Career and Family Aspirations of Female Athletic Trainers Employed in the National Collegiate Athletic Association Division I Setting

Context:Female athletic trainers (ATs) tend to depart the profession of athletic training after the age of 30. Factors influencing departure are theoretical. Professional demands, particularly at the collegiate level, have also been at the forefront of anecdotal discussion on departure factors.Objective:To understand the career and family intentions of female ATs employed in the collegiate setting.Design:Qualitative study.Setting:National Collegiate Athletic Association Division I.Results:Our participants indicated a strong desire to focus on family or to start a family as part of their personal aspirations. Professionally, many female ATs were unsure of their longevity within the Division I collegiate setting or even the profession itself, with 2 main themes emerging as factors influencing decisions to depart: family planning persistence and family planning departure. Six female ATs planned to depart the profession entirely because of conflicts with motherhood and the role of the AT. Only 3 female ATs indicated a professional goal of persisting at the Division I setting regardless of their family or marital status, citing their ability to maintain work-life balance because of support networks. The remaining 17 female ATs planned to make a setting change to balance the roles of motherhood and AT because the Division I setting was not conducive to parenting.Conclusions:Our results substantiate those of previous researchers, which indicate the Division I setting can be problematic for female ATs and stimulate departure from the setting and even the profession.Key Words: retention, attrition, work-life balance

Key Points

• Female athletic trainers decided to depart the Division I setting because the required hours of the job limited the time available for parenting.
• Female athletic trainers working in the Division I setting who were able to persist after having a family credit strong support networks and the development of effective work-life balance strategies.

Traditionally, working women endure more challenges balancing career demands and family responsibilities than working men, often because of their mothering philosophies and traditional gender stereotypes.¹ Surprisingly, gender differences have not been found in the occurrence of conflicts between work and life in the athletic training profession.^2,3 This finding is perplexing because female athletic trainers (ATs) continue to depart from the profession.⁴ Hypothetically, the decline in the number of female ATs in the profession has been linked to the desire to strike a balance among work responsibilities, personal interests, and family obligations.^1–3,5Concerns about work-life balance (WLB) and time for parenting have been found to influence decisions to persist within the collegiate levels, as the job responsibilities often include long hours (>40 h/wk) and travel, which can limit time spent at home with family.^1–3,5 It is an unfortunate reality that female ATs make up only approximately 28% of the full-time collegiate staff.⁵ This is especially concerning when the National Athletic Trainers'' Association indicates that more than 50% of its members are female.⁶ A relationship appears to exist between balancing professional responsibilities with parenthood and retention factors, especially for those who leave the collegiate clinical setting to work in clinical settings more favorable to family life.Female ATs in the National Collegiate Athletic Association Division I setting experience great challenges in maintaining WLB because of the demands of the setting.¹ In a recent study,¹ the primary reasons female ATs continued in the Division I setting were enjoyment of the job and atmosphere, increased autonomy, positive athlete dynamics, and the social support network. It is important for female ATs to have support at work and home to persist in the collegiate or athletic training clinical setting. However, long work hours and the inability to find WLB can stress this support network. Mazerolle and colleagues^2,3 first proposed that motherhood plausibly could lead to departure from the profession as the result of a myriad of factors but mostly because of a lack of time and control over work schedules. Further investigations have supported this theory and also have found that other reasons for leaving the profession are WLB concerns, supervisory and coach conflicts, caring for children, and role overload.^1,4,5Fulfillment of WLB is an important retention factor for female coaches within the collegiate setting,⁷ thus providing some supporting evidence to the suppositions that motherhood can be a mediating factor in the retention of female ATs in the collegiate setting. Additional support can be garnered from Mazerolle et al,² who found that only 22 female ATs with children were employed at the collegiate setting, a statistic supported by Kahanov et al,⁵ who reported that only about a quarter of all full-time ATs at the collegiate setting were female.Concerns about retention, particularly of female ATs, have become an increasingly popular topic within the athletic training literature, with attention focused on the collegiate clinical setting. This setting not only is one of the largest employment settings for the AT⁶ but is recognized as a time-intensive, demanding work environment.^2,3,8,9 Moreover, data suggest women are leaving this particular clinical setting to find a more family-friendly work environment, which may or may not be in the profession of athletic training.^10,11 Additionally, 2 recent studies^10,11 suggest that female athletic training students intend to pursue careers in athletic training, but as highlighted by Kahanov and Eberman,⁴ women are rapidly departing the profession for a variety of reasons. The emigration of female ATs from the profession has been theoretically associated with the desire to attain balance among family commitments, personal time, and work responsibilities.^1,2 Difficulties maintaining WLB and sufficient time for parenting shape decisions to continue at the collegiate level.^1,2Because of the concerning trend of female AT attrition, the purpose of our study was to understand the perspectives of female ATs, regardless of marital status, and to evaluate career and family intentions. Our objective was to gain a more thorough understanding of female ATs'' professional goals as they may be influenced by family planning. Our research questions included, “What factors influence the career intentions of female ATs regarding career longevity?” and “Do female ATs have intentions to remain in the NCAA Division I setting?”     

Program Directors' Perceptions of Undergraduate Athletic Training Student Retention

Context:The average retention rate for students enrolled in undergraduate athletic training programs (ATPs) nationwide has been reported to be 81%, and slightly more than half of program directors (PDs) have indicated that retention of athletic training students (ATSs) is a problem. However, why PDs do or do not believe ATS retention is problematic is unknown.Objective:To determine why PDs do or do not believe ATS retention is problematic.Design:Qualitative study.Setting:Undergraduate ATPs.Results:Program directors believed that retaining ATSs was a problem because students lack information regarding athletic training and the rigor of the ATP. Program directors were consistent in their perception that ATPs do not have a retention challenge because of the use of a secondary admissions process. This finding was likely based on personal use of a secondary admissions process in the ATPs these PDs lead.Conclusions:Program directors who lead ATPs that struggle to retain ATSs should consider using a secondary admissions process. During the preprofessional phase of the ATP, faculty and staff should work to socialize students to the demands of the ATP and the professional lives of athletic trainers.Key Words: athletic training education, persistence, departure, attrition

Key Points

• Early socialization and orientation of athletic training students into the roles and expectations of athletic trainers and the program may help to improve retention.
• Secondary admissions processes may aid athletic training programs in retaining students.

For a multitude of reasons, athletic training student (ATS) retention has become a strong focus in the literature.^1–4 One possibility for the increased attention to ATS retention may stem from the move to accredited professional education programs. Before 2004, prospective athletic trainers could enter the profession through either an accredited program or an internship route. With athletic training education reform, the internship route was abandoned and candidates were required to graduate from an accredited athletic training program before sitting for the Board of Certification examination. Elimination of the internship path has caused the number of undergraduate athletic training programs (ATPs) in the United States to more than double to 343 as of the spring 2011 semester. ⁵ A previous author found that younger ATPs had lower ATS retention rates (Valerie Herzog, written communication, 2006). Because reform has caused a dramatic increase in the number of young programs, perhaps retention is more of a problem now. Another potential reason for the increase in interest in ATS retention may have to do with upholding the ATPs'' reputation⁶ as maintaining high ATS retention rates can help to improve public opinion of ATPs. Finally, reasons for ATS dropout have been identified, particularly the demanding coursework and time-consuming clinical education experiences.⁷ However, whether dropout is considered problematic or a necessity to remove those who cannot complete the ATP or enter professional practice is currently unknown.Most of the existing literature has examined retention and attrition from the student point of view.^1–3 Athletic training students persist when they are integrated academically, socially, and clinically through proper socialization and when they experience positive relationships with other ATP stakeholders.^1,2 Although the findings are insightful and can aid in retention initiatives offered by ATPs, more research is warranted; additional studies must be undertaken before the current state of ATS retention can be fully understood. Understanding the unique vantage point of program directors (PDs) is important as they are responsible for the overall day-to-day operations of ATPs.⁸ One previous study⁹ sought retention and attrition data from PDs of ATPs before the 2004 athletic training educational reform. Programs at institutions with higher enrollments had a larger number of ATSs. Similarly, programs at state institutions and institutions with lower tuition costs had larger athletic training class sizes. The participants, 25 PDs, stated that most ATSs left the ATP in the first 2 semesters after formal acceptance. In addition, the majority of participants confirmed that administrators had not identified the ATS retention rate at their institution as a problem. The authors concluded that larger programs were not as concerned with ATS attrition as smaller programs because they had larger numbers of available ATSs.⁹We should further understand the present condition of ATS attrition before investigating ATS retention factors. The overall national retention rate for ATSs in undergraduate ATPs from formal admittance to graduation has been reported as 81.0%.⁴ Although this rate appears satisfactory compared with other health care professional programs, mainly nursing, which previously set a benchmark of 80%,¹⁰ approximately half of PDs believed that retaining ATSs was a problem facing athletic training education.⁴ Why some PDs believe retention is a problem while others do not, despite the relatively high overall retention rate, is unclear. Therefore, the purpose of our study was to determine why PDs do or do not believe ATS retention is problematic. We gathered data from PDs because we felt they have a broad understanding of retention based on their experience with cohorts of students, typically over multiple years in their current positions. We also believe PDs have conversations with colleagues about such issues, making their insights meaningful. Although the perspectives of ATSs can also be helpful, students have a much more centralized focus, making it difficult for them to know if attrition is a problem in athletic training education. Further, ATSs'' perspectives on reasons for persistence and departure have been explored previously.^1–3 A broader lens allows PDs to draw on experiences with a multitude of ATSs who may have departed or persisted for very different reasons. Understanding why PDs feel that ATS retention is or is not a problem may help other PDs or faculty make curricular changes to improve the retention rates of the ATSs in the ATPs they lead.     

Undergraduate Athletic Training Students' Influences on Career Decisions After Graduation

Context

Career opportunities for athletic training students (ATSs) have increased substantially over the past few years. However, ATSs commonly appear to be opting for a more diversified professional experience after graduation. With the diversity in available options, an understanding of career decision is imperative.

Objective

To use the theoretical framework of socialization to investigate the influential factors behind the postgraduation decisions of senior ATSs.

Design

Qualitative study.

Setting

Web-based management system and telephone interviews.

Patients or Other Participants

Twenty-two ATSs (16 females, 6 males; age = 22 ± 2 years) who graduated in May 2010 from 13 different programs accredited by the Commission on Accreditation of Athletic Training Education.

Data Collection and Analysis

All interviews were transcribed verbatim, and the data were analyzed inductively. Data analysis required independent coding by 2 athletic trainers for specific themes. Credibility of the results was confirmed via peer review, methodologic triangulation, and multiple analyst triangulation.

Results

Two higher-order themes emerged from the data analysis: persistence in athletic training (AT) and decision to leave AT. Faculty and clinical instructor support, marketability, and professional growth were supporting themes describing persistence in AT. Shift of interest away from AT, lack of respect for the AT profession, compensation, time commitment, and AT as a stepping stone were themes sustaining the reasons that ATSs leave AT. The aforementioned reasons to leave often were discussed collectively, generating a collective undesirable outlook on the AT profession.

Conclusions

Our results highlight the importance of faculty support, professional growth, and early socialization into AT. Socialization of pre–AT students could alter retention rates by providing in-depth information about the profession before students commit in their undergraduate education and by helping reduce attrition before entrance into the workforce.Key Words: socialization, attrition, retention, mentorship

Key Points

• Senior athletic training students who persisted in athletic training did so because of faculty and clinical support, improved marketability, and professional growth.
• A shift of interest away from athletic training, lack of respect for the athletic training profession, compensation, time commitment, and athletic training as a stepping stone led senior athletic training students to leave athletic training.

From the beginning of athletic training in the 1950s to the present day, a primary concern has involved the education of students and working professionals.^1,2 The concern is evident with the marked growth of professional (entry-level) athletic training education programs (ATEPs), postprofessional programs, and continuing education programs.^2–4 Both the professional and educational opportunities for the athletic trainer have increased substantially over the past few years and will continue do so in the future.^5–7 Currently, 347 undergraduate programs are accredited by the Commission on Accreditation of Athletic Training Education (CAATE), and this number has grown substantially since the transition away from the internship route to certification.^3,5,6The National Athletic Trainers'' Association⁵ (NATA) estimates it has more than 5000 student members; however, only 600 members are certified graduate students, and overall approximately 1200 are certified members in their first year of employment, indicating attrition away from the profession. The dichotomy in these statistics raises the question of what professions or courses of study these students, who are enrolled in CAATE-accredited ATEPs, planned to pursue after completing their programs. Although a plethora of data exists regarding student retention in higher education programs,^8–10 a paucity of research exists on those students who complete degree programs but choose not to enter the workforce in which they were professionally trained. Presently, peer support, clinical educational experiences, and motivation are linked to retaining students in ATEPs,⁶ whereas stress and burnout predominately lead to attrition for students enrolled in medical and nursing programs^11,12 and postprofessional programs.^4,13 Athletic training students (ATSs) encounter a stressful and demanding lifestyle as they attempt to balance their academic studies, clinical responsibilities, and personal obligations and interests.¹⁴ This stress often leads to burnout among ATSs.¹⁵ Perhaps these same factors can influence the decision of an ATS to become an athletic trainer.After graduation, ATSs have many career options, which can include advanced study in various graduate programs; postprofessional degrees in athletic training; or direct entrance into the workforce via high school, collegiate athletics internships, or outreach positions.^4,16 With these diverse options available and no current mandatory course for postprofessional study, understanding how ATSs arrive at this postgraduation decision is important particularly because the statistics demonstrate a clear decline in students becoming athletic trainers.⁵ A better understanding of the career decision-making process might help increase the number of students who pursue postprofessional educational programs and who become athletic trainers. Neibert et al¹⁶ explored the career decisions of senior ATSs and recent graduates of accredited ATEPs. They found that 82.4% of participants pursued a career as an athletic trainer, whereas the remainder indicated they were not seeking employment as an athletic trainer. Although the statistics reveal a large portion of students become athletic trainers, their socialization experiences and the influence of these experiences on their decisions to leave or stay in athletic training are not clear.Professional socialization is an important and necessary component of an ATS''s educational experiences and is often the theoretical framework used to capture a student''s development into his or her professional role.^7,17–19 As a developmental process, socialization is defined as the process of learning in which an individual acquires the knowledge and skills that enable him or her to function in a particular role.^17–19 This process is a fundamental component in the professional preparation of health care providers, including athletic trainers, as they learn the skills, values, attitudes, and norms of behavior associated with their professions.^17,20 Mentorship has been identified as a critical factor in the professional socialization development of an athletic trainer because the relationship between the mentor and protégé can help reinforce professional roles, advance skill development, and promote lifelong learning for both members.^21,22 Mentorship received during the professional preparation phase can positively or negatively influence the student''s evaluation of the profession²² and potentially can influence postgraduation decisions and future career choices.²³ Clinical instructors are influential in the socialization process, and their levels of passion and excitement can directly affect a student''s overall impression and respect for a given profession.^21,23The roles and responsibilities of the athletic trainer are demanding and complex, and learning how to manage these roles can be daunting at times. Therefore, scholars have begun to critically evaluate the process from a global perspective and the factors that can influence the process. Researchers have a substantial understanding of how students are recruited²⁴ into an ATEP, what factors attract them to a career in athletic training,⁷ what factors keep them enrolled in ATEPs,⁶ and how they are socialized after they work in full-time positions^18–20,25; however, the understanding of the professional preparation and anticipatory socialization of the ATS and its effect on attrition in the workforce is limited.¹⁶ Our hope is to build on previous literature focused on career decisions^{6,7,16,18,19,21,24,26} and socialization^{18–21,26,27} and explore the role that professional socialization plays in the career decisions of ATSs.Therefore, the purpose of our study was to use the theoretical framework of socialization to examine the influences on postgraduation decisions of senior ATSs enrolled in CAATE-accredited ATEPs. The following question guided the data-collection process: Why do ATSs choose to become or not to become athletic trainers?     

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.     

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.     

Feedback in Clinical Education,Part I: Characteristics of Feedback Provided by Approved Clinical Instructors

Context

Providing students with feedback is an important component of athletic training clinical education; however, little information is known about the feedback that Approved Clinical Instructors (ACIs; now known as preceptors) currently provide to athletic training students (ATSs).

Objective

To characterize the feedback provided by ACIs to ATSs during clinical education experiences.

Design

Qualitative study.

Setting

One National Collegiate Athletic Association Division I athletic training facility and 1 outpatient rehabilitation clinic that were clinical sites for 1 entry-level master''s degree program accredited by the Commission on Accreditation of Athletic Training Education.

Patients or Other Participants

A total of 4 ACIs with various experience levels and 4 second-year ATSs.

Data Collection and Analysis

Extensive field observations were audio recorded, transcribed, and integrated with field notes for analysis. The constant comparative approach of open, axial, and selective coding was used to inductively analyze data and develop codes and categories. Member checking, triangulation, and peer debriefing were used to promote trustworthiness of the study.

Results

The ACIs gave 88 feedback statements in 45 hours and 10 minutes of observation. Characteristics of feedback categories included purpose, timing, specificity, content, form, and privacy.

Conclusions

Feedback that ACIs provided included several components that made each feedback exchange unique. The ACIs in our study provided feedback that is supported by the literature, suggesting that ACIs are using current recommendations for providing feedback. Feedback needs to be investigated across multiple athletic training education programs to gain more understanding of certain areas of feedback, including frequency, privacy, and form.Key Words: assessment, evaluation, pedagogy, preceptors

Key Points

• Feedback had several different components that made each feedback exchange unique.
• The feedback that the Approved Clinical Instructors (ACIs) provided mostly was aligned with recommendations in the literature, suggesting our ACIs provided effective feedback to athletic training students and current recommendations are applicable to athletic training clinical education.
• Researchers should continue to assess the feedback that is occurring in different athletic training education programs to gain more understanding of the current use of feedback across several programs so they can guide ACI training and evaluation, including the development of recommendations for the appropriate frequency of feedback.

Feedback is any information provided to a student that helps correct, reinforce, or suggest change in his or her performance.^1,2 It is a type of evaluation that is less formal and judgmental than structured, summative evaluation and assessment² and is an effective educational technique.^3,4 Providing feedback to students also has been described as one of the most important characteristics of clinical instructors in athletic training,^5,6 medicine,^7,8 nursing,⁹ and physical therapy.¹⁰ In addition, feedback has been shown to improve clinical performance in medical^11,12 and nursing students.^13,14Most research on feedback has been focused on the recommended characteristics of feedback, such as its specificity, timing, tone, and relation to educational and career goals.^3,4,15 Much of the existing research is based on student and instructor perceptions of whether these recommendations are followed rather than actual observed feedback.^12,16 Feedback research in athletic training is much less extensive than other areas of clinical education. Most research on feedback in athletic training education has been focused on general effective clinical instructor behaviors.^5,17,18 These investigators have identified feedback as an important behavior of Approved Clinical Instructors (ACIs),⁵ and along with evaluation, it is considered a standard for selecting, training, and evaluating ACIs.^17,18 Several authors^1,19,20 have provided suggestions for giving effective feedback to athletic training students (ATSs) in clinical education. The supervision, questioning, feedback (SQF) model of clinical teaching provides guidelines for giving feedback to ATSs at different developmental levels.¹ Stemmans²¹ compared the quantity of feedback provided by clinical instructors with different amounts of experience. The researcher found that novice clinical instructors provided less feedback to ATSs than more experienced clinical instructors did. Berry et al²² reported that students in outpatient rehabilitation clinics spent more time engaged in active learning than did students in intercollegiate and high school settings. Because learning experiences differ among clinical settings, the feedback exchange also may differ among settings.Providing feedback is considered to be one of the most important roles of ACIs during clinical education experiences.^5,6 However, feedback has been minimally explored in practitioner-based articles and research studies specific to athletic training. Little is known about the feedback ACIs provide to ATSs. Similarly, to our knowledge, no one has examined how feedback is used in different clinical education settings, such as rehabilitation clinics and collegiate athletic training facilities. Therefore, the purpose of our study was to characterize the feedback provided by ACIs to ATSs during clinical education sessions in 1 outpatient rehabilitation clinic and 1 collegiate athletic training facility.     

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.     

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?

     

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.     

Feedback in Clinical Education,Part II: Approved Clinical Instructor and Student Perceptions of and Influences on Feedback

Context:

Approved Clinical Instructors (ACIs; now known as preceptors) are expected to provide feedback to athletic training students (ATSs) during clinical education experiences. Researchers in other fields have found that clinical instructors and students often have different perceptions of actual and ideal feedback and that several factors may influence the feedback exchanges between instructors and students. However, understanding of these issues in athletic training education is minimal.

Objective:

To investigate the current characteristics and perceptions of and the influences on feedback exchanges between ATSs and ACIs.

Design:

Qualitative study.

Setting:

One entry-level master''s degree program accredited by the Commission on Accreditation of Athletic Training Education.

Patients or Other Participants:

Four ACIs and 4 second-year ATSs.

Data Collection and Analysis:

Individual, semistructured interviews were conducted with participants and integrated with field notes and observations for analysis. We used the constant comparative approach to inductively analyze data and develop codes and categories. Member checking, triangulation, and peer debriefing were used to promote trustworthiness of the study.

Results:

Participants described that feedback plays an important role in clinical education and has several purposes related to improving performance. The ACIs and ATSs also discussed several preferred characteristics of feedback. Participants identified 4 main influences on their feedback exchanges, including the ACI, the ATS, personalities, and the learning environment.

Conclusions:

The ACIs and ATSs had similar perceptions of ideal feedback in addition to the actual feedback that was provided during their clinical education experiences. Most of the preferences for feedback were aligned with recommendations in the literature, suggesting that existing research findings are applicable to athletic training clinical education. Several factors influenced the feedback exchanges between ACIs and ATSs, which clinical education coordinators should consider when selecting clinical sites and training ACIs.Key Words: assessment, evaluation, pedagogy, preceptors

Key Points

• Both Approved Clinical Instructors (ACIs) and athletic training students (ATSs) recognized feedback has an important role in clinical education for several reasons.
• Several characteristics of the learning environment influenced ACI-ATS interactions and student learning and should be considered when selecting and improving clinical sites, pairing ACIs and ATSs, and educating ACIs to give good feedback.
• Researchers need to continue investigating the roles that patient volume, supervision, ACI workload, ACI experience, personalities, and similar factors have on student learning and feedback.

Approved Clinical Instructors (ACIs; now known as preceptors) are responsible for providing feedback to athletic training students (ATSs) during their clinical education experiences.^1,2 Feedback provides information to students about their performances that they can use to improve and refine their clinical skills, reasoning, and professional behaviors.^3–6 Several suggestions for providing effective feedback have been given in athletic training^3,7,8; however, current research on the actual use of feedback in athletic training clinical education is limited.Much of the existing research on feedback in medicine^5,9 and nursing¹⁰ is based on student and instructor perceptions of feedback. Whereas students and instructors agree that feedback is important,^9,10 researchers⁵ have found several disagreements over what students, instructors, and experts believe is good feedback. In addition, instructors and students often have different perceptions of the feedback that actually is given in clinical education settings. Clinical instructors often believe they provide effective feedback more often than instructors of medical students do,^9,11,12 and these opinions are frequently different from what is observed by a third party.¹¹ These differences may stem from an inability of instructors to self-assess their behaviors or an inability of students to recognize feedback.^13,14In addition to perceptions of feedback, several investigators in the areas of medical^15–17 and athletic training^18,19 education have examined the factors that influence the feedback exchanges between clinical instructors and students. These investigators have found that several factors influence how feedback is given and received in the clinical education setting, including interpersonal and communication abilities of clinical instructors,^15,16 their abilities to adjust feedback based on student needs,¹⁸ and their past experiences as teachers and learners.²⁰ In addition, student receptivity to feedback,²¹ the clinical environment,¹⁷ and the degree of supervision¹⁹ have been found to influence the feedback exchanges between students and teachers. These aspects of the student-instructor relationship further complicate the delivery and use of feedback in clinical education. Therefore, the purpose of our study was to gain understanding of the complex feedback interactions that occur in athletic training education by investigating the current characteristics and perceptions of and the influences on feedback exchanges between ATSs and ACIs. The findings related to the characteristics of the actual feedback that is being provided were presented in part I of this study. In part II, we include the findings specific to the perceptions of and influences on feedback.     

Pressure on Sports Medicine Clinicians to Prematurely Return Collegiate Athletes to Play After Concussion

Context

 Anecdotal and qualitative evidence has suggested that some clinicians face pressure from coaches and other personnel in the athletic environment to prematurely return athletes to participation after a concussion. This type of pressure potentially can result in compromised patient care.

Objective

 To quantify the extent to which clinicians in the collegiate sports medicine environment experience pressure when caring for concussed athletes and whether this pressure varies by the supervisory structure of the institution''s sports medicine department, the clinician''s sex, and other factors.

Design

 Cross-sectional study.

Setting

 Web-based survey of National College Athletic Association member institutions.

Patients or Other Participants

 A total of 789 athletic trainers and 111 team physicians from 530 institutions.

Main Outcome Measure(s)

 We asked participants whether they had experienced pressure from 3 stakeholder populations (other clinicians, coaches, athletes) to prematurely return athletes to participation after a concussion. Modifying variables that we assessed were the position (athletic trainer, physician) and sex of the clinicians, the supervisory structure of their institutions'' sports medicine departments, and the division of competition in which their institutions participate.

Results

 We observed that 64.4% (n = 580) of responding clinicians reported having experienced pressure from athletes to prematurely clear them to return to participation after a concussion, and 53.7% (n = 483) reported having experienced this pressure from coaches. Only 6.6% (n = 59) reported having experienced pressure from other clinicians to prematurely clear an athlete to return to participation after a concussion. Clinicians reported greater pressure from coaches when their departments were under the supervisory purview of the athletic department rather than a medical institution. Female clinicians reported greater pressure from coaches than male clinicians did.

Conclusions

 Most clinicians reported experiencing pressure to prematurely return athletes to participation after a concussion. Identifying factors that are associated with variability in pressure on clinicians during concussion recovery can inform potential future strategies to reduce these pressures.Key Words: conflict of interest, organizational structure, sex, college

Key Points

• More than half of sports medicine clinicians had experienced pressure from coaches and athletes to return athletes to participation prematurely after a concussion.
• Clinicians experienced greater pressure from coaches at schools where the sports medicine department reported to the athletic department than at schools where the sports medicine department reported to an independent medical institution.
• Female clinicians experienced greater pressure from coaches than male clinicians experienced.
• More research is needed to determine how pressure affects clinical practice and whether pressure on clinicians affects return-to-participation decisions.

Addressing the health burden of mild traumatic brain injury from sport is increasingly considered a public health priority.¹ More than 450 000 college students participate in organized interscholastic sports each year.^2,3 Among collegiate athletes in contact and collision sports, Daneshvar et al⁴ estimated that 43 concussions are sustained per 100 000 athlete-exposures to a game or practice, which is nearly twice the rate of diagnosed concussions sustained by high school athletes competing in the same sports. This estimate likely understates the true incidence of concussions because many are undiagnosed.^5–8 Recent evidence^9–14 has suggested that repeated concussive and subconcussive brain trauma can lead to neurologic problems later in life, including changes in cognition and behavior.Conflict of interest in the care of concussed athletes is a topic of growing ethical discourse.^15–19 Writing for the Chronicle of Higher Education about US collegiate sport, Wolverton²⁰ painted a picture of colleges fraught with pressure on physicians and athletic trainers (ATs) from coaches and athletic administrators. A total of 101 clinicians who provide patient care for football teams in the National Collegiate Athletic Association (NCAA) Division I Football Bowl Subdivision participated in the non–peer-reviewed study, and more than half reported that they had “felt pressure from football coaches to return concussed players to action before they were medically ready.”²⁰ Some of this pressure was attributed to conflicts of interest inherent in the organizational structure and incentives of sports medicine departments. In some instances, ATs reported directly to head football coaches.²⁰ Even in substantially lower-stakes youth sports, Bramley et al²¹ reported that a sample of hockey coaches indicated they would be more likely to allow an athlete who had sustained a concussion to continue participating if the game was considered important, such as for a championship. Consequently, clinicians in collegiate sports medicine departments may find themselves in a challenging situation: having ethical responsibilities to provide appropriate medical care to their patients while facing perceived or real pressure from their employers to return athletes to participation.^15–19,22 In a survey of sports medicine physicians in New Zealand, Anderson and Gerrard²³ observed that whereas all respondents expressed a sense of responsibility to their athlete patients, 72% also believed they had a responsibility to the team coach, and 55% believed they had a responsibility to team management.The National Athletic Trainers'' Association recently released a consensus statement detailing best practices for sports medicine management in secondary schools and colleges, including the advantages and disadvantages of different models of supervisory relationships in sports medicine.²⁴ Supervisory models in which ATs or team physicians are employed by athletic departments are described as having the potential for conflict of interest in the medical care provided to athletes. Pecci and Laursen²⁵ and Laursen²⁶ have advocated for sports medicine departments to be nested within medical units, such as university health centers, rather than athletic departments. They suggested that this organizational structure would reduce real and perceived conflicts of interest in the care of athletes and would have additional benefits, such as easier access to other health care providers and more centralized oversight of medical care.^25,26 Whereas these arguments are intuitive, no researchers have conducted an empirical evaluation of whether supervisory structure is systematically associated with different types of pressure on clinicians regarding the care of collegiate athletes who have sustained concussions.Another potentially important variable that could modify the pressure that clinicians experience is their sex. Approximately half of all ATs are women, but women represent only about one-quarter of full-time staff ATs and only 1 in 8 head ATs in collegiate sports medicine departments.^27–30 Some investigators³¹ have suggested that male and female ATs may have different experiences interacting with coaches and other ATs in the collegiate athletic environment. Mazerolle et al³¹ conducted qualitative interviews with 14 female NCAA Division I ATs and described how they “often encountered gender discrimination when working with a team sport coached by a man.” They described a perception that coaches view female ATs as “more sympathetic and less pragmatic” than male ATs and that this judgment undermines the coaches'' confidence in the care they provide athletes. This differential perception is reinforced by 2 surveys^32,33 in which male collegiate athletes reported being more comfortable receiving care from male ATs. Stereotypical judgments about women in the workplace tend to be strongest when women are an underrepresented minority, as is the case with female ATs in collegiate sports environments, and can inform the control strategies of individuals in positions of power.³⁴ Quantifying the extent to which pressure is experienced in the care of concussed athletes and whether it is modified by clinician characteristics such as sex are important steps in understanding whether institution-level intervention is needed.Therefore, the purpose of our study was to obtain empirical evidence about whether clinicians who provide care to US collegiate sports teams experienced pressure to prematurely clear athletes for participation after a concussion. We hypothesized that clinicians in sports medicine departments reporting to the athletic department would experience greater pressure from coaches and athletes than clinicians in departments reporting to medical institutions and that female clinicians would experience greater pressure from coaches and athletes than male clinicians would experience.     

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?     

The Experiences of Female Athletic Trainers in the Role of the Head Athletic Trainer

Context:Very few women have leadership positions in athletic training (ie, head athletic training positions) in intercollegiate athletics. Research exists on the barriers to attaining the role; however, our understanding about the experiences of those currently engaged in the role is limited.Objective:To examine the experiences of female head athletic trainers as they worked toward and attained the position of head athletic trainer.Design:Qualitative study.Setting:National Collegiate Athletic Association Division I setting.Results:Six major themes emerged from our analysis regarding the experiences of female head athletic trainers. Opportunities to become a head athletic trainer, leadership qualities, and unique personal characteristics were discussed as factors leading to the assumption of the role of the head athletic trainer. Where women hold back, family challenges, and organizational barriers speak to the potential obstacles to assuming the role of head athletic trainer.Conclusions:Female head athletic trainers did not seek the role, but through persistence and encouragement, they find themselves assuming the role. Leadership skills were discussed as important for success in the role of head athletic trainer. Life balancing and parenting were identified as barriers to women seeking the role of head athletic trainer.Key Words: gender, leadership, socialization, career advancement

Key Points

• Female athletic trainers who assumed the role of the head athletic trainer did so because of persistence and strong leadership skills. Many were promoted to the rank of head athletic trainer within their own organizations due to strong job performance.
• Reluctance and life-balancing concerns emerged as barriers to female athletic trainers assuming the role of the head athletic trainer position. The increase in administrative responsibilities and resulting additional demands on their time were potential problems for female athletic trainers.

Since the passage of Title IX legislation, more women have assumed positions within athletic training at the intercollegiate level. Women represented 46.4% of graduate assistant athletic trainers and 47% of assistant or associate athletic trainers in 2010.¹ However, the number of women advancing in the field, specifically to head athletic trainer positions within Division I of the National Collegiate Athletic Association, has not increased significantly. Women held the fewest head and assistant athletic training positions at the Division I level,² only 17.5% of the head athletic trainer positions in 2012.¹ Scant research is available to address why so few women are in head athletic trainer positions. To date, only 1 author³ has examined the experiences of women in head athletic trainer positions at the Division I level.Outside the athletic training literature, gender stereotyping and factors limiting the advancement of women in administrative or leadership roles have been described.^4–8 Within the athletic training literature, scholars have examined how gender-role stereotyping and concerns about power have negatively influenced female athletic trainers, particularly when they are providing athletic training services to male sports or interacting with male coaches while providing athletic training services at the Division I level.⁹ Moreover, additional researchers have suggested that many women transition away from the Division I level to less demanding positions and careers as a result of kinship responsibilities,¹⁰ parenthood,¹¹ and life balancing,¹² which may preclude them from eventually assuming the role of head athletic trainer. Also, Gorant³ noted that female athletic trainers expressed an aversion to the role of head athletic trainer, as that person often assumes the position of lead athletic trainer in charge of football. Providing athletic training services at the Division I level is considered a daunting task requiring long hours; coupling those with the additional administrative responsibilities that accompany the role of the head athletic trainer and the responsibilities of a football sport assignment may deter an athletic trainer from pursuing the role. Gorant³ found that female athletic trainers were reluctant to assume leadership roles as a result of lack of confidence or self-identified lack of skill sets necessary to lead.³ Our purpose was to build upon the work of Gorant,³ as she was the first to examine the barriers female athletic trainers perceived to assuming the role of the head athletic trainer.

Challenges to Advancement to Head Athletic Trainer

Career advancement for female athletic trainers has been described as limited or difficult to achieve.³ Gender stereotyping has been anecdotally and empirically cited as a barrier to career advancement for female athletic trainers in the Division I setting.^3,9,13 Other barriers that have been examined within the athletic training literature include work-family conflict,^6,14,15 kinship responsibility,⁷ parenthood,³ incongruent role perceptions⁸ in collegiate athletic settings, and gender stereotyping of young female athletic trainers early in their careers.⁹ However, many women have been able to persist in athletic training despite these barriers.³ Specifically, a female athletic trainer is more likely to remain in a position that allows her to adequately and efficiently assume all her roles, which may include mother, caretaker, and spouse.¹⁵ Although data are limited on female athletic trainers and their decisions regarding leadership positions, the existing literature indicates some women report higher levels of job satisfaction in lower-ranking positions,^16,17 notably because of the ability to balance work and family obligations.^18,19 Work as an athletic trainer at the collegiate level is time intensive, which limits the ability to fulfill other roles and responsibilities, such as those of caregiver, spouse, or mom.²⁰Gender-role stereotypes are at times applied to women working in male-dominated areas,^21–23 especially in collegiate athletics. Ohkubo¹³ found that gender stereotypes existed within the Division I setting for the female athletic trainer, as student-athletes perceived them to serve in the role of nurturer or “mom.” Burton et al⁹ reported that young female athletic trainers were subject to informal work practices that prevented them from covering the higher-profile sports of men''s basketball and football. In addition, male coaches stereotyped young, female athletic trainers as potential sexual distractions to their athletes, which also served to minimize their professional competence and ability to work with high-profile men''s sports.⁹

Mentorship Support for Female Advancement in Athletic Training

Socialization is a process whereby individuals learn their professional roles and responsibilities through formal and informal training.^24,25 Mentorship has been identified as a necessary facilitator for professional development because the mentor provides guidance, context, and understanding regarding professional expectations, behaviors, and skills. In a recent study examining sex discrimination in the Division I setting, Burton and colleagues⁹ found that female athletic trainers were able to manage situations of sex discrimination because of professional role modeling or mentorship by a peer or supervising athletic trainer. Based on findings of recent investigations,^26,27 examining the balance between motherhood and the role of a Division I athletic trainer, mentorship has been viewed as a critical factor to help retain more women in the workplace. Also, role models and mentors can both assist athletic trainers in the Division I setting to navigate the bureaucratic and political environment of intercollegiate athletics²⁶ and advise young professionals on career advancement and how to improve job satisfaction.²⁷Given the low percentage of women working in head athletic training positions in Division I intercollegiate athletics (15.2%), the purpose of our study was to examine the experiences of women working in those positions. We hoped that by examining their experiences, we could develop a better understanding of what opportunities have led them to those positions, what personal characteristics and organizational contexts have supported their advancement, and what challenges and barriers they have overcome to reach the leadership level in athletic training.     

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?     

Sex and Employment-Setting Differences in Work-Family Conflict in Athletic Training

Context

 Work-family conflict (WFC) has received much attention in athletic training, yet several factors related to this phenomenon have not been examined, specifically a practitioner''s sex, occupational setting, willingness to leave the profession, and willingness to use work-leave benefits.

Objective

 To examine how sex and occupational differences in athletic training affect WFC and to examine willingness to leave the profession and use work-leave benefits.

Design

 Cross-sectional study.

Setting

 Multiple occupational settings, including clinic/outreach, education, collegiate, industrial, professional sports, secondary school, and sales.

Patients or Other Participants

 A total of 246 athletic trainers (ATs) (men = 110, women = 136) participated. Of these, 61.4% (n = 151) were between 20 and 39 years old.

Main Outcome Measures(s)

 Participants responded to a previously validated and reliable WFC instrument. We created and validated a 3-item instrument that assessed willingness to use work-leave benefits, which demonstrated good internal consistency (Cronbach α = 0.88), as well as a single question about willingness to leave the profession.

Results

 The mean (± SD) WFC score was 16.88 ± 4.4 (range = 5 [least amount of conflict] to 25 [highest amount of conflict]). Men scored 17.01 ± 4.5, and women scored 16.76 ± 4.36, indicating above-average WFC. We observed no difference between men and women based on conflict scores (t₂₄₄ = 0.492, P = .95) or their willingness to leave the profession (t₂₄₄ = −1.27, P = .21). We noted differences among ATs in different practice settings (F_8,245 = 5.015, P <.001); those in collegiate and secondary school settings had higher reported WFC scores. A negative relationship existed between WFC score and comfort using work-leave benefits (2-tailed r = −0.533, P < .001). Comfort with using work-leave benefits was different among practice settings (F_8,245 = 3.01, P = .003).

Conclusions

 The ATs employed in traditional practice settings reported higher levels of WFC. Male and female ATs had comparable experiences of WFC and willingness to leave the profession.Key Words: work-life balance, work-leave benefits, retention, attrition

Key Points

• Work-family conflict (WFC) continues to be an important employment concern in athletic training.
• The level of perceived WFC did not differ between men and women but did differ among practice settings.
• Comfort using work-leave benefits to address family challenges was negatively correlated with WFC.
• Researchers need to examine the role of workplace policies in mitigating WFC.

The ever-changing demographic makeup of the workforce appears to drive scholarly attention toward work and family challenges. Work-family and work-life balance have become predominant concerns for working Americans. Americans work more hours than people in other industrialized countries,¹ which affects the time available to address nonwork responsibilities and personal hobbies and interests. Whereas these factors have been cited among all occupations, health care professionals, such as physicians² and athletic trainers (ATs),³ are susceptible to challenges with work-family balance because of the long work hours, inflexible work schedules, and demands associated with patient care.^2,3Work-family conflict (WFC) appears to be emerging as a greater concern in athletic training because of its association with retention,^3,4 particularly of female ATs.^4–6 In a recent report, Kahanov and Eberman⁷ noted that many female ATs leave the profession before they are 30 years old, indicating a relationship between starting a family and incompatibility with a career in athletic training. Hours worked are linked repeatedly to this dichotomy between a lifelong career in athletic training and the demands of parenthood.^6,8,9 Dodge et al¹⁰ were among the first to report concerns about the time-intensive nature of the profession and longevity, noting that some athletic training students changed majors to more family-friendly career paths. This observation directly links the importance of early socialization and mentoring of students because their results implied that some students decide to leave the profession before serving as ATs. Whereas female ATs appear to make career-setting or occupational-setting changes due to motherhood, limited data exist to support sex differences in the profession. Researchers^5,7,9 have postulated that male ATs shift occupational settings to accommodate the need to provide for the family financially, both in the traditional sense and with job security, whereas female ATs make career changes to fulfill their parenting roles. Despite the strong speculation that sex mitigates experiences of WFC mostly because of the traditional ideology that exists about parenting roles and needs, no such differences have been found in athletic training.⁸ The lack of a sex difference is potentially misleading because the data were based only on a large group of ATs working in the collegiate setting, which provides rationalization for future research.In addition, a facet of WFC that has not been explored is the use of work-related benefits, including personal time, sick days, and appropriate family-medical leave, that allow a person to attend to necessary family and personal obligations. Many organizations have family-friendly workplace policies to help employees more easily balance and manage their family and work obligations. A variety of policies are commonly offered, including flex time, job sharing, telecommuting, maternity/paternity leave, and child care options.^3,9 Researchers^3,9 have suggested that these policies are more readily accessible to and are used more often by women because of the gendered nature of the policies. The advantages of workplace benefits that allow for fulfillment of work-family balance include job and life satisfaction, improved workplace productivity, and retention of quality employees.¹¹ Despite these universal workplace benefits, little is known about ATs'' comfort levels in using them to address personal and family needs and, thus, to potentially mitigate WFC.The collegiate setting appears to be an occupational setting that precipitates departure because of the hours worked, along with other demands placed on the ATs employed in that setting.⁴ Whereas information on WFC in the collegiate and secondary school settings is available, it is limited within emerging practice settings, such as military and industrial. The experiences of ATs working in the National Collegiate Athletic Association Division I-A and secondary school settings cannot be generalized among all athletic training populations, as job demands and responsibilities may differ and affect experiences of WFC. Researchers^5–8 have reported that WFC in athletic training is facilitated by many organizational factors; thus, we need to understand occupational-setting differences. Most data that exist on occupational settings and experiences of WFC are qualitative, and although these data are valuable and insightful, transferability is limited. In most cases, the sample sizes are small, and the intended purpose is to gain exploratory knowledge on a particular topic for a holistic understanding. Therefore, the purpose of our study was multifaceted: (1) to investigate if a difference exists in perception of WFC between sexes in athletic training, (2) to determine whether sex differences exist in how WFC affects willingness to leave the profession, (3) to access how occupational settings affect WFC, (4) to examine the comfort level in using work-leave benefits, and (5) to evaluate whether this comfort level differs by practice setting. We hypothesized that female ATs would perceive more WFC than male ATs and that female ATs would be willing to leave athletic training based on WFC. We also hypothesized that a difference would exist among settings for WFC and willingness to leave the profession.     

Lower Extremity Biomechanics in Athletes With Ankle Instability After a 6-Week Integrated Training Program

Context:

Plyometric exercise has been recommended to prevent lower limb injury, but its feasibility in and effects on those with functional ankle instability (FAI) are unclear.

Objective:

To investigate the effect of integrated plyometric and balance training in participants with FAI during a single-legged drop landing and single-legged standing position.

Design:

Randomized controlled clinical trial.

Setting:

University motion-analysis laboratory.

Patients or Other Participants:

Thirty athletes with FAI were divided into 3 groups: plyometric group (8 men, 2 women, age = 23.20 ± 2.82 years; 10 unstable ankles), plyometric-balance (integrated)–training group (8 men, 2 women, age = 23.80 ± 4.13 years; 10 unstable ankles), and control group (7 men, 3 women, age = 23.50 ± 3.00 years; 10 unstable ankles).

Intervention(s):

A 6-week plyometric-training program versus a 6-week integrated-training program.

Main Outcome Measure(s):

Postural sway during single-legged standing with eyes open and closed was measured before and after training. Kinematic data were recorded during medial and lateral single-legged drop landings after a 5-second single-legged stance.

Results:

Reduced postural sway in the medial-lateral direction and reduced sway area occurred in the plyometric- and integrated-training groups. Generally, the plyometric training and integrated training increased the maximum angles at the hip and knee in the sagittal plane, reduced the maximum angles at the hip and ankle in the frontal and transverse planes in the lateral drop landing, and reduced the time to stabilization for knee flexion in the medial drop landing.

Conclusions:

After 6 weeks of plyometric training or integrated training, individuals with FAI used a softer landing strategy during drop landings and decreased their postural sway during the single-legged stance. Plyometric training improved static and dynamic postural control and should be incorporated into rehabilitation programs for those with FAI.Key Words: plyometric training, balance training, landings, ankle injuries

Key Points

• After 6 weeks of isolated plyometric or combined plyometric and balance training, people with functional ankle instability demonstrated increased lower extremity maximal sagittal-plane angles and decreased maximal frontal-plane and transverse-plane angles on ground contact.
• Static and dynamic postural control improved with plyometric training, which should be included in rehabilitation programs for patients with functional ankle instability.

Ankle sprains often occur during physical activities such as basketball and soccer that require sudden stops, jumping, landing, and rotation around a planted foot. Although a patient with an ankle sprain may recover without experiencing persistent pain and swelling, most patients go on to develop chronic dysfunction, such as recurrent ankle sprain or instability.¹ Athletes report a 73% recurrence rate of lateral ankle sprain,² and the impairments associated with ankle sprain persist in 40% of patients 6 months after injury.³ These findings demonstrate that prolonged ankle dysfunction or disability is commonly attributable to ankle sprain.Functional ankle instability (FAI) is identified in those with symptoms such as frequent episodes of ankle giving way and feelings of ankle instability⁴ after ankle sprains and often presents with sensorimotor deficits in muscle reaction time, joint position sense, postural sway, and time to stabilization (TTS) of ground reaction force.^5,6 Several outcome measures, including center-of-pressure (COP) sway, leg reaching with the Star Excursion Balance Test, surface electromyography, and kinematics, are used to evaluate the neuromuscular and biomechanical characteristics of individuals with FAI. Measurement of COP sway during the single-legged stance is an easy way to evaluate static postural stability.⁷ People with ankle instability had greater variation in the magnitude of medial-lateral COP than a healthy group.⁸ In addition, TTS is effective for detecting differences between unstable and healthy groups.^9,10 The TTS for ground reaction force is the time required to achieve stability after a dynamic perturbation, and this time is longer in those with FAI.^9,11 In addition to TTS for ground reaction force, TTS for kinematics is a novel method to investigate the ability to regain balance in people with FAI; participants with FAI took longer TTS for ankle inversion after 1-legged hopping.¹² The advantage of using TTS for kinematics instead of TTS for ground reaction force is to provide more specific information about dynamic neuromuscular control of body segments.Rehabilitation programs for ankle sprain include muscle-strengthening, balance-training, neuromuscular-training, and proprioceptive-training protocols. The use of balance training for ankle reeducation has become common in recent years and is effective in reducing episodes of inversion.¹³ Balance training focuses on improving the ability to maintain a position through conscious and subconscious motor control.¹⁴ Certain tools, such as the balance board,¹⁵ Dura Disc, minitrampoline,¹⁶ biomechanical ankle platform system (BAPS),¹⁷ and Star Excursion Balance Test,¹⁸ can be used to assist training. In individuals with FAI, a 12-week BAPS exercise program with progressive testing reduced the radius of COP in single-legged standing.¹⁷ Another study¹⁹ showed that 4 weeks of balance improved shank-rearfoot coupling stability during walking. Proprioceptive training attempts to restore proprioceptive sensibility, retrain afferent pathways, and enhance the sensation of joint movement.¹⁴ Eils and Rosenbaum²⁰ found that 6 weeks of multi-station proprioceptive exercise in individuals with ankle instability reduced the standard deviation of COP (referring to the 68.2% range of COP dispersion) and maximum sway of COP (referring to the maximum range of COP dispersion) in the medial-lateral direction. However, Coughlan and Caulfield²¹ reported no change in ankle kinematics during treadmill walking and running after a 4-week neuromuscular training program with the “both sides up” (BOSU) balance trainer.Plyometric training has positive effects on sport performance, including distance running,²² jumping,²³ sprinting, and leg-extension force.²⁴ The focus of plyometric training is the stretch-shortening cycle induced in the muscle-tendon complex, where soft tissues repeatedly lengthen and shorten.²⁵ Plyometric exercise is described as “reactive neuromuscular training”²⁶ because it increases the excitability of the neurologic receptors and improves reactivity of the neuromuscular system. Plyometric training desensitizes the Golgi tendon organs through adaptation to the stretch-shortening exercise, which allows the elastic components of muscles to tolerate greater stretching.²⁷ Previously, plyometric training was theorized to improve neuromuscular control and dynamic stability, reduce the incidence of serious knee injuries,²⁸ and reduce the risk of injury by increasing functional joint stability of the lower limbs.^23,28 Furthermore, 6 weeks of plyometric exercise enhanced results on functional performance testing in athletes after lateral ankle sprain.²⁹ Plyometric exercise is thought to enable segments to absorb joint force effectively by promoting the mechanical advantage of soft tissue structures³⁰ through increasing initial and maximal knee and hip flexion during the jump-landing task.³⁰ The increased knee-flexion and hip-flexion angles during landing protect the knee via hamstrings tension.^31,32To date, investigations on the effect of plyometric training have emphasized functional performance^28,29 or preventing anterior cruciate ligament injuries.^33,34 Data on the feasibility and effectiveness of plyometric training in those with FAI are very limited.²⁹ Therefore, our purposes were to determine the effects on lower extremity biomechanics of a 6-week plyometric-training program or a 6-week integrated program with plyometric and balance training in athletes with FAI. We hypothesized that both training programs would increase maximum joint angles in the sagittal plane and reduce the time needed to regain stability during drop-landing tasks. We further hypothesized that the integrated training would reduce postural sway during single-legged stance and decrease the center of mass (COM)-COP deviation during drop-landing tasks.     

Motherhood and Work–Life Balance in the National Collegiate Athletic Association Division I Setting: Mentors and the Female Athletic Trainer

Context:

One of the greatest catalysts for turnover among female athletic trainers (ATs) is motherhood, especially if employed at the National Collegiate Athletic Association Division I level. The medical education literature regularly identifies the importance of role models in professional character formation. However, few researchers have examined the responsibility of mentorship and professional role models as it relates to female ATs'' perceptions of motherhood and retention.

Objective:

To evaluate perceptions of motherhood and retention in relation to mentorship and role models among female ATs currently employed in the collegiate setting.

Design:

Qualitative study.

Setting:

Female athletic trainers working in National Collegiate Athletic Association Division I.

Patients or Other Participants:

Twenty-seven female ATs employed in the National Collegiate Athletic Association Division I setting volunteered. Average age of the participants was 35 ± 9 years. All were full-time ATs with an average of 11 ± 8 years of clinical experience.

Data Collection and Analysis:

Participants responded to questions by journaling their thoughts and experiences. Multiple-analyst triangulation and peer review were included as steps to establish data credibility.

Results:

Male and female role models and mentors can positively or negatively influence the career and work–life balance perceptions of female ATs working in the Division I setting. Female ATs have a desire to see more women in the profession handle the demands of motherhood and the demands of their clinical setting. Women who have had female mentors are more positive about the prospect of balancing the rigors of motherhood and job demands.

Conclusions:

Role models and mentors are valuable resources for promoting perseverance in the profession in the highly demanding clinical settings. As more female ATs remain in the profession who are able to maintain work–life balance and are available to serve as role models, the attitudes of other women may start to change.Key Words: role models, retention, quality of life

Key Points

• Role models and mentors are being identified by female athletic trainers working in the Division I setting.
• Perceptions of work–life balance can be positively affected by how role models and mentors maintain balance within their own lives. Conversely, those individuals who cannot maintain balance can negatively affect their proteges'' perceptions of work–life balance.
• Female athletic trainers working in the Division I setting desire more female role models who are effectively balancing the multiple responsibilities of their personal and professional lives.

The positive and negative influences of role models and mentors have been well established in the medical literature, specifically in academic medicine.^1–3 In a published systematic review of the literature,¹ mentorship in academic medicine was reported to enhance personal and career development, as well as research productivity, including publications and grant awards. Mentoring was described in the late 1970s by Levinson,⁴ who exposed the relationship as one of the most significant influences an individual can have in early adulthood. Mentoring has been emphasized as a critical element for personal and career advancement and career selection.^1,2 However, mentoring is not always a positive experience. Repeated negative learning experiences may adversely affect the development of professionalism in medical students and residents.⁵ A lack of mentoring may contribute to career success deficiencies in academic medicine, especially for women.^1,3 Furthermore, female physicians are less likely than their male colleagues to identify role models for work–life balance (WLB).⁶Role models and mentors differ in that mentors are senior members of a group who intentionally encourage and support younger colleagues in their careers.⁵ Mentoring often includes role modeling. A role model teaches predominantly by example and helps to form one''s professional identity and commitment by promoting observation and comparison.⁵ Role modeling is less intentional, more informal, and more episodic than mentoring. Individuals serving as supervisors are the gatekeepers to establishing an environment that enhances a family-friendly atmosphere and ensures that their employees realize WLB. Work–life balance is attained when an individual''s right to a contented life inside and outside paid work is accepted and valued as the norm. Mazerolle et al⁷ found that head athletic trainers (ATs) informally try to encourage WLB through role modeling. Therefore, supervisors and bosses may incidentally act as role models.Of great concern in the field of athletic training is the subject of retention among female ATs, which has recently been heavily researched.^8–11 The departure of female ATs from the profession has been theoretically linked to the desire to strike a balance between family obligations and personal time with work responsibilities.^12,13 The National Collegiate Athletic Association Division I clinical setting holds unique professional challenges for ATs. Long road trips, 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 are some of the stresses faced by an AT working in the Division I setting.¹⁴ Concerns regarding WLB and time for parenting influence decisions to persist at the collegiate level.^12,13 Several investigators^11,13 in athletic training have suggested that motherhood is a primary factor leading to the departure of females from the profession. Role models and mentoring have emerged as possible factors to aid in the retention of females in the collegiate setting once they become mothers.Limited research on mentoring exists in the context of athletic training. Two studies^15,16 have examined the effects of professional socialization among high school and collegiate ATs. Similar to mentoring, professional socialization is a process by which individuals learn the knowledge, skills, values, roles, and attitudes associated with their professional responsibilities.¹⁷ The mentoring roles of ATs evolve over their careers. Initially, ATs make network connections in order to learn, but as they become more experienced, they take on more of a mentoring role. This occurs as a result of being contacted by less experienced colleagues for advice on how to deal with problems in their clinical settings.¹⁶ Additionally, a recent study¹⁸ examined female athletic training students'' perceptions on motherhood in the athletic training profession; the students felt strongly that a female mentor who had children would greatly benefit them personally as well as professionally. Though the students named mentorship as an important retention factor, they had very limited direct mentorship from a female AT with children employed in the collegiate setting. This finding mirrors research in the medical literature⁶ highlighting a lack of role models or mentors being identified by females in various professions. Although Pitney¹⁶ highlighted the presence of mentors in the athletic training profession, a scarcity of information exists regarding the part mentors and role models play for female ATs specifically and in their influence on WLB views. The purpose of our study, therefore, was to examine the effect of role models and mentors on perceptions of career and motherhood among female ATs working in the Division I setting. This study will be the first to assess perceptions of mentors and role models among female ATs throughout the life experience spectrum (single, married, married with children). The following central research question guided this study: how do role models and mentors within athletic training influence female ATs employed in the Division I setting?