an emotional investment within each role, and enjoyment and fulfillment from each role.¹ When the demands of either role become overwhelming or difficult to manage, conflict can arise. Work-life imbalance is a documented concern for the medical care provider^2,3 and the athletic training professional.^4–8 Many factors have been linked to the occurrence of work-life imbalance in athletic training; most notable, however, are the time demands associated with patient care and administrative responsibilities held by the athletic trainer (AT) and the inflexibility related to work scheduling.^4,6Athletic trainers working in the collegiate setting can experience conflicts between their workplace and domestic responsibilities,^4–6 primarily due to the unconventional work schedules associated with athletics, long work hours, travel, and the demands and expectations placed on them by coaches.⁶ Whereas the antecedents of work-life imbalance can be multifactorial,^9,10 many appear to be rooted in the organizational structure of the workplace for the collegiate AT. In addition to long, demanding work hours, an inadequate number of full-time athletic training staff also has been identified as a major culprit in work-life imbalance.^4–6,11 Beyond patient care responsibilities, ATs can be engaged in clinical instruction or supervision and administrative duties that compete for their time and energy and may lead to role strain and conflict.¹² Current empirical data present the sources of work-life imbalance from the perspective of the assistant AT, and whereas this is a common position held by ATs in the collegiate setting, information regarding factors leading to conflict for the AT in a supervisory role is limited.^4–6,11,13 In addition to providing patient care, the AT in this role must complete administrative and supervisory responsibilities, which require additional time during the workday. Given that the role of the head AT requires additional responsibilities beyond the role of the assistant AT, a different set of factors can contribute to experiences of work-life imbalance. Therefore, investigating which factors potentially cause stress and conflict from the perspective of the head AT is important.Despite the reports, ATs working in the collegiate setting empirically and anecdotally have been able to establish WLB.⁶ Establishment of WLB requires prioritizing time away from the role as an AT, having personal hobbies and stress-reduction outlets, and establishing boundaries between personal and professional responsibilities.^6,14 Working in the collegiate setting, particularly the National Collegiate Athletic Association (NCAA) Division I setting, is stressful mostly owing to the long work hours and travel. Therefore, time away to rejuvenate and reenergize is necessary to promote continuing professional commitment for the AT.¹⁵ Often, this is accomplished by exercising, spending time with friends and family, and participating in leisure activities.^6,13 A positive workplace culture, specifically having coworkers who share a teamwork mentality and a supervisor who supports and implements WLB policies,¹³ is necessary for the AT to fulfill WLB while fulfilling a full-time role as an AT in the collegiate setting. Research on work-life conflict antecedents and strategies used to reduce their occurrence is often either from the perspective of the assistant AT alone or the perspectives of head ATs are examined collectively with other staff ATs'' perspectives. Furthermore, the head AT is a critical component in creating WLB for the AT and in mentoring, which can be associated with a supervisory role and has been suggested as an important socializing agent in the role of an AT and a means to facilitate WLB.¹³Work-life imbalance is inevitable for every working professional and can be influenced by a host of factors. Specifically, for those working in the sport culture, this can be a combination of organizational, personal, and socioeconomic factors.¹⁰ Little information regarding WLB exists from the perspective of the head AT. Therefore, the purpose of our study was to investigate the workplace dynamic that occurs at an NCAA Division I university and its effect on WLB from the perspective of the head AT. The central research questions guiding our study were (1) What factors or challenges influence the achievement of WLB for the head AT? and (2) What strategies or motivations do head ATs use to personally achieve WLB?     

Perceptions of National Collegiate Athletic Association Division I Female Athletic Trainers on Motherhood and Work-Life Balance: Individual- and Sociocultural-Level Factors

Context

A multilevel model of work-life balance (WLB) has been established in the sports management literature to explain interactions among organizational/structural, individual, and sociocultural factors and their effects on individual responses and attitudes toward WLB. These factors influence experiences and outcomes related to WLB.

Objective

To examine individual and sociocultural factors that may influence perceptions of female athletic trainers (ATs) employed in the National Collegiate Athletic Association Division I setting, particularly any sex-specific influences.

Design

Qualitative study.

Setting

National Collegiate Athletic Association Division I.

Patients or Other Participants

A total of 27 women (14 single with no children, 6 married with no children, 7 married with children) currently employed as full-time ATs in the Division I setting participated.

Data Collection and Analysis

Participants responded to a series of open-ended questions via reflective journaling. Data were examined using a general inductive approach. Trustworthiness was established by multiple-analyst triangulation, member interpretive review, and peer review.

Results

Participants recognized that their sex played a role in assessing WLB and a long-term career as an AT. In addition, they identified various individual- and sociocultural-level factors that affected their perceptions of WLB and attitudes toward a career goal.

Conclusions

Our data suggested that female ATs may hold traditional sex ideologies of parenting and family roles, which may influence their potential for career longevity.Key Words: sex influence, quality of life, retention, attrition

Key Points

• A traditional sex ideology of parenting and family roles may contribute to the persistence and departure of female athletic trainers in the National Collegiate Athletic Association Division I setting.
• Female athletic trainers preferred an adaptive lifestyle, but personal preferences and sociocultural factors also influenced their career decisions.
• Work-life balance is multifaceted, with various factors leading to experiences of conflict.

Work-life balance (WLB) concerns have been identified as having an important effect on the experiences and retention of female athletic trainers (ATs).^1–4 The field of athletic training, for the most part, is unique because these health care professionals work within sport settings. As are coaches^5,6 and physicians,⁷ ATs are susceptible to struggling with WLB because of a myriad of factors related to the organizational demands placed on them. Dixon and Bruening⁵ suggested, however, that WLB is influenced not only by organizational factors but also by individual and sociocultural factors. Traditionally, authors of the WLB literature have examined the construct unidimensionally, looking at it from the organizational, individual, or sociocultural perspective only. However, Dixon and Bruening⁵ argued that individual responses and attitudes toward WLB can influence organizational culture and climate from the bottom up. Thus, they presented a multilevel model that integrates 3 factors to illustrate the complexity of the topic: organizational/structural, individual, and sociocultural.Organizational/structural factors, particularly in the sport industry, have been linked fundamentally to experiences of WLB.^1,8,9 The model that Dixon and Bruening⁵ developed and examined showcases the experiences of female coaches at the National Collegiate Athletic Association (NCAA) Division I level and has application to ATs and other health care professionals who have long (≥8 h) work days. Long and irregular work hours, travel, and time spent at work (ie, “face time” in the office) have been reported as major challenges to WLB for the coach,⁸ with comparable antecedents for physicians⁷ and ATs.^2,9 In fact, long work hours negatively affect the professional commitment of female ATs, who often change employment settings or leave the profession to achieve WLB.^3,10,11Researchers^12–14 have indicated that individuals differ in their experiences of WLB and abilities to cope because of differences in individual characteristics in a given context. These individual characteristics include values, personality, coping skills, support systems, and sex. Often, the negative effects of work-life imbalance stem from internal feelings of conflict. Individual-level differences can be particularly noticeable when examining people in the same or similar occupations. For example, athletic training jobs can be similar in the types of role strain employees face (lack of control over schedules, hours, and travel; perceived inadequate compensations; and overall job demands), but in a recent study, Naugle et al¹⁵ demonstrated that women reported a higher incidence of burnout than their male counterparts even though the male ATs worked more hours on average than the female ATs. Researchers^3,4,9,10 examining retention and WLB in female ATs have identified the time commitment of the profession, particularly in the collegiate setting, as problematic, especially for ATs trying to balance motherhood and athletic training.An extension of the individual-level factors described in the Dixon and Bruening⁵ model can include the work of Hakim.¹⁶ She theorized that female positions in the workforce and in the family reflect the preferences of women and not social constraints.¹⁶ Her preference theory contends that a woman''s preference is based on her personal needs and goals, which are likely independent of other factors, such as societal contentions or organizational views. Preference theory states that women can be classified broadly into 3 groups: adaptive, work centered, and home centered. Adaptive women prefer to combine family and careers without giving a fixed priority to either, essentially desiring to enjoy the best of both worlds. Work-centered women fit their family lives around their work, with many remaining childless even when married. Home-centered women prefer to give priority to their families after they marry.The inclusion of sociocultural factors in the Dixon and Bruening⁵ model highlights additional important dynamics in the perception of work-life imbalance and gives credence to many who argue that preference alone does not dictate female career trajectories. Sociocultural-level factors, which are not considered in preference theory, examine norms and values associated with work and family. Given existing sex norms, women typically have a more difficult time maintaining both work and family responsibilities and report that they must constantly “prove their worthiness.”¹⁷ In addition, regardless of marital status, women who have children and work outside the home frequently experience feelings of guilt, self-doubt, and degradation because they feel aberrant.^18,19 Women more often than men interrupt their careers to have children, work part time, or leave work to take care of sick children. These choices slow their career progress and are potentially detrimental to their earning potential.²⁰ Social norms not only make women believe that they have to choose work or family but also impart a negative social connotation in choosing work over family.⁵Therefore, based on the divergent nature of preference theory and the multilevel model of WLB, the purpose of our study was to examine if individual and sociocultural factors, as described first by Dixon and Bruening,⁵ are evident in female ATs employed in the NCAA Division I setting. Specifically, we focused on the following research questions while acknowledging that both research questions focus on sex-specific influences: (1) Are individual and sociocultural factors evident in the perceptions of female ATs employed in the NCAA Division I setting regarding WLB? (2) Is any evidence available to suggest that female ATs employed at the Division I setting exhibit tendencies consistent with preference theory?     

Athletic Trainers' Facilitators of Professional Commitment in the Collegiate Setting

Context:

Professional responsibility, rewards and respect, and time for rejuvenation are factors supporting professional commitment for athletic trainers (ATs) in the high school setting. The inherent complexities of an occupational setting can mitigate perceptions of professional commitment. Thus far, evidence is lacking regarding professional commitment for ATs in other occupational settings.

Objective:

To extend the literature on professional commitment of the AT to the collegiate setting.

Design:

Qualitative study.

Setting:

Collegiate.

Patients or Other Participants:

Thirty-three Board of Certification-certified ATs employed in the collegiate setting (National Collegiate Athletic Association Division I = 11, Division II = 9, Division III = 13) with an average of 10 ± 8 years of clinical experience volunteered. Data saturation guided the total number of participants.

Data Collection and Analysis:

Online journaling via QuestionPro was used to collect data from all participants. Two strategies, multiple-analyst triangulation and peer review, were completed to satisfy data credibility. Data were evaluated using a general inductive approach.

Results:

Likert-scale data revealed no differences regarding levels of professional commitment across divisions. Two themes emerged from the inductive-content analysis: (1) professional responsibility and (2) coworker support. The emergent theme of professional responsibility contained 4 subthemes: (1) dedication to advancing the athletic training profession, (2) ardor for job responsibilities, (3) dedication to the student-athlete, and (4) commitment to education. Our participants were able to better maintain their own professional commitment when they felt their coworkers were also committed to the profession.

Conclusions:

The collegiate ATs investigated in this study, regardless of division, demonstrated professional commitment propelled by their aspiration to advance the profession, as well as their dedication to student-athletes and athletic training students. Maintaining commitment was influenced by a strong sense of coworker support.Key Words: learning, professional responsibility, support

Key Points

• Collegiate athletic trainers were internally motivated and professionally committed to their roles as health care providers.
• Their professional commitment was propelled by their aspiration to advance the profession, dedication to student-athletes and athletic training students, and the value they placed on education.

In the health care professions, providers must deliver quality care at all times. In athletic training, however, the demanding work environment can pose challenges in providing care. The collegiate clinical settings possess unique professional challenges to athletic trainers (ATs): for example, long road trips, extended nights away from home, pressure to win, supervision of athletic training students, infrequent days off, high athlete-to-AT ratios, athletes on scholarship, and extended competitive seasons.^1–5 These numerous obligations may challenge collegiate ATs'' commitments for a prolonged period of time throughout their careers and make it difficult for ATs to remain excited about their role² and to maintain engagement as health care professionals.The negative consequences of ATs trying to navigate the demands of their jobs have been well documented. Work-family conflict^5,6 and burnout⁷ encumber an AT''s ability to effectively perform the role and develop professionally. Membership statistics from the National Athletic Trainers'' Association⁸ (NATA) suggest a decline in the number of certified members of the athletic training profession between 2001 and 2006.⁸ Whether this number represents ATs actually leaving the profession or simply a failure to renew membership is unknown. However, it is a troubling trend. Research⁷ in the early 1990s showed that attrition among ATs was influenced by time commitments, low salaries, and limited advancement. Declining NATA membership in recent years has sparked conversations regarding professional commitment. The positive aspects of the athletic training work setting and individuals'' ability to maintain commitment to their professional roles have been examined² and may offer insights into how to address the high attrition rates in our profession.Meyer et al⁹ defined 3 distinct concepts of professional commitment: (1) affective, (2) continuance, and (3) normative. Affective professional commitment refers to identifying with a profession and being loyal and psychologically attached to it. Individuals with strong affective professional commitment remain in the profession because they want to, and they pursue professional development by subscribing to trade journals and attending professional meetings. Normative professional commitment reflects a moral obligation to the profession. Individuals with strong normative commitment remain in a profession because they feel it is simply the right thing to do.⁹ Continuance professional commitment reflects the perceived costs associated with leaving the profession. Individuals with strong continuance professional commitment remain in the profession because they feel they have more to lose by not doing so. These individuals are less likely to pursue professional development⁹; they are confined to their roles and do not feel they can leave without negative consequences.¹⁰ All 3 components have implications for an individual remaining in or leaving the profession.Limited research has focused on professional commitment in the context of athletic training. Pitney¹¹ examined professional commitment among ATs working within the secondary school environment and found a strong sense of professional responsibility to both patients and the athletic training discipline. This professional commitment was influenced by both intrinsic and extrinsic rewards and respect from others. Winterstein¹⁰ concluded that head ATs in the collegiate setting were committed to both the athletic training student and the intercollegiate student-athlete. Although Pitney¹¹ contributed to our knowledge of professional commitment in the secondary school setting and Winterstein¹⁰ in the collegiate context among head ATs, the ability of collegiate ATs to maintain commitment to their professional role has not been investigated. Additionally the Winterstein study,¹⁰ which was published 16 years ago, sought the perspective of only head ATs. At the end of 2011, 24% of all certified members of the NATA were working in the college/university setting.⁸ Most of these are employed as assistant or associate ATs and subject to the stressors specific to this setting. Therefore, it is important to examine the professional commitment of the collegiate AT.The purpose of our study was to examine how ATs working in the collegiate clinical setting identified professional commitment and upheld this commitment in a professionally demanding environment. The central focus of this study was to identify the positive influences affecting professional commitment for ATs working in the collegiate setting. A separate article¹² discusses the negative aspects of professional commitment. The following central research questions guided this investigation:

• 1.How did ATs working in the collegiate setting characterize professional commitment?
• 2.Which factors positively influenced ATs in upholding their professional commitment over the course of their careers?

     

Athletic Trainers' Familiarity With and Perceptions of Academic Accommodations in Secondary School Athletes After Sport-Related Concussion

Context:

Sport-related concussion can affect athletes'' sport participation and academic success. With the recent emphasis on cognitive rest, student-athletes may benefit from academic accommodations (AA) in the classroom; however, athletic trainers'' (ATs'') perceived familiarity with, and use of, AA is unknown.

Objective:

To assess secondary school ATs'' perceived familiarity with, attitudes and beliefs about, and incorporation of AA for student-athletes after sport-related concussion. A secondary purpose was to determine whether employment status altered familiarity and use of AA.

Design:

Cross-sectional study.

Setting:

Online survey.

Patients or Other Participants:

Of 3286 possible respondents, 851 secondary school ATs accessed the survey (response rate = 25.9%; 308 men [36.2%], 376 women [44.2%], 167 respondents [19.6%] with sex information missing; age = 37.3 ± 10.1 years).

Main Outcome Measure(s):

Participants were solicited via e-mail to complete the Beliefs, Attitudes and Knowledge Following Pediatric Athlete Concussion among Athletic Trainers employed in the secondary school setting (BAKPAC-AT) survey. The BAKPAC-AT assessed ATs'' perceived familiarity, perceptions, and roles regarding 504 plans, Individualized Education Programs (IEPs), and returning student-athletes to the classroom. Independent variables were employment status (full time versus part time), employment model (direct versus outreach), years certified, and years of experience in the secondary school setting. The dependent variables were participants'' responses to the AA questions. Spearman rank-correlation coefficients were used to assess relationships and Mann-Whitney U and χ² tests (P < .05) were used to identify differences.

Results:

Respondents reported that approximately 41% of the student-athletes whose sport-related concussions they managed received AA. Respondents employed directly by the school were more familiar with 504 plans (P < .001) and IEPs (P < .001) and had a greater belief that ATs should have a role in AA. Both the number of years certified and the years of experience at the secondary school were significantly correlated with perceived familiarity regarding 504 plans and IEPs.

Conclusions:

The ATs employed directly by secondary schools and those with more experience as secondary school ATs were more familiar with AA. Understanding AA is important for all ATs because cognitive rest and “return to learn” are becoming more widely recommended in concussion management.Key Words: adolescent sport-related concussions, concussion management, 504 plans, Individualized Education Programs

Key Points

• The patients in nearly one-half of the sport-related concussion cases managed by secondary school athletic trainers received academic accommodations.
• For proper management of and successful recovery from concussions, academic accommodations are often important.
• Athletic trainers should become more familiar with academic accommodations to ensure that student-athletes can return successfully to the classroom.

The Centers for Disease Control and Prevention estimated that 1.6 to 3.8 million sport- and recreational-related concussions occurred annually in the United States.¹ For high school athletes, an estimated 8.9% of all injuries are concussions.² Early recognition and appropriate management of these prevalent injuries are especially important in adolescents to reduce the risk of more serious conditions and to facilitate proper recovery.³ In the secondary school setting, that recognition and management are often components of athletic training services, delivered by certified or state-licensed (or both) athletic trainers (ATs) who frequently assist with concussion management from initial evaluation through return to play. With the increased occurrence of concussions,¹ it is imperative that best practices for proper management of the injuries be implemented and that those practices be consistent with expert recommendations and guidelines.The signs and symptoms of concussion can broadly affect the student-athlete''s life both in and out of athletic participation.⁴ After a concussion, the student-athlete may experience an array of clinical signs and symptoms. Those symptoms may include cognitive deficits,^5,6 such as poor concentration and difficulty remembering, sensitivity to noise and light, dizziness, and most commonly, headaches.^4,7–10 Unfortunately for the student-athlete, those signs and symptoms can be exacerbated by any activity requiring cognitive demand, such as watching TV, listening to music, reading, playing video games, and even performing school work. In fact, normal academic demands are a major source of cognitive exertion in student-athletes after sport-related concussion.Effectively managing this complex and often-unpredictable collection of signs and symptoms can be aided through the use of individualized concussion-management plans, especially those plans that encourage a return to school in an appropriate and stepwise manner.^11,12 One important component of such an individualized plan is cognitive rest. Cognitive rest is imperative for the healing process because it allows the brain time to recover without exacerbating symptoms.¹³ Consensus guidelines,¹⁴ expert opinion,^15,16 and some evidence¹³ suggested that cognitive rest is beneficial in recovery. However, a common limitation of individualized concussion-management plans is that they typically omit or place less emphasis on components that are unrelated to athletics, such as limiting cognitive activity and modifying cognitive demands, specifically in academics.¹⁷ That lack is problematic because although abundant published research pertains to acute diagnosis, management, and return to play after a concussion, little research about school reintegration or return to learn has been conducted to date. Consequently, comprehensive concussion-management guidelines for student-athletes often fail to include information about both return to play and school and home functioning.⁷One way of modifying cognitive demands is through academic accommodations (AA). Academic accommodations can include both informal alterations in classroom activity and formal accommodations, such as 504 plans and Individualized Education Programs (IEPs).⁴ One distinction between informal and formal accommodations is the temporary nature of the former. Informal accommodations allow the student-athlete to receive accommodations in school immediately after a concussion and are intended to provide temporary modifications to enhance academic performance and to aid in physical recovery.⁴ Informal accommodations include longer testing periods, homework extensions, lighter school days and breaks throughout the day, excused absences, relief from light and noise when necessary, excused practices or gym classes, and other arrangements.⁴ With selected informal AA, the student-athlete can recover and improve in the classroom over time.^13,15 Section 504 plans and IEPs are formal plans that guarantee students academic assistance as well as protection from discrimination in response to an identified disability.¹⁸Although formal accommodations are available to all high school students, including student-athletes, it is unclear how familiar ATs are with AA. Therefore, the purpose of our study was to assess the perceived familiarity with and perceptions of ATs employed in the secondary school setting (SSATs) regarding AA for adolescent student-athletes after sport-related concussion. Secondary and tertiary purposes were to determine the availability of academic-support teams in secondary schools and whether employment status altered familiarity with, and use of, AA.     

Athletic Trainers' Barriers to Maintaining Professional Commitment in the Collegiate Setting

Context:

Professional commitment simply describes one''s obligation to his or her work. For athletic trainers (ATs), the demanding work environment and job expectations may affect their characterization of professional commitment. Our breadth of knowledge regarding professional commitment within athletic training is narrow.

Objective:

To evaluate the professional commitment of ATs in the collegiate setting.

Design:

Qualitative study.

Setting:

Collegiate.

Patients or Other Participants:

Thirty-three Board of Certification-certified ATs employed in the collegiate setting (National Collegiate Athletic Association Division I = 11, Division II = 9, Division III = 13) with an average of 10 ± 8 years of clinical experience volunteered. Data saturation guided the total number of participants.

Data Collection and Analysis:

Online journaling via QuestionPro was completed by all participants. Multiple-analyst triangulation and peer review were conducted for data credibility. Analysis followed a general inductive method.

Results:

Four themes speak to the factors that negatively affect ATs'' professional enthusiasm and commitment: (1) life stage, (2) work overload, (3) organizational climate, and (4) human resources. The latter 3 speak to the effect the workplace can have on ATs'' professional commitment, and the first speaks to the effect outside responsibilities can have.

Conclusions:

Our results suggest that several of the factors that negatively influence the professional commitment of collegiate ATs are modifiable organizational components. Developing resiliency strategies at the individual and organizational levels may help to facilitate improved professional commitment for the AT.Key Words: resiliency, organizational climate, role overload

Key Points

• Professional commitment describes one''s emotional attachment to a profession, the sense of obligation to the profession, and the cost : benefit perception of departure from the profession.
• The professional commitments of collegiate athletic trainers were negatively affected by their life stage, work overload, organizational climate, and human resources.
• Work overload, organizational climate, and human resources are components that can be addressed at the organizational level to facilitate work-life balance and enhance professional commitment.

Professional commitment is a construct that centers on an individual''s commitment to his or her profession and to the employer organization. Many definitions exist, but as described by Vandenberg and Scarpello,^1(p535) professional commitment can be summarized as “a person''s belief in and acceptance of the values of his or her chosen occupation or line of work and a willingness to maintain membership in that occupation.” Meyer et al² contended that 3 specific, distinct components exist and provide substance to one''s assessment of the professional commitment: affective, normative, and continuance commitment.Affective professional commitment is the emotional connection made with an individual''s profession and organization.² An athletic trainer (AT) with a strong affective professional commitment, for example, is more likely to become involved professionally, specifically by attending conferences, participating in professional committees, seeking current methods in professional journals, or being an active pillar of the profession (or a combination of these). When professional commitment waivers, an AT is likely to reduce involvement or withdraw from extracurricular activities and opportunities to give back to the profession. A concern in athletic training,^3–5 burnout is characterized by emotional exhaustion and depersonalization, such that one''s work is fatiguing and results in disinterest, which can lead to a reduced level of commitment for the work or role that is deemed taxing.^4–6 Normative professional commitment is related to one''s identification with the profession and organization. An AT with a strong normative commitment has adopted beliefs and attitudes likely through professional socialization⁷ and remains committed because of his or her enthusiasm for the role. Role strain, role overload, and work-life balance problems have been reported in the collegiate practice setting^4,8,9; these are often facilitated by working long hours, feeling underappreciated, and a lack of resources, mostly in the form of insufficient full-time staff members to provide appropriate medical coverage.⁵ Role strain, role overload, and work-life imbalance can influence an AT''s enthusiasm, which can alter perceptions of commitment, particularly if the AT does not feel supported or valued.¹⁰ The final component, continuance of professional commitment is relative to the cost : benefit ratio for the individual. An AT will make decisions regarding retention within the profession based upon the cost of staying versus leaving. As presented by Kahanov and Eberman,¹¹ departure from the collegiate setting is occurring, and multiple factors are at play, 1 of which is a reduction in professional commitment and the appeal of other jobs or careers.^12,13 Underpinning the 3 facets is the psychological state of the AT and how that influences his or her commitment to the profession and organization. The development of professional commitment has a direct link to an AT''s decision to persist. A strong connection to the student-athlete and the ability to provide appropriate and necessary medical care seems to define professional commitment for the AT in the secondary school setting.¹⁰Limited research exists in athletic training regarding the professional commitment of the AT, particularly in the collegiate setting. The information currently available is presented from distinct perspectives, including the head AT,¹⁴ the male AT,¹⁵ and the female AT.¹² A host of factors have been identified as facilitators for retaining the collegiate AT, including student-athletes and athletic training students,¹⁴ support from peers and coworkers,^12,15 and enjoyment of the workplace and culture.¹⁵ Although previous researchers have contributed to our understanding of professional commitment and retention in the collegiate setting, limitations of those studies include a homogeneous sampling (ie, head ATs, 1 sex, or 1 level only), dated information, and a focus on only those elements fostering professional commitment. Items that can reduce the professional commitment of ATs include role strain, work-life imbalance, and burnout.^5,6,16 However, to our knowledge, the specific factors that negatively affect professional commitment have not been described. Our purpose, therefore, was to describe the factors that can negatively influence professional commitment for the AT employed in the collegiate setting. We focused primarily on factors that reduced the professional commitment of the AT.     

Career Commitment of Postprofessional Athletic Training Program Graduates

Context:Choosing to pursue an advanced degree in athletic training appears to indicate professional commitment and passion for the profession. Currently, there is a paucity of information regarding why some athletic trainers pursue enrollment in a postprofessional athletic training program (PPATP), indicating commitment to the profession, but later depart for another primary role outside of athletic training.Objective:To understand why athletic trainers invested in advanced training via a PPATP but then decided to leave the profession.Design:Qualitative study.Setting:Online data collection.Results:Two higher-order themes emerged regarding the career commitment of former athletic trainers who were PPATP graduates: (1) departure from an athletic training career and (2) partial continuance in athletic training. Two second-order themes emerged from the reasons for departure: (1) decreased recognition of value and (2) work-life imbalance. Finally, we identified 2 third-order themes from the participants'' reasons for departure because of a perceived lack of value: (1) low salary and (2) long, inconsistent hours worked.Conclusions:Most of our participants intended to stay in the profession when they chose to attend a PPATP. However, during role inductance in either the clinical experience of the PPATP they attended or early in their careers, they began to have thoughts of leaving mainly because of inadequate financial compensation, challenging work schedules, or both.Key Words: retention, attrition, career inductance

Key Points

• Despite their initial intentions to remain in the profession, athletic trainers who departed cited low salaries and long, inconsistent hours as the main factors in their decisions.
• Also influencing the decision to leave athletic training were decreased perceived value as a health care provider and work-life imbalance.

On graduation from a Commission on Accreditation of Athletic Training Education–accredited athletic training program, many athletic training students (ATSs) opt to pursue a graduate degree, as indicated by the nearly 70% of all athletic trainers (ATs) who possess a master''s degree.¹ The decision to pursue a graduate degree is often fostered by the ATS''s desire to gain additional mentorship and training before assuming a full-time position as an AT.² Diversity exists, however, in the graduate degrees sought by ATs, which can include biomechanics, exercise science, physical therapy, sports or business administration, or athletic training.²Choosing to pursue an advanced degree in athletic training appears to indicate professional commitment and passion for the profession.³ Professional commitment is commonly designated by the strength of an individual''s identification with, and involvement in, a profession.⁴ Many factors affect one''s professional commitment; rewards, coworker support, and love of the job can positively influence that commitment,⁵ whereas organizational climate, low salary, and limited staffing can negatively influence it.⁶ Long-term professional goals that include a career in athletic training and pursuit of advanced skills in athletic training provide the experience necessary to reach that goal.³ Many factors contribute to the initial attraction of a degree from a postprofessional athletic training program (PPATP),^2,3 but the opportunity to gain formal socialization through a clinical assistantship appears to be a strong attractor for the ATS and can have a strong influence on the final selection of a graduate program and degree.³ Completion of a PPATP provides the AT with the chance to gain clinical autonomy while being mentored in a learning environment that helps develop an expert clinician.³ Moreover, unlike the traditional graduate assistantship position, which is modeled as an apprenticeship, attendance at a PPATP allows the AT to acquire advanced skills in athletic training while continuing to develop clinical competence. The choice to enter a PPATP may indicate a strong interest in the material, the desire to advance an entry-level skill set, and the intention to pursue a career in athletic training.As demonstrated in a recent study,⁷ ATs entering PPATP education were motivated to pursue careers in athletic training. This finding supports the research of Mazerolle and Dodge,³ who found that first-year ATs enrolled in PPATPs were motivated to pursue full-time athletic training positions after graduation. Despite the clear link between attending a PPATP and retention in the field, it appears many ATs may leave the profession of athletic training after completing their postprofessional athletic training degrees. The topic of retention within athletic training has received attention recently, as the profession looks to solidify its role in health care and the medical community. Although the literature is rich with information on retention and factors associated with it,^7–10 there is a paucity of information regarding why athletic trainers make the decision to pursue a degree from a PPATP, indicating commitment to the profession, but later depart for another primary role outside of athletic training. Consequently, the purpose of our investigation was to understand why ATs invested in advanced training via a PPATP but then decided to leave the profession. We were specifically concerned with which factors led to their departure, what they were currently doing professionally, and whether they had any plans to return to athletic training.     

Exploring the Transition to Practice for the Newly Credentialed Athletic Trainer: A Programmatic View

Context Some newly credentialed athletic trainers (ATs) pursue a postprofessional degree with a curriculum that specifically advances their athletic training practice. It is unknown how those postprofessional programs assist in their transition to practice.Objective To gain an understanding of initiatives used by postprofessional athletic training programs to facilitate role transition from student to professional during their graduate degree programs.Design Qualitative study.Setting Semistructured telephone interviews.Results Three facilitators of transition to practice emerged: orientation sessions, mentoring, and assistantship. Participants used orientation sessions ranging from a few hours to more than 1 week to provide and discuss program polices and expectations and to outline roles and responsibilities. Faculty, preceptors, and mentors were integrated into the orientation for the academic and clinical portions of the program. All participants described a mentoring process in which students were assigned by the program or informally developed. Mentors included the assigned preceptor, a staff AT, or peer students in the program. The clinical assistantship provided exposure to the daily aspects of being an AT. Barriers to transition to practice included previous educational experiences and time management. Participants reported that students with more diverse didactic and clinical education experiences had easier transitions. The ability to manage time also emerged as a challenge.Conclusions Postprofessional athletic training programs used a formal orientation session as an initial means to help the newly credentialed AT transition into the role. Mentoring provided both more informal and ongoing support during the transition.Key Words: mentoring, orientation, time management

Key Points

• Program directors used orientation sessions and mentoring to help support the transition from student to credentialed athletic trainer.
• The clinical assistantship provided the foundations for transition, as it conveyed role engagement.
• Mentoring was mostly informal but provided the ongoing support needed during the transition from student to credentialed athletic trainer.

Recent debate and anecdotal evidence have suggested that newly credentialed athletic trainers (ATs) are not as prepared for the demands of professional practice as they once were.^1–6 However, these ATs still are expected to be completely autonomous practitioners and provide safe patient care. Most of these newly credentialed ATs are employed in graduate assistantship positions and are navigating workloads comparable with those of full-time staff members and associated expectations of patient care.⁷Whereas new ATs have met all credentialing requirements and are viewed as being able to function as ATs, having complete autonomy and ultimate decision-making power is a new experience. In fact, many recent graduates who gain certification seek positions that will provide support while they build confidence with decision making.^8–11 Many of these positions are as graduate assistants, which allow for continued clinical experience coupled with didactic learning. Clinical independence combined with mentoring has emerged as not only an attractor to the graduate-student role¹¹ but also an expectation for socializing them into their roles as graduate students.^9,10 Athletic trainers who become graduate assistants are placed in a unique situation, as they are expected to juggle roles as students; health care providers; and in some cases, preceptors or classroom instructors. Role strain and burnout are likely to manifest, especially due to the demands placed on them at such an early stage in their careers as they attempt to gain role inductance and experience as ATs.^7,12The ability to provide safe patient care is a concern for many health care providers but is of great concern for newly credentialed ATs. During this period, they are attempting for the first time to make decisions regarding patient care without clinical supervision and feedback. A high rate of medical errors and burnout occurs among newly credentialed health care providers.¹³ Graduate assistants, who are often newly credentialed ATs, do experience burnout,⁷ and if medical errors result because of burnout, they are likely to affect the ATs'' professional development and clinical competence. The National Council of State Boards of Nursing issued an initiative to begin exploring transition-to-practice techniques to formalize the transition to practice for new nurses.¹⁴ This initiative aims to reduce medial errors, reduce turnover, and enhance patient safety and care. Recently, the National Athletic Trainers'' Association (NATA) Executive Committee for Education recommended exploring the employer''s responsibility to provide development and supervision for newly credentialed ATs to create effective support models for their transition to practice.¹⁵ Attending a postprofessional athletic training program is one model that can help newly credentialed ATs transition to practice. Currently, 16 postprofessional athletic training programs are accredited by the Commission on Accreditation of Athletic Training Education (CAATE),¹⁶ and a host of other programs offer comparable curriculums but are not accredited to date. These programs lead to a master''s or doctorate degree for learners who are already credentialed as ATs and expand the depth and breadth of the applied, experiential, and propositional knowledge and skills of ATs through didactic, clinical, and research experiences. Most often, students in these postprofessional programs have recently completed their undergraduate athletic training education, have no work experience, and are transitioning from student to newly credentialed AT. Furthermore, individuals enrolled in these postprofessional programs are looking for experiences that will nurture their growth as ATs from both clinical and didactic standpoints.¹¹ The graduate-assistant role is recognized as a “rite of passage” used to acclimate the AT and allow for improved decision making¹⁷; however, the initiatives that postprofessional programs use to assist the student transitioning into this role are unknown. By identifying these initiatives, educational models that support transition to practice can be identified. Therefore, the purpose of our study was to gain an understanding of initiatives used by postprofessional athletic training programs to facilitate role transition from student to professional during their graduate degree programs. Little information exists from the program viewpoint; thus, we need to gain a comprehensive understanding of the role-transition process for the AT, which includes facilitators and barriers that may exist in the transition. Facilitators¹⁸ are likely those factors that are supportive, ongoing, and viewed as a positive aspect of role transition. Conversely, barriers¹⁸ are factors that may hinder transition or cause a delay in transition; these likely include lack of confidence and unawareness of their new role.     

Experiences of Work-Life Conflict for the Athletic Trainer Employed Outside the National Collegiate Athletic Association Division I Clinical Setting

Context

The intercollegiate setting receives much of the scholarly attention related to work-life conflict (WLC). However research has been focused on the National Collegiate Athletic Association Division I setting. Multiple factors can lead to WLC for the athletic trainer (AT), including hours, travel, and lack of flexibility in work schedules.

Objective

To investigate the experiences of WLC among ATs working in the non-Division I collegiate setting and to identify factors that contribute to fulfillment of work-life balance in this setting.

Design

Qualitative study.

Setting

Institutions in the National Collegiate Athletic Association Divisions II and III, the National Association of Intercollegiate Athletics, and the National Junior College Athletic Association.

Patients or Other Participants

A total of 244 ATs (128 women, 114 men; age = 37.5 ± 13.3 years, experience = 14 ± 12 years) completed phase I. Thirteen participants (8 women, 5 men; age = 38 ± 13 years, experience = 13.1 ± 11.4 years) completed phase II.

Data Collection and Analysis

For phase I, participants completed a previously validated and reliable (Cronbach α > .90) Web-based survey measuring their levels of WLC and work-family conflict (WFC). This phase included 2 WFC scales defining family; scale 1 defined family as having a partner or spouse with or without children, and scale 2 defined family as those individuals, including parents, siblings, grandparents, and any other close relatives, involved in one''s life. Phase II consisted of an interview. Qualitative data were evaluated using content analysis. Data source and multiple-analyst triangulation secured credibility.

Results

The WFC scores were 26.33 ± 7.37 for scale 1 and 20.46 ± 10.14 for scale 2, indicating a moderate level of WFC for scale 1 and a low level of WFC for scale 2. Qualitative analyses revealed that organizational dimensions, such as job demands and staffing issues, can negatively affect WLC, whereas a combination of organizational and personal dimensions can positively affect WLC.

Conclusions

Overload continues to be a prevalent factor in negatively influencing WLC and WFC. Supervisor and peer support, personal networks, and time away from the role positively influenced work-life balance and WFC. Athletic trainers are encouraged to support one another in the workplace, especially when providing flexibility in scheduling.Key Words: overload, personnel management, organizational support

Key Points

• Organizational factors influenced work-life conflict and work-life balance (WLB) for the athletic trainer.
• Overload was a prevalent negative influence on WLB.
• Supervisor and peer support, personal networks, and time away from the role positively influenced WLB.
• Athletic trainers should support each other in the workplace, and supervisors should encourage and support the concept of job sharing.

Work-family balance often is discussed as the extent to which an individual is equally involved in and equally satisfied with his or her work and personal and family roles.¹ Conceptually, the work and family interface is viewed as one that is either in balance or in conflict. Thus, the terms work-family balance and work-family conflict (WFC) reflect the perspective that is viewed as either negative (conflict) or positive (balance). The concept of WFC or work-life conflict (WLC) has become a focus of attention within athletic training, particularly as it has been linked directly to perceptions of job satisfaction and retention in the field.^2–5 Initially, the concept of WFC was investigated by Mazerolle et al,^2,3 but after finding no differences among demographic characteristics, such as sex, age, and marital status, they suggested WLC as a more appropriate term, because WFC suggests the need to have a spouse or children to experience a conflict. Therefore, when discussing conflicts that arise from balancing multiple roles, the term WLC is used, whereas when the domains are viewed in balance, the term work-life balance (WLB) is used.The growing body of literature has highlighted the idea that hours worked, travel, work-schedule flexibility, and coaches'' expectations and demands can contribute to WLC for the athletic trainer (AT).^2,3,6,7 The experiences of WLC for the AT are comparable with others employed within the sports industry, including coaches^8–10 and sports information personnel.¹¹ The underlying cause of WLC appears to stem from the organizational structure of the work setting, including work schedules, hours worked, and job demands.⁸ Work-schedule flexibility and hours worked appear to be the biggest culprits in creating WLC for the AT,^2,3,6,12 especially for ATs employed in the collegiate setting.^2,12 However, these factors appear to be synonymous for anyone working in the sport industry, as long hours are expected, are required, and have become a part of the organizational culture.^9,10 Outside of the collegiate setting, sources of conflict may vary due to different job expectations.Differences have been reported within the various employment settings in athletic training, particularly for sources of conflict.⁷ For example, ATs employed in the rehabilitation or clinical setting have more structured work schedules and report fewer concerns with WLC than ATs employed in more traditional settings that require working 40 or more hours each week and frequent travel. Whereas we have a strong understanding of the National Collegiate Athletic Association (NCAA) Division I setting, we have a limited understanding of the experiences of ATs working outside the NCAA Division I collegiate setting (non-Division I setting), including NCAA Divisions II and III, National Association of Intercollegiate Athletics, and National Junior College Athletic Association institutions. Given that clinical setting can influence the experience or source of conflict for the AT, we need to fully understand the collegiate setting, as demands and role expectations can vary. According to Brumels and Beach,¹³ the role of the AT in the collegiate setting can be demanding and complex due to travel; obligations to multiple teams; and competing roles, such as teaching, supervision of students, and other administrative duties required of the position. When coupled with the high expectations and needs of coaches and athletes, the potential for overload and conflict with outside responsibilities is created.As mentioned, researchers have noted differences in occupational setting within athletic training related to sources of WLC or WFC, but most of the literature on this concept in the collegiate setting has stemmed from the Division I setting. The NCAA suggested that differences exist among collegiate programs specifically related to finances and academics.¹⁴ The investments made within each program can influence expectations of all members of the athletics department, including ATs. Differences in atmosphere and priorities can affect the workplace culture, which is strongly related to WLC and WFC for the AT.¹⁵ Thus, despite the strong knowledge base about the Division I setting, more information is necessary regarding the WLC experiences of ATs who work outside the Division I setting, as resources and expectations likely are different. Therefore, the purpose of our study was twofold. First, we sought to explore WLC among ATs working in the non-Division I setting and to identify factors that contribute to fulfillment of WLB in this setting. Second, we wanted to gain insight and understanding about which factors mitigate WLC outside the Division I setting. The following questions guided our investigation: (1) To what extent do ATs in the non-Division I setting perceive WLC? (2) Is there a connection between the level of WLC and various demographic variables (eg, sex, marital status, family-unit size)? (3) Does the work environment outside Division I influence the occurrence of WLC? (4) What factors are perceived to reduce WLC?     

Psychosocial Aspects of Athletic Injuries as Perceived by Athletic Trainers

Context:

Despite the Psychosocial Strategies and Referral content area, athletic trainers (ATs) generally lack confidence in their ability to use this information.

Objective:

The current study''s primary purpose was to determine (a) perceived psychological responses and coping behaviors athletes may present to ATs, (b) psychosocial strategies ATs currently use with their athletes, (c) psychosocial strategies ATs deem important to learn more about, and (d) ATs'' current practices in referring athletes to counseling or sport psychology services.

Design:

 Mixed-methods study.

Setting:

Online survey containing both quantitative and qualitative items.

Patients or Other Participants:

  A total of 215 ATs (86 male, 129 female), representing a response rate of 22.50%.

Main Outcome Measure(s):

The Athletic Training and Sport Psychology Questionnaire.

Results:

Stress/anxiety (4.24 ± 0.82), anger (3.70 ± 0.96), and treatment adherence problems (3.62 ± 0.94) were rated as the primary psychological responses athletes may present upon injury. Adherence and having a positive attitude were identified as key determinants in defining athletes'' successful coping with their injuries. The top 3 selected psychosocial strategies were keeping the athlete involved with the team (4.57 ± 0.73), using short-term goals (4.45 ± 0.67), and creating variety in rehabilitation exercises (4.32 ± 0.75). The top 3 rated psychosocial strategies ATs deem important to learn more about were understanding motivation (4.29 ± 0.89), using effective communication (4.24 ± 0.91), and setting realistic goals (4.22 ± 0.97). Of the sample, only 59 (27.44%) ATs reported referring an athlete for counseling services, and 37 (84.09%) of those who had access to a sport psychologist (n = 44) reported referring for sport psychology services.

Conclusions:

 These results not only highlight ATs'' current use of psychosocial strategies but also their desires to increase their current knowledge and understanding of these strategies while caring for injured athletes.Key Words: psychology, clinical skills, professional preparedness, athletic training

Key Points

• • Athletic trainers appear to be mindful of the psychological ramifications that athletes often experience as a result of their injuries.
• • Although athletic trainers apparently used some psychosocial strategies within injury rehabilitation, they also stressed the importance of learning more about these strategies.

Traditional rehabilitation programs are designed to ensure an athlete''s full return to preinjury levels of physical fitness, but a growing body of research highlights the importance of also addressing psychological responses within the rehabilitation context.^1–6 One of the ways in which the injured athlete''s psychological response to sport injuries has been explained is through the Integrated Model of Response to Sport Injury Rehabilitation.⁷ According to the model, an individual athlete''s cognitive appraisal of the injury (ie, how the athlete views the situation), as well as the athlete''s emotional (ie, how he or she feels about the injury) and behavioral (ie, how he or she acts and reacts to the injury situation) responses are influenced by a range of personal (eg, injury characteristics and individual differences) and situational (eg, sport, social, and environmental influences, including social support and the sports medicine team) factors. The model recognizes the interaction among the cognitive appraisal and emotional and behavioral responses as a dynamic and bidirectional cyclic process, which in turn has an effect on both physical and psychological recovery outcomes.⁷Thus far, a wealth of evidence exists in support of the model. Most athletes appear to be psychologically affected (emotional response) when injured,^8–10 and these psychological responses can have a significant influence on the quality and speed of the sport-injury rehabilitation process.^3–5 Support for the use of psychosocial strategies (a behavioral response) during sport-injury rehabilitation has also been documented in the literature. For example, goal setting, imagery, positive self-talk, and relaxation strategies have been useful in helping athletes cope with pain, stress, and anxiety and address self-efficacy, self-esteem, and confidence-related apprehensions, as well as concerns with rehabilitation motivation and adherence.^5,11,12 In addition, the role of sports medicine professionals (a situational factor) in influencing injured athletes'' cognitive appraisal of the injury, emotional and behavioral responses, the rehabilitation process, and the physical and psychological recovery outcomes is also important.^13–18 Therefore, it has been suggested that sports medicine professionals, such as athletic trainers (ATs), play an integral part in the sport-injury rehabilitation process and that they are best suited to inform, educate, and assist injured athletes with the psychological and physical process of injury.^4,19,20 Indeed, many sports medicine professionals believe they must address psychological aspects of injuries in order for their work to be effective.^2,8,10,21Recognizing the importance of providing psychological support to injured athletes, the National Athletic Trainers'' Association (NATA) Executive Committee for Education has recently released the 5th edition of the Educational Competencies, which includes the Psychosocial Strategies and Referral (PS) content area.²² These competencies and clinical integration proficiencies were, in part, specifically designed to ensure that ATs are exposed to information and applied learning situations that will increase their ability to provide psychological support to injured athletes and ensure a holistic approach to injury rehabilitation. According to the PS competencies, all ATs “must be able to recognize clients/patients exhibiting abnormal social, emotional and mental behaviors.”²²(p116) This should be coupled with the ability to implement psychosocial strategies, intervene, and refer when necessary²² (for more details on the PS content area, see the aforementioned reference).As a result of changes to the educational content areas, it was believed that, with the addition of the Psychosocial Intervention and Referral content area²³ to athletic training education programs (ATEPs), ATs “would consider the psychological aspects of an injury within their scope of practice.”^1(p5) However, Stiller-Ostrowski et al²⁴ noted that, although the content is required by ATEPs, no specific and standardized guidelines are provided regarding the actual teaching of this information. As a result of the lack of consistent training, it can be presumed that ATs may lack confidence and readiness to address the psychosocial aspects of athletic injuries. Stiller-Ostrowski and Hamson-Utley¹ reported that ATs lacked confidence in their ability to make use of the techniques taught via the psychosocial content area within the context of injury rehabilitation. This lack of confidence, according to Kamphoff et al,²⁵ can be attributed to the fact that ATs perceive themselves to not be “fully trained in the implementation” of these skills within this context.^(p116) Additional research by Stiller-Ostrowski and Ostrowski²⁶ corroborated the above findings and revealed that ATs did not feel adequately prepared by their ATEPs to deal with psychological responses presented by injured athletes. Gordon²⁷ also noted that sports medicine professionals were concerned about their ability to deal with psychological responses, in addition to being able to use psychosocial strategies to address these responses, due to their lack of in-depth training in the area. Furthermore, Jevon and Johnston¹³ reported conflicts between formal and informal roles with regard to using psychosocial strategies as part of the rehabilitation process. Thus, it appears that, despite the stated intentions of the psychosocial content area, ATs still seem to lack knowledge and confidence in their ability to address some of the psychological responses with which injured athletes may present.Previous work gaining insight into sports medicine professionals'' views on the psychological content of their practice is limited.^2,8–10,28 Thus far, the only study in the United States addressing these issues was conducted by Larson et al.² They surveyed practicing ATs (n = 482) using the Athletic Training and Sport Psychology Questionnaire (ATSPQ). A total of 226 ATs (47%) perceived that the athletes they treat experience psychological trauma as a result of their athletic injuries. Moreover, according to Larson et al,² even though ATs used a variety of psychosocial strategies, they wanted more in-depth training to be better able to use these strategies within the context of sport-injury treatment and rehabilitation. Similar studies have recently been conducted with sports medicine professionals working with injured athletes in the United Kingdom,^8–10,28 but their findings may not be directly applicable to the US sample due to differences in professional training and professional titles. Because Larson et al² performed their research more than 15 years ago and given the recent inclusion of psychosocial content areas within ATEPs, further study is warranted to gain greater insight into ATs'' perceptions of the psychological aspects of athletic injuries in the United States.Thus, the aim of the current study was to extend the work by Larson et al² by surveying practicing ATs to determine (a) perceived psychological responses and coping behaviors athletes may present to ATs, (b) psychosocial strategies ATs currently use with their athletes, (c) psychosocial strategies ATs deem important to learn more about, and (d) ATs'' current practices in referring athletes to counseling or sport psychology services.     

Neuromuscular Fatigue and Tibiofemoral Joint Biomechanics When Transitioning From Non–Weight Bearing to Weight Bearing

Context:Fatigue is suggested to be a risk factor for anterior cruciate ligament injury. Fatiguing exercise can affect neuromuscular control and laxity of the knee joint, which may render the knee less able to resist externally applied loads. Few authors have examined the effects of fatiguing exercise on knee biomechanics during the in vivo transition of the knee from non–weight bearing to weight bearing, the time when anterior cruciate ligament injury likely occurs.Objective:To investigate the effect of fatiguing exercise on tibiofemoral joint biomechanics during the transition from non–weight bearing to early weight bearing.Design:Cross-sectional study.Setting:Research laboratory.Intervention(s):Participants were tested before (preexercise) and after (postexercise) a protocol consisting of repeated leg presses (15 repetitions from 10°–40° of knee flexion, 10 seconds'' rest) against a 60% body-weight load until they were unable to complete a full bout of repetitions.Results:The axial compressive force (351.8 ± 44.3 N versus 374.0 ± 47.9 N; P = .018), knee-flexion excursion (8.0° ± 4.0° versus 10.2° ± 3.7°; P = .046), and anterior tibial translation (6.7 ± 1.7 mm versus 8.2 ± 1.9 mm; P < .001) increased from preexercise to postexercise. No significant correlations were noted.Conclusions:Neuromuscular fatigue may impair initial knee-joint stabilization during weight acceptance, leading to greater accessory motion at the knee and the potential for greater anterior cruciate ligament loading.Key Words: knee, anterior cruciate ligament, axial loading

Key Points

• After closed chain exercise, participants demonstrated an increase in anterior tibial translation during simulated lower extremity weight acceptance.
• Observed alterations of knee biomechanics in a fatigued state may suggest increased anterior cruciate ligament strain during the latter part of the competition.

The anterior cruciate ligament (ACL) is one of the most commonly injured ligaments in the knee.^1–4 Injuries to the ACL frequently result from noncontact mechanisms, occurring when the knee is near full extension at the time of foot strike during activities such as landing, cutting, and deceleration-type maneuvers.⁵ Neuromuscular fatigue has been defined as any exercise-induced loss in the ability to produce force with a muscle or muscle group, involving processes at all levels of the motor pathway between the brain and the muscle.^6–8 Furthermore, fatigue has been suggested as a contributing risk factor for noncontact ACL injury^9–14 because the risk of noncontact knee injuries appears to increase later in games.^15,16 Specifically, prolonged exercise, which contributes to the delayed activation of muscles agonistic to the ACL,^13,17 has been suggested to increase risk of knee injury.¹³The quadriceps and hamstrings play a critical role in providing dynamic stability of the knee joint during sports activities,¹⁸ so various lower extremity fatigue protocols have been used to decrease the force-producing capabilities of these muscles.^10,19,20 Commonly, fatigue has been induced using isokinetic exercise protocols.^12,14,21,22 However, the true nature of muscle function and its effect on functional knee-joint biomechanics during sporting activity is likely difficult to assess from isolated forms of isometric, concentric, or eccentric contractions. Exercise that results in complete volitional exhaustion of a single muscle or muscle group rarely occurs during functional activity. Therefore, fatigue protocols that involve total lower extremity actions incorporating submaximal stretch-shortening cycles^23,24 may better mimic the type of muscular fatigue associated with prolonged weight-bearing activity.A number of authors^23,25,26 have examined the effect of lower extremity muscle fatigue on knee-joint biomechanics during jumping and landing activities. These results suggest that, depending on the fatigue protocol and task used, knee-flexion excursion (KF_EXC) may be either decreased or increased postexercise, thus modulating joint stiffness.^25,27 These changes in KF_EXC appear to primarily depend on the peak knee flexion obtained,^11,27 given that little to no change in the initial knee-flexion landing angle has been reported at ground contact in response to fatiguing exercise.^9,20 Moran et al²⁸ examined the effect of an incremental treadmill protocol and reported that exercise-induced alterations in tibial peak-impact acceleration were not attributed to changes in the knee angles at foot contact during a drop jump. This suggests that fatiguing exercise does not alter the initial knee-position angle at ground contact, but it may have a profound effect on knee-joint biomechanics during the weight-acceptance phase of landing. Because ACL injuries typically occur near the time of foot strike^1,4 with the knee in shallow flexion (average, 23° of initial knee flexion),²⁹ understanding the effect of fatiguing exercise on knee-joint biomechanics during this early weight-acceptance phase may lend further insight into the role of fatigue in ACL injury mechanisms.As the knee transitions from non–weight bearing (NWB) to weight bearing (WB), the natural anterior translation of the tibia (ATT) relative to the femur at low knee-flexion angles (eg, 15°–30°)^30,31 is restrained by the ACL.³¹ Greater axial loads^30,32,33 and slowing of the quadriceps and hamstrings onset times in response to an anterior tibial load may contribute to increased ATT¹⁴ at shallow knee-flexion angles; hence, fatigue may compromise the biomechanics of the tibiofemoral joint during weight acceptance, thereby modifying the strain placed upon the ACL with continued loading and subsequent maneuvers (eg, plant and cut). This may be particularly problematic in landing situations where KF_EXC decreases in response to fatiguing exercise.^9,25,34 Although decreased KF_EXC may represent a compensatory strategy to prevent collapse of the body due to fatigue of the quadriceps muscles,^10,34 the reduced KF_EXC may increase axial loads at the knee joint, and these greater axial loads may increase the amount of ATT.³⁵The purpose of our study was to investigate the effects of a lower extremity exercise protocol on tibiofemoral-joint biomechanics as the knee transitioned from NWB to WB in vivo. Based on previous fatigue studies of submaximal total lower extremity actions,^9,25 our expectation was that fatiguing exercise would decrease KF_EXC, increase axial compressive force (ACF), and subsequently increase ATT during transition from NWB to WB.     

Strength-Training Protocols to Improve Deficits in Participants With Chronic Ankle Instability: A Randomized Controlled Trial

Context:Although lateral ankle sprains are common in athletes and can lead to chronic ankle instability (CAI), strength-training rehabilitation protocols may improve the deficits often associated with CAI.Objective:To determine whether strength-training protocols affect strength, dynamic balance, functional performance, and perceived instability in individuals with CAI.Design:Randomized controlled trial.Setting:Athletic training research laboratory.Intervention(s):Both rehabilitation groups completed their protocols 3 times/wk for 6 weeks. The control group did not attend rehabilitation sessions.Results:The resistance-band protocol group improved in strength (dorsiflexion, inversion, and eversion) and on the visual analog scale (P < .05); the proprioceptive neuromuscular facilitation group improved in strength (inversion and eversion) and on the visual analog scale (P < .05) as well. No improvements were seen in the triple-crossover hop or the Y-Balance tests for either intervention group or in the control group for any dependent variable (P > .05).Conclusions:Although the resistance-band protocol is common in rehabilitation, the proprioceptive neuromuscular facilitation strength protocol is also an effective treatment to improve strength in individuals with CAI. Both protocols showed clinical benefits in strength and perceived instability. To improve functional outcomes, clinicians should consider using additional multiplanar and multijoint exercises.Key Words: functional ankle instability, functional performance, rehabilitation, Star Excursion Balance Test

Key Points

• Proprioceptive neuromuscular facilitation is an alternate strength-training protocol that was effective in enhancing ankle strength in those with chronic ankle instability.
• Neither the resistance-band protocol nor the proprioceptive neuromuscular facilitation protocol improved dynamic balance or functional performance in individuals with chronic ankle instability.

Lateral ankle sprains are very common in athletes¹ and account for 80% of injuries to the ankle.² These injuries can cause damage to the ligaments, muscles, nerves, and mechanoreceptors that cross the lateral ankle.³ Repetitive occurrences of lateral ankle sprains can lead to chronic ankle instability (CAI),^4–6 which is characterized by a subjective feeling of recurrent instability, repeated episodes of giving way, weakness during physical activity, and self-reported disability.^5,7,8 Patients with CAI often exhibit deficits in functional performance,^9–13 proprioception,^5,14–16 and strength.^4,5,16,17Because muscle weakness is associated with CAI, strength training is an essential part of the rehabilitation protocol¹⁷ to reduce the residual symptoms and, we hope, to prevent further episodes of instability from occurring. Strength training improves the physical conditioning of participants with ankle instability.^16,18–25 Strength training is thought to promote muscular gains during the first 3 to 5 weeks because it enhances neural factors.²⁶ Therefore, strength training may improve proprioception and balance deficits.^18,24,25 Conflicting findings exist in the current literature^14,23; thus, the relationship between strength training and other factors, such as balance, proprioception, or functional performance, requires further investigation.Most authors^{18,20,21,23,25} who have investigated the effect of strength training in people with CAI have used resistive-tubing exercises 3 times/wk for 4 weeks²⁰ to 6 weeks.^18,21,23,25 Other rehabilitation protocols have involved manual resistance at the ankle²² and isokinetic strength training.²⁴ Some researchers^{18,21,23–25} focused on strength-training protocols alone, whereas others^{19,20,22,27,28} have used multicomponent protocols that included balance exercises. Improvements in strength,^18,24,25 static balance,²⁴ joint position sense,¹⁸ and functional performance tests²⁴ were reported.Proprioceptive neuromuscular facilitation (PNF) is another form of progressive strength training that emphasizes multiplanar motion.²⁹ The goal of PNF techniques is to promote functional movement through facilitation (strengthening) and inhibition (relaxation) of muscle groups.³⁰ Although it is used more often at the shoulder, hip, and knee joints, PNF can also be used at the ankle.³¹ Two studies^32,33 compared the differences between common lower extremity strength-training programs and PNF strength-training patterns. The PNF pattern for both studies used the sequential movements of toe flexion, ankle plantar flexion and eversion, knee and hip extension, abduction, and internal rotation in the lower extremity. The PNF strength patterns were as effective as isokinetic training³² and weight training³³ in improving knee strength and functional performance. Based on the deficits seen in patients with CAI, PNF may be a beneficial treatment approach. Because PNF patterns are similar to functional movement patterns,²⁹ PNF strength techniques may also improve dynamic balance and functional performance.Although a multicomponent rehabilitation protocol is often used after an injury, examining 1 component, such as strength, in a controlled research setting will allow us to determine the effectiveness of a single approach. If strength training alone can improve multiple deficits seen in patients with CAI, it could save time for both clinician and patient. A resistance-band protocol has already been established as an effective strength-training protocol in improving some deficits in people with CAI.^18,24,25 Therefore, the purpose of our study was to compare the effects of resistance-band (RBP) and PNF protocols on strength, dynamic balance, functional performance, and perceived instability in individuals with CAI.