Organizational Infrastructure in the Collegiate Athletic Training Setting, Part III: Benefits of and Barriers in the Medical and Academic Models

Organizational-Professional Conflict in the Collegiate and Secondary School Practice Settings: A Sequential, Mixed-Methods Study

CONTEXT

Athletic trainers (ATs) are employed in various settings, which may use 1 of 3 organizational infrastructure models: (1) the sport/athletic model, (2) the medical model, and (3) the academic model. These different settings and organizational infrastructure models may result in varying levels of organizational-professional conflict (OPC). However, how OPC may differ across infrastructure models and practice settings is not known.

OBJECTIVE

To examine the prevalence of OPC among ATs in various organizational infrastructures and explore ATs' perceptions of OPC, including its precipitating and mitigating factors.

DESIGN

Sequential explanatory mixed-methods study with equal emphasis on quantitative and qualitative components.

SETTING

Collegiate and secondary school institutions.

PATIENTS OR OTHER PARTICIPANTS

Five hundred ninety-four ATs from collegiate and secondary schools.

DATA COLLECTION AND ANALYSIS

We conducted a national cross-sectional survey using a validated scale to assess OPC. We then followed the quantitative survey with individual interviews. Trustworthiness was established with multiple-analyst triangulation and peer debriefing.

RESULTS

Athletic trainers experienced low to moderate degrees of OPC with no differences across practice settings or infrastructure models. Poor communication, others' unfamiliarity with the AT's scope of practice, and lack of medical knowledge were precipitating factors for OPC. Organizational relationships founded on trust and respect for one another; administrative support in that ATs were listened to, decisions were endorsed, and appropriate resources provided; and autonomy given to the AT were key components to preventing OPC.

CONCLUSIONS

Most ATs experienced primarily low to moderate OPC. However, OPC continues to permeate professional practice to some extent in collegiate and secondary school settings, regardless of the infrastructure model used. The findings of this study highlight the role of administrative support that allows for autonomous AT practice as well as effective communication that is direct, open, and professional to decrease OPC.

Factors and expectations influencing concussion disclosure within NCAA Division I athletes: A mixed methodological approach

BACKGROUND

Participation in sports is associated with many benefits to all aspects of health; however, it also comes with the risk of injury, particularly concussions. Self-disclosure and care seeking following a concussion are especially important because of the lack of outwardly visible signs and/or symptoms. Although recent research has explored factors affecting concussion disclosure, use of isolated methodologies limits the ability to contextualize how disclosure or nondisclosure occurs. Therefore, the purpose of this study was to describe the factors and expectations of National Collegiate Athletic Association (NCAA) athletes that may influence concussion disclosure.

METHODS

This mixed-methods convergent parallel research study included 25 NCAA Division I athletes representing 13 sports, all of whom completed a concussion-education session with pre-/post-test surveys and a semistructured interview. Eligible athletes were at least 18 years old and on an NCAA roster. The surveys focused on previous concussion-related disclosure behaviors, knowledge, attitudes, beliefs, norms, and intentions about disclosing concussion. Interviews focused on the athletes' experiences related to concussion disclosure. Survey data were analyzed using descriptive statistics and Mann-Whitney U tests. Interviews were analyzed using a Consensual Qualitative Research tradition.

RESULTS

Participants had good concussion knowledge (median = 46.0), positive attitudes (median = 38.0), strong beliefs (median = 13.0), and strong intentions to disclose concussion symptoms (median = 7.0). None of the constructs differed by participants' gender. Although quantitative findings were mostly positive, interview data highlighted factors that may explain why some participants are successful in disclosing concussions and why others may find disclosure difficult. Educational efforts, sport culture, and medical professional presence were the primary facilitators discussed by participants. Stigma, pressure, and a lack of team support were perceived as disclosure barriers.

CONCLUSION

The context in which concussion disclosure occurs or does not occur is vital to the success of educational interventions. Interventions must prioritize stakeholder- and team-based perspectives on concussion to establish a network supportive to disclosure.

Collegiate Athletic Trainers' Experiences Implementing Return-to-Sport Policies and Procedures During COVID-19: A Qualitative Research Study

CONTEXT

Athletic trainers (ATs) were critical personnel in the development of policies and procedures for the safe return to campus and resumption of sport during the 2020-2021 academic year. Policies focused on preventing the potential spread of COVID-19, as well as screening, testing, and management of cases; however, which aspects of implementation were successful or more challenging was unknown.

OBJECTIVE

To identify successes and challenges in the implementation of return-to-sport policies and procedures during the 2020-2021 academic year amid the COVID-19 pandemic.

DESIGN

Qualitative study.

SETTING

National Collegiate Athletic Association Divisions I, II, and III.

PATIENTS OR OTHER PARTICIPANTS

A total of 27 ATs (9 women [33.3%], mean age = 48.5 ± 9.8 years, years of experience = 25.0 ± 10.5) who were in positions of leadership or who were actively involved in developing and then implementing COVID-19 return-to-sport policies and procedures completed Zoom interviews.

DATA COLLECTION AND ANALYSIS

Semistructured Zoom interviews were audio and video recorded and later transcribed. The data were analyzed by a team of 4 experienced researchers using the consensual qualitative research approach. Field notes, intercoder reliability, and multiple-analyst triangulation were used to establish data credibility.

RESULTS

Emerging themes were implementation of public health interventions, interprofessional collaboration, and advancing the profession of athletic training. Participants described establishing and strengthening collaborations with other health care professionals as well as key stakeholders on campus as a positive outcome of the pandemic, but variations in policies among institutions and states made policy communication and enforcement more challenging.

CONCLUSIONS

The ATs played a pivotal role in policy development, communication, and enforcement. Overall, participants took pride in serving as health care leaders for their universities and opening the eyes of colleagues to the breadth of their athletic training skill sets.

Collegiate Athletic Trainers' Experiences With Work-Family Conflict and Work-Family Guilt Based Upon Organizational Factors

CONTEXT

The collegiate athletic setting has been described as having high workloads and working demands. The extensive time commitment required of athletic trainers working in this setting has been identified as a precursor to work-family conflict (WFC) and work-family guilt (WFG). Although individualized, experiences in the work-life interface can largely be affected by organizational factors (ie, elements specific to the workplace). Staff size and patient load may influence the athletic trainer's feelings of WFC and WFG, yet these factors have not been directly studied.

OBJECTIVE

To examine organizational factors and experiences of WFC and WFG among collegiate athletic trainers.

DESIGN

Cross-sectional study.

SETTING

Collegiate setting.

PATIENTS OR OTHER PARTICIPANT(S)

A total of 615 (females = 391, gender variant or nonconforming = 1, males = 222, preferred not to answer = 1) athletic trainers responded to an online survey. The average age of participants was 33 ± 9 years, and they were Board of Certification certified for 10 ± 8 years. A total of 352 participants (57.2%) worked in National Collegiate Athletic Association Division I, 99 in Division II (16.1%), and 164 in Division III (26.7%).

MAIN OUTCOME MEASURE(S)

Participants responded to demographic and workplace characteristic questions (organizational infrastructure, staff size, and number of varsity-level athletic teams). They completed WFC and WFG scales that have been previously validated and used in the athletic trainer population.

RESULTS

Work-family conflict and WFG were universally experienced among our participants, with WFC scores predicting WFG scores. Participants reported more time-based conflict than strain- or behavior-based conflict. No differences in WFC and WFG scores were found among organizational infrastructures. Weak positive correlations were present between staff size and WFC scores and WFG scores. The number of athletic teams was not associated with WFC or WFG scores.

CONCLUSIONS

Organizational factors are an important component of the work-life interface. From an organizational perspective, focusing on improving work-life balance for the athletic trainer can help mitigate experiences with WFC and WFG.

The Quantitative Examination of the Relationship Between Job Satisfaction and Organizational Fit in Athletic Trainers

CONTEXT

Athletic trainers' (ATs') job satisfaction has been extensively researched, yet little is known about how satisfaction relates to organizational culture.

OBJECTIVE

To examine ATs' level of job satisfaction with and organizational-fit perceptions of their employment setting.

DESIGN

Cross-sectional study.

SETTING

Web-based questionnaire.

PATIENTS OR OTHER PARTICIPANTS

A total of 5704 ATs (full-time employment, nonacademic appointment) were contacted via email; 841 participants began our survey (access rate = 14.7%), and 285 completed it (5.0% response rate; 33.9% completion rate). Demographic characteristics were men = 107 (37.5%), women = 178 (62.5%); age = 34.8 ± 9.9 years; and employment setting = 34.7% (n = 99) from National Collegiate Athletic Association Division I, 18.9% (n = 54) from Division II, 29.5% (n = 84) from Division III, and 16.9% (n = 48) other.

MAIN OUTCOME MEASURE(S)

Participants responded to an online survey consisting of demographic questions, a 36-item Likert-scale Job Satisfaction Survey, and the Cable and Judge revision of the O'Reilly, Chatman, and Caldwell 40-item ranking Organizational Culture Profile survey. Multiple linear regression models for total or subscale job satisfaction were used to analyze the data. All models adjusted for the same demographic measures, and the independent variables of interest were created from the organizational culture survey responses.

RESULTS

Coworkers (minimum [min] = 9, maximum [max] = 24, ρ = .79), communications (min = 9, max = 24, ρ = .78), and work itself (min = 4, max = 24, ρ = .71) were most correlated with the total job satisfaction score (min = 96, max = 175). Of the respondents, 54% selected adaptability, stability, and taking individual responsibility as 1 of their 2 most characteristic attributes in the organizational culture profile. In addition, 83% of respondents indicated being aggressive, receiving high pay for good performance, and being distinctive or different from others as their 2 least characteristic traits.

CONCLUSIONS

The job satisfaction of these ATs was affected most by organizational factors, such as coworkers and communication, as well as by individual attributes such as adaptability, stability, and taking personal responsibility.

Evolving Expectations of the Orthopedic Team Physician: Managing the Sidelines and Landmines

ABSTRACT

The role of orthopedic team physicians has evolved greatly over the past decade having been influenced by advances in sports science and performance, new surgical and biologic technologies, social media, medicolegal liability, marketing, and sexual misconduct cases by some team physicians. The great variety of events and sports that are covered from high school and collegiate to the Olympic and professional levels requires a myriad of skills outside of the traditional medical training curriculum. In the current climate of increasing media scrutiny from a 24-h news cycle it is imperative for orthopedic team physicians, whether operative or nonoperative, to continually adapt to the needs and expectations of athletes who also are patients. This is especially true in the wake of the COVID-19 pandemic. Orthopedic team physicians' responsibilities continue to evolve ensuring their relevance and necessity on the sidelines and in the training room as well as in the operative suite.

Documentation Practices of Athletic Trainers Employed in the Clinic, Physician Practice, and Emerging Clinical Settings

CONTEXT

The documentation practices of athletic trainers (ATs) employed in the secondary school setting, including their strategies for, barriers to, and perceptions of documentation, have been characterized in previous research. The documentation practices of ATs employed in other settings have yet to be studied in depth.

OBJECTIVE

To examine the documentation practices of ATs employed in the clinic, physician practice, and emerging clinical settings.

DESIGN

Qualitative study.

SETTING

Web-based interviews.

PATIENTS OR OTHER PARTICIPANTS

A total of 22 ATs 11 employed in the clinic or physician practice setting and 11 employed in an emerging clinical setting.

DATA COLLECTION AND ANALYSIS

The ATs employed in the settings of interest were recruited with purposeful, convenience, and snowball sampling. Participants were interviewed using a Web-based platform so that we could learn about their behaviors and perceptions of documentation. Data were analyzed using the consensual qualitative research approach, followed by a thematic analysis. Trustworthiness was addressed using data source triangulation, multiple-analyst triangulation, and an established interview guide and codebook.

RESULTS

Participants described following clear guidelines for documentation established by regulatory agencies, employers, and electronic medical record templates. They were motivated to document for patient safety and to demonstrate value. Participants typically documented in real time and continuously, which was facilitated by employer requirements. The ATs described experiencing a learning curve for documentation due to the unique requirements of their settings, but learning was facilitated by employer guidance and mentorship.

CONCLUSIONS

Employer guidelines, training, and ongoing support facilitated effective and thorough documentation in these clinical settings. Athletic trainers and employers in a variety of settings should consider establishing clear guidelines to promote thorough and effective documentation.

Sports Medicine Staffing Across National Collegiate Athletic Association Division I, II, and III Schools: Evidence for the Medical Model

CONTEXT

The ratio of clinicians to patients has been associated with health outcomes in many medical contexts but has not been explored in collegiate sports medicine. The relationship between administrative and financial oversight models and staffing is also unknown.

OBJECTIVE

To (1) evaluate staffing patterns in National Collegiate Athletic Association sports medicine programs and (2) investigate whether staffing was associated with the division of competition, Power 5 conference status, administrative reporting structure (medical or athletic department), or financial structure (medical or athletic department).

DESIGN

Cross-sectional study.

SETTING

Collegiate sports medicine programs.

PATIENTS OR OTHER PARTICIPANTS

Representatives of 325 universities.

MAIN OUTCOME MEASURE(S)

A telephone survey was conducted during June and July 2015. Participants were asked questions regarding the presence and full-time equivalence of the health care providers on their sports medicine staff. The number of athletes per athletic trainer was determined.

RESULTS

Responding sports medicine programs had 0.5 to 20 full-time equivalent staff athletic trainers (median = 4). Staff athletic trainers at participating schools cared for 21 to 525 athletes per clinician (median = 100). Both administrative and financial oversight from a medical department versus the athletics department was associated with improved staffing across multiple metrics. Staffing levels were associated with the division of competition; athletic trainers at Division I schools cared for fewer athletes than athletic trainers at Division II or III schools, on average. The support of graduate assistant and certified intern athletic trainers varied across the sample as did the contributions of nonphysician, nonathletic trainer health care providers.

CONCLUSIONS

In many health care settings, clinician : patient ratios are associated with patient health outcomes. We found systematic variations in clinician : patient ratios across National Collegiate Athletic Association divisions of competition and across medical versus athletics organizational models, raising the possibility that athletes' health outcomes vary across these contexts. Future researchers should evaluate the relationships between clinician : patient ratios and athletes' access to care, care provision, health care costs, health outcomes, and clinician job satisfaction.

Challenges Faced by Collegiate Athletic Trainers, Part I: Organizational Conflict and Clinical Decision Making

CONTEXT

Organizational conflict, particularly between coaches and medical professionals, has been reported in collegiate athletics. Different values create room for conflict between coaches and athletic trainers (ATs); however, ATs' experiences when making medical decisions are not fully understood.

OBJECTIVE

To investigate the presence of organizational conflict regarding medical decision making and determine if differences exist across athletic affiliations.

DESIGN

Cross-sectional study.

SETTING

Collegiate athletics (National Collegiate Athletic Association [NCAA], National Association of Intercollegiate Athletics [NAIA], National Junior College Athletic Association [NJCAA]).

PATIENTS OR OTHER PARTICIPANTS

A total of 434 ATs responded (age = 27.7 ± 3.2 years, years certified = 5.2 ± 2.7), representing the NCAA Division I (DI; n = 199), Division II (DII; n = 67), Division III (DIII; n = 108); NAIA (n = 37); and NJCAA (n = 23) settings.

MAIN OUTCOME MEASURE(S)

The survey instrument contained quantitative measures and open-ended questions, with affiliation as our primary independent variable. Responses to Likert-scale questions (1 = strongly agree, 5 = strongly disagree) regarding organizational pressures within athletics served as the dependent variables. Kruskal-Wallis analysis-of-variance and Mann-Whitney U post hoc tests assessed differences in organizational conflict across affiliations. Open-ended questions were analyzed inductively.

RESULTS

We obtained a 14.47% (434 of 3000) response rate. National Collegiate Athletic Association DI ATs disagreed less than NCAA DII and DIII and NJCAA ATs that they would worry about job security if turnover in the head coaching position occurred (P < .05). Regarding the influence of coaches on job performance, differences were found between NCAA DI and DIII and between DI and NJCAA ATs (P < .01). Visibility of the injury and situational factors influenced the level of perceived pressure.

CONCLUSIONS

Athletic trainers perceived pressure from coaches regarding medical decision making. Division I ATs placed greater emphasis on the role that coaches played in their job performance and job security. Athletic departments should consider transitioning to patient-centered models of care to better align values and reduce the external pressures placed on ATs.

Sports Medicine Delivery Models: Legal Risks

Educational institutions sponsoring competitive athletics may use an athletics model, academic model, or medical model for delivery of sports medicine to student-athletes. Four types of legal risk are considered for these 3 models: litigation, contract, regulatory, and structural. The athletics model presents the greatest legal risk to institutions, whereas the medical model presents the least legal risk. Institutional administrators should consider these risks when selecting or maintaining a delivery model for sports medicine.

Role Strain, Part 2: Perceptions Among Athletic Trainers Employed in the Professional Practice Setting

CONTEXT

  Athletic trainers (ATs) employed in the professional sport setting (ATPSSs) demonstrate moderate to high degrees of role strain. The experiences and perceptions of these ATs provide insight regarding the sources of role strain as well as ways to reduce it.

OBJECTIVE

  To investigate the perceptions of ATPSSs regarding role strain.

DESIGN

  Qualitative study.

PATIENTS OR OTHER PARTICIPANTS

  From a purposeful sampling of 389 ATs employed in the 5 major sport leagues (Major League Baseball, Major League Soccer, National Basketball Association, National Football League, and National Hockey League), we identified 34 participants willing to participate in phone interviews. Data Collection and Procedures:  Semistructured phone interviews. Inductive data analysis was based on a grounded theory approach. Credibility was addressed with member checks and a peer debriefing.

RESULTS

  Three first-order emergent themes materialized from the data: (1) sources of role strain, (2) consequences of role strain, and (3) strategies to alleviate role strain in ATPSSs. Participants described the antecedents of role strain as emerging from the competing expectations of the professional athlete, the organization, and the sport league. Consequences of role strain included effects on direct patient care and work-life imbalance. Improving organizational factors such as inadequate staffing and poor communication within the organization were strategies described by participants for decreasing role strain in the professional sports setting.

CONCLUSIONS

  Our participants discussed experiencing role strain, which was facilitated by trying to meet the competing demands placed on them with limited time and often with an inadequate support staff. Participant role strain affected health care and contributed to work-life imbalance. Participants described changing the organizational factors that contributed to role strain as a strategy to alleviate the perceived stress.

Organizational Infrastructure in the Collegiate Athletic Training Setting, Part II: Benefits of and Barriers in the Athletics Model

CONTEXT

 The athletics model, in which athletic training clinical programs are part of the athletics department, is the predominant model in the collegiate athletic training setting. Little is known about athletic trainers' (ATs') perceptions of this model, particularly as it relates to organizational hierarchy.

OBJECTIVE

 To explore the perceived benefits of and barriers in the athletics model.

DESIGN

 Qualitative study.

SETTING

 National Collegiate Athletic Association Divisions I and III.

PATIENTS OR OTHER PARTICIPANTS

 Eight full-time ATs (5 men, 3 women; age = 41 ± 13 years, time employed at the current institution = 14 ± 14 years, experience as a certified AT = 18 ± 13 years) working in the collegiate setting using the athletics model.

DATA COLLECTION AND ANALYSIS

 We conducted semistructured interviews via telephone or in person and used a general inductive approach to analyze the qualitative data. Multiple-analyst triangulation and peer review established trustworthiness.

RESULTS

 Two benefits and 3 barriers emerged from the data. Role identity emerged as a benefit that occurred with role clarity, validation, and acceptance of the collegiate AT personality. Role congruence emerged as a benefit of the athletics model that occurred with 2 lower-order themes: relationship building and physician alignment and support. Role strain, staffing concerns, and work-life conflict emerged as barriers in the athletics model. Role strain occurred with 2 primary lower-order themes: role incongruity and role conflict.

CONCLUSIONS

 The athletics model is the most common infrastructure for employing ATs in collegiate athletics. Participants expressed positive experiences via character identity, support, trust relationships, and longevity. However, common barriers remain. To reduce role strain, misaligning values, and work-life conflict, ATs working in the athletics model are encouraged to evaluate their relationships with coaches and their supervisor and consider team physician alignment. Moreover, measures to increase quality athletic training staff from a care rather than a coverage standpoint should be considered.