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.

A Theoretical Model of Transition to Practice for Athletic Trainers.

CONTEXT: The transition to practice of newly credentialed athletic trainers (ATs) has become an area of focus in the athletic training literature. However, no theoretical model has been developed to describe the phenomenon and drive investigation. OBJECTIVE: To better understand the lived experience of the transition to practice and develop a theoretical model of transition to practice for ATs. DESIGN: Qualitative study. SETTING: Telephone interviews. PATIENTS OR OTHER PARTICIPANTS: Fourteen professional master's athletic training students (7 men, 7 women, age = 25.6 ± 3.7 years, from 9 higher education institutions) in the first year of clinical practice as newly credentialed ATs. DATA COLLECTION AND ANALYSIS: Participants completed semistructured phone interviews at 3 timepoints over 12 to 15 months. The first interview was conducted just before graduation, the second 4 to 6 months later, and the third at 10 to 12 months. The interviews were transcribed and analyzed using a grounded theory approach. RESULTS: We developed a theoretical model to explain the causal conditions that triggered transition, how the causal conditions were experienced, the coping strategies used to persist through the first year of practice, and the consequences of those strategies. CONCLUSIONS: The model provides a framework for new athletic training clinicians, educators, and employers to better understand the transition process in order to help new clinicians respond by accepting or adapting to their environment or their behaviors.

The Role Mentoring Plays in the Transition to Practice of Newly Credentialed Athletic Trainers.

CONTEXT: Mentoring has been identified as an important method of supporting newly credentialed athletic trainers (ATs) during their transition to practice. Gaining a better understanding of this relationship could provide valuable insights that may assist employers and professional programs in developing a plan to better facilitate the transition. OBJECTIVE: To examine which aspects of the mentoring relationship provided the most benefit during the transition to practice of newly certified ATs. DESIGN: Qualitative study. SETTING: Individual phone interviews. PATIENTS OR OTHER PARTICIPANTS: A total of 13 ATs who graduated from a professional master's program, were certified from February through July 2016, and obtained employment from July through August 2016 participated in this study (6 women, 7 men; age = 26 ± 3 years; work settings included professional sports, college, secondary and middle school, and clinic). Data saturation guided the number of participants. DATA COLLECTION AND ANALYSIS: Phone interviews using a semistructured interview guide were conducted at 3, 8, and 12 months of work experience. Data were analyzed using a constant comparative approach. Credibility was established via investigator triangulation, peer debriefing, and member checks. RESULTS: Participants recognized the mentoring relationship as a foundational aspect of the transition to practice. Mentors should be available by phone, email, or text to answer questions, provide feedback, or discuss ideas. Respondents wanted honest feedback, even when that feedback was constructively critical. Feedback was sought regarding topics such as patient care, communication, and networking. Participants needed reassurance and support from their mentors to help validate and improve their self-confidence. CONCLUSIONS: Newly credentialed ATs should seek mentors who will be available to communicate in various ways and will provide regular and constructive feedback. Future researchers should investigate how mentoring relationships influence other aspects of the transition to practice, such as patient care, overall job performance, turnover, and satisfaction.

Work-Family Conflict of Collegiate and Secondary School Athletic Trainers Who Are Parents.

CONTEXT: The work-life interface has been a much discussed and researched area within athletic training. The National Athletic Trainers' Association position statement on work-life balance highlighted the profession's interest in this topic. However, gaps in the literature remain and include the roles of time-based conflict and social support. OBJECTIVE: To compare work-family conflict (WFC) and social support among athletic trainers (ATs) employed in the 2 most common practice settings. DESIGN: Cross-sectional observational survey. SETTING: Collegiate and secondary school settings. PATIENTS OR OTHER PARTICIPANTS: A total of 474 (females = 231, males = 243) ATs who were employed in the collegiate (205, 43.2%) or secondary school (269, 56.8%) setting. MAIN OUTCOME MEASURE(S): Data were collected through a Web-based survey designed to measure conflict and social support. Likert responses were summed. Demographic information was analyzed for frequency and distribution. Independent t tests and Mann-Whitney U tests were calculated to determine group differences. Linear regression was used to determine if social support predicted WFC. RESULTS: Social provisions and WFC were negatively correlated, and the social provisions score predicted WFC. No WFC differences (P = .778) were found between collegiate and high school ATs even though collegiate ATs worked more hours (63 ± 11) during their busiest seasons compared with those in the high school setting (54 ± 13, P < .001). Similarly, no difference (P = .969) was present between men and women, although men worked more hours. Our participants scored highest on time-based WFC items. CONCLUSIONS: Work-family conflict was experienced globally in 2 of the most common athletic training settings and between sexes. This indicates WFC is universally experienced and therefore needs to be addressed, specifically with a focus on time-based conflict. In addition to time-management strategies, ATs need support from coworkers, peers, and family members.

Collegiate Athletic Trainers' Experiences With External Pressures Faced During Decision Making.

CONTEXT: Conflict is prevalent between sports medicine professionals and coaching staffs regarding return-to-play decisions for athletes after injury in the National Collegiate Athletic Association (NCAA) Division I setting. The firsthand experiences of athletic trainers (ATs) regarding such conflict have not been fully investigated. OBJECTIVE: To better understand the outside pressures ATs face when making medical decisions regarding patient care and return to play after injury in the NCAA Division I Football Bowl Subdivision (FBS) setting. DESIGN: Qualitative study. SETTING: Semistructured one-on-one telephone interviews. PATIENTS OR OTHER PARTICIPANTS: Nine ATs (4 men, 5 women; age = 31 ± 8 years [range = 24-48 years]; years certified = 9 ± 8). DATA COLLECTION AND ANALYSIS: Interviews were audio recorded and later transcribed. Thematic analysis was completed phenomenologically. Researcher triangulation, peer review, and member checks were used to establish trustworthiness. RESULTS: Two major themes emerged from the qualitative analysis: (1) pressure is an expected component of the Division I FBS AT role, and (2) strategies can be implemented to mitigate the negative effects of pressure. Three subthemes supported the second major theme: (1) ensuring ongoing and frequent communication with stakeholders about an injured athlete's status and anticipated timeline for return to play, (2) providing a rationale to coaches or administrations to foster an understanding of why specific medical decisions are being made, and (3) establishing positive relationships with coaches, athletes, and administrations. CONCLUSIONS: External pressure regarding medical decisions was an anticipated occurrence for our sample. Such pressure was described as a natural part of the position, not negative but rather a product of the culture and environment of the Division I FBS setting. Athletic trainers who frequently face pressure from coaches and administration should use the aforementioned strategies to improve the workplace dynamic and foster an environment that focuses on patient-centered care.

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.

Challenges Faced by Collegiate Athletic Trainers, Part II: Treating Concussed Student-Athletes.

CONTEXT: Conflict between athletic trainers (ATs) and other stakeholders can occur because of competing interests over medical decisions regarding concussion. However, we are unaware of any studies specifically exploring these situations across various collegiate athletic affiliations. OBJECTIVE: To investigate the challenges faced by ATs when treating concussed student-athletes. DESIGN: Qualitative study. SETTING: Online questionnaire. PATIENTS OR OTHER PARTICIPANTS: A total of 434 ATs (267 women, 166 men, 1 missing data; age = 27.73 ± 3.24 years, experience = 5.17 ± 2.67 years) completed the questionnaire (response rate = 14.47%). Our participants represented multiple employment settings within intercollegiate athletics. DATA COLLECTION AND ANALYSIS: We sent an online questionnaire to 3000 ATs working in the collegiate and university setting across the United States. A survey expert verified face, content, and construct validity of the questionnaire in 2 rounds of review, and 3 ATs completed a content-validity tool before we finalized the survey. We analyzed the qualitative data using a general inductive approach and ensured trustworthiness through multiple-analyst triangulation and peer review. RESULTS: When we examined the responses from our participants regarding their work with student-athletes who had sustained concussions, we found 2 major themes, each with subthemes. First, educational efforts appeared to be only modestly effective because of a lack of honesty, noncompliant actions, and coach interference. Second, return to learn was challenging because of a lack of communication among stakeholders, athletes being anxious about needing accommodations, and difficulty convincing faculty to provide reasonable accommodations. CONCLUSIONS: Based on our findings, we recommend continued efforts to improve the culture surrounding concussion in collegiate athletes. Athletic trainers should include key stakeholders such as coaches, student-athletes, parents, faculty, and other educational administrators in their educational efforts to improve the policies and culture surrounding concussion treatment.

Emergency Action Plans in Secondary Schools: Barriers, Facilitators, and Social Determinants Affecting Implementation.

CONTEXT: Secondary schools (SSs) inconsistently adopt emergency action plans (EAPs) for athletics. OBJECTIVE: To describe the barriers, facilitators, and social determinants influencing EAP adoption in SSs in the United States. DESIGN: Cross-sectional study. SETTING: Secondary schools. PATIENTS OR OTHER PARTICIPANTS: A national sample of athletic trainers (ATs; n = 9642) and athletic directors (ADs; n = 9687) were invited to participate in a Web-based questionnaire. A total of 1273 (13.2%) ATs and 702 (9.2%) ADs responded to the survey. MAIN OUTCOME MEASURE(S): The questionnaire addressed self-reported barriers to, facilitators of, and social determinants (eg, locale, funding classification [eg, public or private SS]) of EAP adoption. The responses of ATs and ADs were analyzed separately. Barriers, facilitators, and social determinants were evaluated using descriptive statistics. Contingency (2 × 2) tables were used to calculate the odds ratios (ORs) of adopting an EAP and the presence of each social determinant. RESULTS: Perceived barriers to implementation were a lack of knowledge about how to implement an EAP and financial limitations. Facilitators were having access to health care personnel, state mandates, and support from a person in an authoritative position. Compared with ATs at rural schools, ATs at suburban schools displayed greater odds of having an EAP (χ2 = 5.63, P = .01, OR = 1.63 [95% confidence interval = 1.08, 2.44]). According to the ADs' responses, a larger SS enrollment (≥500) led to greater odds of adopting an EAP (OR = 2.02 [95% confidence interval = 1.41, 2.89]). CONCLUSIONS: Perceived barriers to EAP adoption suggest that ATs and ADs need to be educated so they can provide additional information on the low cost of EAP adoption. Further, ADs described state mandates as facilitators to improve EAP adoption; therefore, efforts to educate state leaders about the need for mandated policies may be warranted. Certain social determinants (eg, school enrollment) may affect EAP adoption, but not every proposed determinant significantly affected adoption.

Challenges for Newly Credentialed Athletic Trainers During Their Transition to Practice.

CONTEXT: Understanding the challenges faced by newly credentialed athletic trainers (ATs) as they transition into clinical practice could assist employers and professional programs in developing initiatives to enhance this transition. OBJECTIVE: To explore the challenges faced by newly credentialed ATs during their transition from student to autonomous practitioner. DESIGN: Qualitative study. SETTING: Individual phone interviews. PATIENTS OR OTHER PARTICIPANTS: A total of 34 ATs certified between January and September 2013 participated in this study (18 women, 16 men; age = 24 ± 2 years; work settings = college, secondary school, clinic, and other). Data saturation guided the number of participants. DATA COLLECTION AND ANALYSIS: An interview guide was used. All interviews were recorded and transcribed verbatim. Data were analyzed via phenomenologic reduction, with data coded for common themes and subthemes. Trustworthiness was established via intercoder reliability, member checks, and peer review. RESULTS: Initially, participants had difficulty making decisions independently. However, making decisions and receiving positive feedback helped them develop confidence. Communication with coaches and parents was challenging, especially for those in the secondary school setting. Participants also experienced role ambiguity, as they were unsure of basic organizational and administrative structures and expectations. Mentor inaccessibility was the final challenge described by respondents. In particular, those in the secondary school setting and with part-time employment felt they did not have a supervisor or mentor whom they could contact for support and guidance. CONCLUSIONS: Professional programs should educate students on potential challenges to help them understand what they might encounter during the transition to clinical practice. Employers should provide clear expectations and job descriptions to alleviate some of the stress and role ambiguity. If a mentor is not provided by the employer, the newly credentialed AT should seek one to assist during the transition.