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EXPLORING THE LIVES OF GRADUATE ASSISTANT
ATHLETIC TRAINERS: THE RELATIONSHIPS BETWEEN
WORK, LEISURE, PERCEIVED STRESS, AND BURNOUT

presented by

STEPHANIE CARZOO

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EXPLORING THE LIVES OF
GRADUATE ASSISTANT ATHLETIC TRAINERS:
THE RELATIONSHIPS BETWEEN WORK, LEISURE,
PERC EIV ED STRESS, AND BURNOUT

By

Stephanie Carzoo

A THESIS

Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of

MASTER OF SCIENCE
Kinesiology

2010

ABSTRACT
EXPLORING THE LIVES OF GRADUATE ASSISTANT ATHLETIC TRAINERS:
THE RELATIONSHIPS BETWEEN WORK, LEISURE, PERCEIVED STRESS, AND
BURNOUT
By
Stephanie Carzoo

m: This study examined the relationships between work and leisure hours with
perceived stress and the three constructs of burnout in graduate assistant athletic trainers.
This study also examined the relationships between NCAA Division, patient load, and
occupational setting with work and leisure hours, perceived 'stress, and burnout.
M: A survey composed of the Perceived Stress Scale, Maslach Burnout Inventory,
demographic, and time allocation sections was distributed to 1,000 members of the
National Athletic Trainers’ Association “student-certified” category.
Res_ul§: Results revealed that work and leisure hours were significantly related to
emotional exhaustion (BE) in graduate assistant athletic trainers. No significant
relationships were found between work or leisure hours and perceived stress,
depersonalization (DP), or personal accomplishment (PA). NCAA Division had no effect
on work hours, perceived stress or burnout. On-campus participants worked significantly
more hours and had higher EE than off-campus participants. Patient load was
significantly correlated with EB and DP for off-campus participants.
Conclusion: The results of this study provided valuable demographic and time allocation
information, as well as perceived stress and burnout baselines for graduate assistant
athletic trainers. The results of this study may be used to further expand the literature on

burnout and better the lives of athletic trainers.

ACKNOWLEDGEMENTS

The process of writing a thesis is a collaborative experience involving the efforts
and responses of many people. I want to express my gratitude to everyone whose support
and encouragement made this thesis possible, including the National Athletic Trainers’
Association Research and Education Foundation for funding this study.

I would especially like to thank my advisors, Dr. Sally Nogle, Dr. Marty Ewing,
and Dr. Tracey Covassin. Sally, your immensely quizzical nature about what we do in
athletic training has taught me to always assess what could be made better or done
differently to improve our practice and profession. Dr. Ewing, your literature review
assignment in Sports Psychology is what led me to investigate this topic more deeply.
Your non-athletic training perspective on this project and extensive knowledge of the
research process has been invaluable. And Tracey, thank you for the countless hours you
spent reading, revising, and advising me through this project and the grant writing
process. Without your guidance — and stress-relieving hockey talk - I would have
struggled through these two years.

I would also like to thank the administrative staff of the Kinesiology department,
people who often do their jobs without thanks. Without their help at certain phases of
this project, completion would have been impossible. Thank you to my classmates, both
past and present, who helped to revise the survey, and all those who participated in this
study.

Lastly, I want to express my gratitude to my parents and friends, whose support in
whatever I choose to do have always been unwavering, and whose ears have always been

willing to listen.

iii

TABLE OF CONTENTS

LIST OF TABLES ............................................................................................................. vi
CHAPTER 1

INTRODUCTION ............................................................................................................... l

1.1. Overview of the Problem ........................................................................................ 1

1.2. Significance of the Problem .................................................................................... 4

1.3. Purpose of the Study ............................................................................................... 8

1.4. Hypotheses .............................................................................................................. 9

1.5. Operational Definition of Terms .......................................................................... 11
CHAPTER 2

REVIEW OF LITERATURE ............................................................................................ 14

2.1. Introduction ........................................................................................................... 14

2.2. Overview of Stress ................................................................................................ 14

2.3. Overview of Burnout ............................................................................................ 15

2.3.1. Definitions of Burnout ............................................................................... 15

2.3.2. Smith’s Cognitive-Affective Model of Athletic Burnout .......................... 16

2.4. Stress and Burnout in Athletic Training ............................................................... 20

2.4.1. Overview .................................................................................................... 20

2.4.2. Situational Characteristics: Demands Versus Resources ........................... 21

2.4.2.1. Role Overload .............................................................................. 21

2.4.2.2. Role Ambiguity ............................................................................ 23

2.4.2.3. Role Conflict ................................................................................ 24

2.4.2.4. Social Interaction and Support ..................................................... 25

2.4.3. Cognitive Appraisal ................................................................................... 26

2.4.3.1. Job Satisfaction ............................................................................ 27

2.4.3.2. Work-Family Conflict .................................................................. 28

2.4.3.3. Intention to Leave Job Position or Profession ............................ 29

2.4.4. Physiological Reactions ............................................................................. 31

2.4.5. Outcomes and Behavior ............................................................................. 33

2.4.6. Personality and Motivational Influences ................................................... 36

2.5. Burnout Prevention and Intervention .................................................................... 38

2.6. Conclusion ............................................................................................................ 43
CHAPTER 3

METHODOLOGY ............................................................................................................ 44

3.1. Purpose ................................................................................................................. 44

3.2. Research Design ................................................................................................... 44

3.3. Sample Population and Participant Selection ....................................................... 45

3.4. Instrumentation ..................................................................................................... 45

3.4.1. Demographic Survey ................................................................................. 45

3.4.2. Time Allocation Survey ............................................................................ 46

3.4.2.1. Time Allocation Operational Definitions .................................... 47

iv

3.4.3. Perceived Stress Scale ................................................................................ 49

3.4.4. Maslach Burnout Inventory ....................................................................... 51

3.5. Data Collection and Management ........................................................................ 53

3.6. Data Analysis ........................................................................................................ 54
CHAPTER 4

RESULTS .......................................................................................................................... 56

4.1 . Overview ............................................................................................................... 56

4.2. Demographic Data ................................................................................................ 56

4.2.1. General Demographics ............................................................................... 56

4.2.2. Position Demographics .............................................................................. 58

4.3. Time Allocation Data ........................................................................................... 62

4.3.1. Work Responsibilities ................................................................................ 63

4.3.2. Leisure Activities ....................................................................................... 63

4.3.3. Comparisons between Occupational Settings ............................................ 64

4.3.4. Miscellaneous ............................................................................................ 67

4.4. PSS and MBI Data ................................................................................................ 69

4.5. Assessment of Hypotheses ................................................................................... 70
CHAPTER 5

DISCUSSION .................................................................................................................... 83

5.1. Overview ............................................................................................................... 83

5.2. General Demographics of Time Allocation and Burnout ..................................... 83

5.3. Time Allocation, Perceived Stress, and Burnout .................................................. 85

5.4. The Influence of Setting on Time Allocation, Perceived Stress, and Burnout ..... 87

5.5. Patient Load and Burnout ..................................................................................... 90

5.6. Limitations ............................................................................................................ 91

5.7. Future Research Considerations ........................................................................... 93

5.8. Conclusion ............................................................................................................ 95

APPENDICES ................................................................................................................... 96

A. Demographic Questionnaire ............................................................................ 97

B. Time Allocation Questionnaire ...................................................................... 101

C. Perceived Stress Scale .................................................................................... 104

D. Maslach Burnout Inventory ........................................................................... 106

E. Letter to Survey Participants .......................................................................... 107

REFERENCES ................................................................................................................ 109

4-3

4-4

4-5

4-6

4-8

4-9

4-10

4-11

4-12

4-13

4-14

4-15

4-16

4-17

4-18

LIST OF TABLES
Percentage of NCAA Divisions Represented by Graduate Assistant Athletic
Trainers .................................................................................................................. 57

Percentage of NATA Districts Represented by Graduate Assistant Athletic
Trainers .................................................................................................................. 58

Percentage of On-Campus Settings for Graduate Assistant Athletic Trainers ......59

Percentage of Teams Assigned to On-Campus Graduate Assistant Athletic
Trainers .................................................................................................................. 60

Percentage of Off-Campus Assignments for Graduate Assistant Athletic
Trainers ................................................................................................................. 61

Percentage of Teams Assigned to Off—Campus Graduate Assistant Athletic

Trainers .................................................................................................................. 62
Means, Standard Deviations, and Ranges for Work and Leisure Time ................ 62
Means, Standard Deviations, and Ranges for Work Time Categories .................. 63
Means, Standard Deviations, and Ranges for Leisure Time Categories ................ 64
Independent T-Test Analysis of Total Leisure and Work Hours by Occupational
Setting .................................................................................................................... 65
Independent T-Test Analyses of Work Hour Categories by Occupational

Setting .................................................................................................................... 66
Independent T-Test Analyses of Leisure Hour Categories by Occupational

Setting .................................................................................................................... 67
Miscellaneous Opinion Questions ......................................................................... 69
Means, Standard Deviations, and Ranges for PSS and MBI Data ......................... 70

Dependent T-Test Analysis of Total Work Hours Versus Total Leisure Hours....70

Descriptives for Work Hours by NCAA Division ................................................. 73
Univariate Analysis of Variance for Work Hours and NCAA Division ............... 73
Descriptives for Emotional Exhaustion by NCAA Division ................................. 74

vi

4-19

4-20

4-2 1

4-22

4-23

4-24

4-25

4-26

4-27

4-28

4-29

4-30

4-31

4-32

4-33

4-34

4-35

5-1

Univariate Analysis of Variance for Emotional Exhaustion and NCAA

Division .................................................................................................................. 74
Descriptives for Depersonalization by NCAA Division ........................................ 75
Univariate Analysis of Variance for Depersonalization and NCAA Division ...... 75
Descriptives for Personal Accomplishment by NCAA Division ........................... 76
Univariate Analysis of Variance for Personal Accomplishment and NCAA

Division .................................................................................................................. 76
Descriptives for Perceived Stress by NCAA Division ......................................... 77
Univariate Analysis of Variance for Perceived Stress and NCAA Division ......... 77
Descriptives for Work Hours by Occupational Setting ......................................... 78
Univariate Analysis of Variance for Work Hours and Occupational Setting ........ 78
Descriptives for Emotional Exhaustion by Occupational Setting .......................... 79

Univariate Analysis of Variance for Emotional Exhaustion and Occupational

Setting .................................................................................................................... 8O
Descriptives for Depersonalization by Occupational Setting ................................ 80
Univariate Analysis of Variance for Depersonalization and Occupational

Setting .................................................................................................................... 80
Descriptives for Personal Accomplishment by Occupational Setting ................... 81

Univariate Analysis of Variance for Personal Accomplishment and Occupational

Setting .................................................................................................................... 81
Descriptives for Perceived Stress by Occupational Setting ................................... 82
Univariate Analysis of Variance for Perceived Stress and Occupational

Setting .................................................................................................................... 82
Comparison of MBI Results in Athletic Training Literature ................................. 84

Comparison of MBI Results by Occupational Setting with Data from
Giacobbi (2009) ..................................................................................................... 89

vii

CHAPTER 1
INTRODUCTION
1.1 OVERVIEW OF THE PROBLEM

Burnout, a condition caused by chronic stress, is a common problem in medical
and allied health professions including the profession of athletic training. Graduate
assistant athletic trainers may be susceptible to stress and bumout because of conflicting
demands, long hours, large patient loads, and changes in responsibilities due to
certification. Because of their busy work and/or academic schedules, these athletic
trainers may not have adequate personal time in which to relieve their stress. Research
has shown that decreased leisure time may promote the development of burnout
(Mazerolle, Bruening, & Casa, 2008a; Pitney, 2006; Reed & Giacobbi, 2004). To date,
no studies have examined the time commitments and leisure choices among graduate
assistant athletic trainers, and very few researchers have explored stress and burnout in
this population.

Certified athletic trainers are healthcare professionals specializing in the
prevention, management, and rehabilitation of injuries and illnesses in physically active
populations. To become certified, candidates must graduate from an accredited
undergraduate athletic training program and pass the Board of Certification examination.
Once certified, some choose to pursue further education at the graduate level. Graduate
assistantships in athletic training offer reduced or no cost education in exchange for work
experiences and responsibilities. Graduate assistant athletic trainers may be assigned
sport coverage, administrative duties, research responsibilities, or they may be teaching

assistants or instructors for undergraduate courses. They also may supervise, mentor, and

teach undergraduate athletic training students as clinical instructors. Clinical assignments
may be on-campus with varsity, club, or intramural athletics, or off-campus at local high
schools, clinics, hospitals, or smaller colleges. The typical assistantship lasts for two
years and requires the completion of 30 academic credits. Most also require completion
of a research project such as a thesis or capstone experience. The assistantship allows
graduate athletic trainers to obtain a Master’s degree while simultaneously accruing
experience as a certified athletic trainer. Upon graduation, those with master’s degrees
have an advantage in gaining employment in prestigious settings such as professional
sports or National Collegiate Athletic Association (NCAA) Division I athletics.

Due to the nature of their positions, graduate assistant athletic trainers anecdotally
work long hours, possiblytlimiting their personal time. These athletic trainers may have
to balance multiple athletic teams (and subsequently large numbers of athletes), as well as
coursework, teaching and research responsibilities, and/or administrative duties. Their
work loads in combination with feelings that they may not be compensated for the effort
they put forth may create and exacerbate stress. Furthermore, those who are newly
certified also must cope with the change in authority and nature of their work that comes
with certification. These professionals often must adjust to new and different
environments that differ from their undergraduate experiences in clinical and
organizational policies and procedures. The change of environment has the potential to
overwhelm new graduates, especially if they are unsure of their skills because they are
newly certified.

Stress and burnout are linked but they are not the same entity. Stress develops

from perceptions that demands exceed available resources (Smith, 1986). Stress levels

have been shown to positively correlate with and predict all three constructs of burnout in
a group of 206 certified athletic trainers (Kania et a1., 2009). However, burnout is a
syndrome of long-term unresolved stress that involves multiple complex processes and is
a known problem in the profession of athletic training (Hendrix, Acevedo, & Hebert,
2000; Kania, Meyer, & Ebersole, 2009; McLaine, 2006). Maslach and Jackson (1981)
defined burnout using three constructs: 1) emotional exhaustion, 2) depersonalization,
and 3) decreased feelings of personal accomplishment. Emotional exhaustion is
exhibited by feelings of fatigue and emotional overextension due to patient and colleague
interaction (Maslach, Jackson, & Leiter, 1996). Depersonalization is characterized by an
unfeeling or uncaring response for patients (Maslach et a1., 1996). Decreased feelings of
personal accomplishment, such as feelings of worthlessness or failure, also define this
syndrome (Maslach et a1., 1996). Using these three constructs, Maslach and Jackson
(1981) developed the Maslach Burnout Inventory (MBI) which has become the gold
standard for the measurement of burnout in the human services professions.

Smith’s (1986) Cognitive-Affective Model of burnout suggested that burnout
evolves from the long-term evaluation of perceived demands and resources. This
evaluation may result in physiological changes as well as detrimental outcomes. The
process is further affected by motivational and personality differences among individuals.
Stressors common in athletic training that may contribute to the development of chronic
stress and bumout include long hours, high work volume, unclear roles and
responsibilities, conflicting responsibilities, and interpersonal conflicts. Often the
cognitive appraisal of these stressors influences job satisfaction, work-family conflict or

work-life conflict, and intentions to leave a particular job or the profession of athletic

training entirely. Unresolved burnout may result in decreased performance, increased
absence from work, increased job turnover, and even attrition (Capel, 1990).

Many methods of resolving and preventing this problem have been suggested but
none have been proven effective. The most frequently cited solution for burnout is to
decrease the number of hours spent at work, thereby increasing leisure and personal time.
This would allow working professionals to feel refreshed and revitalized during their
work hours. Increased leisure time might also promote positive health behaviors such as
exercise and proper nutrition, two proven regulators of stress and possible components of
a solution to burnout (Scriber & Alderman, 2005). Other suggestions have included
increasing and bettering interpersonal communication, as well as promoting education
about stress management techniques (Stilger, Etzel, & Lantz, 2001). While there is a
small amount of literature about stress and burnout in the profession of athletic training,
there is much left to be discovered.

1.2 SIGNIFICANCE OF THE PROBLEM

Graduate assistant athletic trainers may be prime candidates to experience high
stress and the beginnings of burnout. These professionals must balance adjustments to a
new environment with a multitude of assigned responsibilities and educational
obligations. 1f the stress from these responsibilities is too great and/or not adequately
managed, chronic stress may develop and possibly lead to burnout. Very few
investigations into the professional and personal lives of graduate assistant athletic
trainers have been undertaken, leaving the stress and burnout literature in this population

relatively nonexistent.

No data are available on how much time graduate assistant athletic trainers
commit to their work responsibilities. Graduate assistantships often state in formal
contracts the approximate number of hours students are expected to work to fulfill
assigned duties. Commonly appointed “half-time” assistantships are supposed to
correspond with 20 hours per week committed to contracted responsibilities. However,
many graduate assistants perform multiple duties, perhaps exceeding these hours.
Because these positions are the lowest compensated and hold the lowest authority
positions, responsibilities that may not be included in their contracts are often delegated
to these professionals, increasing their workload and hours. Mazerolle, Bruening, and
Casa (2008a) found the average weekly workload of 587 Division 1 certified athletic
trainers surveyed to be 62 :I: 14 hours per in-season week and 46 i 11 hours per out-of-
season week. However, it is unknown if graduate assistants commonly follow this same
pattern. Interestingly, the number of hours spent on professional responsibilities has been
logically suggested to positively correlate with stress and burnout (Hendrix et a1., 2000;
Scriber & Alderman, 2005); yet, there are no definitive studies relating these concepts.

Just as in athletics, recovery time from work is vital to maintaining happiness and
motivation during work hours. Exercise, hobbies, interacting with friends and family,
and religion have all been cited as coping mechanisms that graduate assistant athletic
trainers have utilized to reduce stress (Reed & Giacobbi, 2004). Furthermore, these are
activities in which people participate and enjoy in their leisure time. However, limited
personal time due to increased work hours may prevent these activities and prevent
adequate recovery. Mazerolle et al. (2008a) reported that many athletic trainers felt that

their social support networks were diminished because of the significant time

commitment to work. Hendrix et a1. (2000) also found that those with decreased social
support had the tendency to make poor lifestyle choices and exhibited negative behavior
such as increased alcohol use. Kania et al. (2009) found that there was a positive
relationship between the number of leisure hours per week and personal accomplishment,
a construct of burnout, among ATCs surveyed. These data reinforced the hypothesis that
increased leisure time may help alleviate stress and reduce the potential for burnout,
while decreased leisure time may negatively interact with stress and even perhaps
promote burnout. Though many authors have anecdotally supported these ideas
(McLaine, 2005; Scriber & Alderman, 2005), more research is warranted to make
definite conclusions about the relationships between leisure time and stress and burnout.

Other variables that contribute to stress and burnout may be present in graduate
assistant athletic trainers’ experiences that have not been explored, such as the NCAA
Division of their institutions, the environment and setting of their positions, and patient
load. NCAA Division 1 athletic programs are the most prestigious academically-based
setting in which athletic trainers may be employed. Athletic trainers accepting graduate
assistant positions often have a desire to experience a Division I setting because of its
high level of competition, increased resources and financial means, and “win at all costs”
attitude as compared to Division II or Division III settings. Burnout has been
investigated more among Division I athletic trainers than any other population of athletic
trainers (Hendrix et al, 2000; Clapper & Harris, 2008). This is most likely due to
Division 1’s inherent environmental characteristics which are suggested to cause high
stress for athletic trainers in this setting, creating a population that may be more

susceptible to burnout. It is unknown though whether the NCAA Divisions of graduate

assistant athletic trainers’ institutions are factors in their perceptions of stress and
burnout. It is also unclear if the more competitive, high profile environments of Division
I also coincide with more demanding workloads and longer hours for this group of
athletic trainers.

Along with NCAA Division, the employment settings of graduate assistant
athletic trainers have not been documented, nor have the relationships between setting
and stress and burnout been explored. Graduate assistants may be employed on-campus
with varsity, club, or intramural sports, but sometimes they are contracted out to
institutions in the area that have an agreement with the graduates’ educational providers.
They may work in middle or high schools, other local colleges or universities, hospitals,
or clinics. Little research has examined the levels of stress and burnout in each of these
settings among a career oriented population of athletic trainers, let alone among graduate
assistant athletic trainers. 1

Lastly, patient load has been shown to correlate with stress and burnout. In 1986,
Capel determined the average number of patients (athletes) under the care of one athletic
trainer to be 263. Kania et al.’s (2009) more recent study discovered that 55.3% of
certified athletic trainers surveyed were responsible for 70 or more patients. While not
all graduate assistants are newly certified, many have only been certified for less than
five years, which is just the start of their careers. If indeed delegations are made to these
professionals and their patient loads increase, a precarious situation may occur due to
their lack of experience. The graduate assistants may become frustrated or be unable to
perform their duties effectively due to the overwhelming demands of high patient loads.

Depersonalization was found to be positively related to the number of teams for which

athletic trainers were responsible (Kania et a1., 2009). Furthermore, Capel (1986)
discovered the athletic trainers in her sample had an average of 41 .3 direct patient contact
hours per week and a positive correlation of these hours with burnout. Maslach, Jackson,
and Leiter (1996) also found that doctors who had more administrative responsibilities
were less emotionally exhausted than those who had more patient interaction. However,
few studies have examined the relationships between stress, burnout, and patient load,
and none have specifically investigated graduate assistant athletic trainers.

Increasing personal time in which leisure activities can be utilized to promote
recovery is a common suggestion to ameliorate the effects of stress and reduce burnout
(McLaine, 2005; Scriber & Alderman, 2005). However, athletic trainers who spend the
majority of their time working due to a multitude of responsibilities subsequently have
little personal time. This may be a common problem in graduate assistantship
experiences in athletic training. The potential for high stress in combination with the lack
of personal time may result in chronic stress over time and the experience of burnout.
Ultimately, these conditions could cause a number of newly certified athletic trainers to
leave the profession. As burnout has been hypothesized to occur early in a career (Kania
et a1., 2009), it is important that attention be given to professionals who have recently
entered athletic training in order to retain members and improve the work lives of
graduate assistants.

1.3 PURPOSE OF THE STUDY

The purpose of this study was to examine the time commitments and leisure

choices of graduate assistant athletic trainers. This study also investigated the

relationship between the hours spent on professional responsibilities and the hours spent

on leisure activities with the three constructs of burnout and levels of perceived stress.
Lastly, individual demographic characteristics (on- or off-campus position assignments,
patient load, and NCAA Divisions of current institutions) were compared to levels of
burnout and perceived stress as well as to the number of hours working and at leisure.
1.4 HYPOTHESES

The study examined the following hypotheses:
H1: Graduate assistant athletic trainers will contribute more time to work responsibilities
than to leisure activities.
H2: There will be a positive relationship between the number of hours dedicated to work
responsibilities and emotional exhaustion.
H3: There will be a positive relationship between work hours and depersonalization.
H4: There will be a negative relationship between work hours and personal
accomplishment.
H5: There will be a negative relationship between. the number of hours dedicated to
leisure activities and emotional exhaustion.
H6: There will be a negative relationship between the number of hours dedicated to
leisure activities and depersonalization.
H7: There will be a positive relationship between the number of hours dedicated to
leisure activities and personal accomplishment.
H8: There will be a positive relationship between the number of hours dedicated to work
responsibilities and perceived stress as measured by the perceived stress scale (PSS)

among graduate assistant athletic trainers.

H9: There will be a negative relationship between the number of hours dedicated to
leisure activities and perceived stress as measured by the PSS among graduate assistant
athletic trainers.

H10: There will be a positive relationship between the number of athletes for which the
athletic trainers are responsible and their levels of emotional exhaustion.

H11: There will be a positive relationship between the number of athletes for which the
athletic trainers are responsible and their levels of depersonalization.

H12: Graduate assistant athletic trainers at NCAA Division I institutions will spend
significantly more time on work responsibilities than those at Division II and 1H
institutions.

H13: Graduate assistant athletic trainers at NCAA Division I institutions will have
significantly higher levels of emotional exhaustion and depersonalization and lower
levels of personal accomplishment than the athletic trainers at NCAA Division II or III
institutions.

H14: Graduate assistant athletic trainers at NCAA Division I institutions will have
significantly higher levels of perceived stress (as measured by the PSS) than the athletic
trainers at NCAA Division II or 11] institutions.

H15: Graduate assistant athletic trainers working in on-campus positions will spend
significantly more time on work responsibilities than those in off-campus positions.
H16: Graduate assistant athletic trainers working in on-campus positions will have
significantly higher levels of emotional exhaustion and depersonalization and lower

levels of personal accomplishment than those working in off-campus positions.

10

H17: Graduate assistant athletic trainers working in on-campus positions will have
significantly higher levels of perceived stress than those working in off-campus positions.
1.5 OPERATIONAL DEFINITION OF TERMS

Bur_no_ut_ - a chronic phenomenon composed of three constructs: high levels of emotional
exhaustion and depersonalization and low levels of personal accomplishment
(Maslach, Jackson, & Leiter, 1996).

Certified Athletic Trainer (ATC) — a healthcare professional specializing in the
prevention, care, and rehabilitation of injuries and illnesses in physically active
populations.

Depersonalization (DP) — a construct of burnout characterized by cynicism and an
unfeeling response toward patients, colleagues, and others in the work
environment (Maslach, Jackson, & Leiter, 1996).

EmotiongExlgiustion (EE) — a construct of burnout characterized by feelings of
emotional overextension due to work (Maslach, Jackson, & Leiter, 1996).

Graduate Assistant Athletic Trainer — usually an ATC who concurrently obtains his or
her master’s degree in exchange for clinical, teaching, or research responsibilities.

“High” level of burnout — Maslach Burnout Inventory results that display high scores for
emotional exhaustion and depersonalization, and low scores for personal
accomplishment (Maslach, Jackson, & Leiter, 1996).

Lem — defined in this study as the time spent doing non-work responsibilities and

commitments. This includes the sub-categories as follows: exercise/sports,

TV/movies, computer/video games/electronics, talking on the phone, hanging out

11

informally with friends, hanging out formally with friends, family gatherings,
religion, recreation (non sports/exercise), and performance/event attendance.

“Low” level of burnout — Maslach Burnout Inventory results that display low scores for
emotional exhaustion and depersonalization and high scores for personal
accomplishment (Maslach, Jackson, & Leiter, 1996).

Maslach Bur_nout Inventory (MB 1 - originally developed in 1981, the MBI is the gold
standard in the measurement of work-related burnout in human services
professions. It measures each of the three subscales separately (Maslach, Jackson,
& Leiter, 1996).

m1 Athletic Trainers’ Association — the professional organization for certified
athletictrainers and athletic training students.

Occupationgrlietting — the location where participants provided'clinical services.
Defined in this study as either on-campus or off-campus.

On-camnus Setting — clinical services provided at the same institution in which the
participants were enrolled. This setting included varsity, club, or intramural
athletics.

Off-0mm Setting — clinical services provided to a different institution than in which the
participants were enrolled This setting included middle school, high school,
private school (k—l 2), junior or community college, clinic, hospital, or another
college or university different from where the participants were enrolled.

Perceived Stress Scale (PSS) - originally developed in 1983, the PSS is designed to
measure the amount of cognitively appraised stress an individual attributes to

events in his or her life (Cohen, Kamarck, & Mermelstein, 1983).

12

Personal Accomplishment (PA) — a construct of burnout characterized by feelings of
success and accomplishment at work (Maslach et a1., 1996). Note: the burned out
individual experiences decreased feelings of personal accomplishment.

Stress — an acute or chronic physical and emotional response to an imbalance between

 

demands and resources available to accommodate the demands (Cohen, Kamarck,
& Mermelstein, 1983).

Wo4rk Responsibilities — defined in this study as the time spent firlfilling responsibilities
in a graduate assistant or intern athletic training position. This included the sub
categories as follows: coursework, thesis/capstone project, clinical athletic
training, travel, administrative duties, teaching, studying/homework, and

professional development.

13

CHAPTER 2
REVIEW OF LITERATURE

2.1 INTRODUCTION

Burnout, a condition in which individuals are emotionally exhausted,
depersonalize those with whom they work, and feel unaccomplished, is a chronic
phenomenon widely studied in occupational settings. Its analysis in sport, including in
the profession of athletic training, emerged in the 1980s along with Smith’s Cognitive-
Affective Model of Athletic Burnout and the Maslach Burnout Inventory. The following
chapter will highlight the components that Maslach and Smith defined by reviewing the
definitions and dimensions of stress and 'bumout and explaining their development and
manifestations. Research specifically focusing on stress and burnout among athletic
trainers will be examined through each component of Smith’s model, and the chapter will
conclude with a discussion of prevention and intervention techniques.
2.2 OVERVIEW OF STRESS

Stress occurs most often when the perceived demands of a situation exceed the
resources (Smith, 1986). Though stress is a vital component of life and work, it can
cause more harm than good when it creates feelings of powerlessness and begins to alter
quality of life (McChesney & Peterson, 2005). How people react to stress depends on
how they view the situation: Some people thrive on stress where others succumb to it
(Scriber & Alderman, 2005). If an individual interprets a situation as very demanding
and/or feels that he or she does not have sufficient resources to mediate the challenges,
stress results (Cohen, Kamarck, & Mermelstein, 1983). General job-related stressors

may include work load and overload, inadequate salary, lack of control over the work and

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environment, interpersonal conflict, staffing issues, and limited resources (Cohen et a1.,
1983; McLaine, 2005). Symptoms of stress include irritability, emotional instability and
tenseness, concentration and memory problems, fatigue, and changes in appetite (Stilger,
Etzel, & Lantz, 2001). If stress is not handled properly and/or allowed to culminate over
time, long term health problems may result, potentially emerging concomitantly with
burnout (Scriber & Alderman, 2005).

Though Smith’s (1986) Cognitive-Affective Model of Athletic Burnout parallels
his model of stress, stress and burnout are innately different. The consequences of
burnout may be more significant than those of stress: Stress tends to only affect the
people experiencing it, but burnout affects the individuals around these people as well
(Kania, Meyer, & Ebersole, 2009). Chronic, long-term stress and inadequate recovery
are two ofien-associated influences in burnout (Goodger, Gorely, Lavallee, & Harwood,
2007). Many recommendations to prevent or decrease burnout utilize stress relieving
methods such as proper diet and exercise, stress management coursework, and assertion
of control (Capel, 1986; Gieck, 1986; Gould, 1996; Smith, 1986). Due to their linked
nature, this chapter will thoroughly examine the relationships between stress, burnout,
and the athletic trainer.

2.3 OVERVIEW OF BURNOUT

2.3.1. Definitions of Burnout

When psychologists first defined burnout, they deemed it a reaction to stress over
a long period of time (McLaine, 2006). Dale and Weinberg (1990) described burnout as
an imbalance between the demands of an organization and what individuals are actually

capable of doing in response to the demands. As research has evolved, a more specific

15

stress-based definition was constructed by Dr. Christina Maslach, who explained burnout
as an interaction between personal characteristics and situational influences. Burnout is
illustrated by three different dimensions: emotional exhaustion, depersonalization, and a
reduced sense of personal accomplishment (Maslach & Jackson, 1981). Emotional
exhaustion is a state in which individuals feel emotionally overextended because of work,
resulting in physical, mental, and/or emotional exhaustion (Dale & Weinberg).
Depersonalization, a defensive coping mechanism, occurs when individuals lose concern
for the people with whom they work (Hendrix et a1., 2000; Lee & Ashforth, 1996).
Depersonalization is ofien exhibited through cynicism and an unfeeling response toward
patients, colleagues, and others in the work environment (Dale & Weinberg). Lastly,
burned out individuals describe reduced feelings of accomplishment and success at work,
as well as decreased perceived. competence and negative self-appraisal (Hendrix et al.).
Depression, perceived failure, and lowered self-esteem also characterize this construct
(Dale & Weinberg). The presentation of the three dimensions in this particular order is
common in the literature; however, it should be noted that they do not necessarily occur
in sequence. Each construct develops at different times and in different ways (Lee &
Ashforth). Though individual researchers and theorists may have their own nuances to
describe this phenomenon, burned out individuals ultimately must cope with feelings of
long-term stress toward a once enjoyable activity or experience (Smith, 1986).

2.3.2. Smith’s Cognitive-Affective Model of Athletic Burnout

Most of the widely accepted contemporary theories about burnout are focused on
the syndrome as a response to stress. The most salient model in the body of research that

is pertinent to sport is Ronald Smith’s Cognitive-Affective Model of Athletic Burnout

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(Smith, 1986). Smith stated that athletic burnout is the result of four components:
situational aspects, cognitive appraisal, physiologic reactions, and outcomes and
behaviors. These components interact amongst each other and manifest themselves in a
cyclical nature while being influenced by individual personality and motivational
differences (Gould, 1996).

Situational aspects begin the Cognitive—Affective Model of Athletic Burnout.
Smith (1986) stated that the key to this component is the perception of balance or
imbalance between demands and resources. Overload occurs when perceived demands
exceed the available resources (Smith). Demands are either internal or external,
reflecting individuals’ personal expectations of the quality of work they put forth or
others’ wants, needs, and desires. Demands can be in the form of environmental factors,
such as access to supplies, number of staff, availability of knowledge and information, or
internal self-directed goals. Lee and Ashforth (1996) suggested that people tended to be
more cognitively sensitive to demands than resources. They also rationalized that
emotional exhaustion was associated with demands, while depersonalization and
decreased personal accomplishment corresponded with resources. Types of stressors that
may influence individuals include work environment, lack of autonomy and independent
decision making, time demands, and interpersonal difficulties (Smith).

Gould (1996) stated that if a demand is required of a group of people, not all
individuals will perceive it equally. Some will interpret it as threatening, others as
challenging, and others as overwhelming. These differences illustrate the cognitive
appraisal component of Smith’s model, where the individuals evaluate the status of the

demands and resources (Smith, 1986). Smith defined four elements as part of cognitive

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appraisal. Individuals must (1) appraise the demands of the situation, (2) appraise the
resources available to meet the demands, and (3) acknowledge the consequences that will
result if the demands are not met. Lastly, the individuals develop interpretations of the
various outcomes on the situation (Smith). The way the stressors are appraised effects
how people will respond to and manage such stress. Individuals experiencing stress may
feel a wide variety of emotions resulting from their interpretation of the circumstances,
ranging from anxiety to anger (Smith). Self-derogation, decreases in self-appraisal and
self-esteem also occur during this stage. For instance, feelings of decreased personal
accomplishment may lead to a perceived decrease in control of the situation, resulting in
an inability to differentiate what components of the situation can be controlled and what
cannot. The challenge of finding control can in itself enhance a perceived lack of control
and perhaps exacerbate stress and further the cycle (Maslach & Jackson, 1981).

Physiological responses develop from individuals’ cognitive appraisal of the
situational demands and resources. Reactions such as sleep disturbances, fatigue,
tension, and health issues manifest themselves and provide a positive feedback
mechanism to the stress response cycle. These signs and symptoms often further
experienced stress and can promote burnout (Smith, 1986).

The last component of the Cognitive-Affective Model is the behavioral and
outcome component, or how individuals cope with stress. Burned out people frequently
withdraw from others, which Smith (1986) stated decreases their ability to cope through
social-based processes and can deplete a social support network, especially in the long-
term Other coping mechanisms, whether task-oriented, social, or of another variety,

occur here and result in varying outcomes (Smith, 1986). Outcomes can be positive or

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negative, but those who are burned out commonly exhibit decreased efficiency,
behavioral disorganization, and attrition (Smith).

Though Smith’s model emphasizes having a cyclical nature, there are two more
influential variables that must also be considered. Individual personality and
motivational differences play a direct role in cognitive appraisal and behavioral outcomes
(Smith, 1986). These individual differences, defined by Smith as “predispositions to seek
out certain situations and goals and to perceive, think, and respond emotionally and
behaviorally in certain ways” (p. 42), make each individual’s experience of stress unique.
Elements such as past experience, social support, and self-concept, as well as Type-A
personality, locus of control, hardiness, and anxiety-proneness all influence the complex
interactions in Smith’s model.

Maslach’s three dimensions of burnout can be aligned with certain areas of
Smith’s model. Lee and Ashworth (1996) suggested that emotional exhaustion was a
form of strain and that feelings of decreased personal accomplishment was a form of self-
evaluation. They also identified depersonalization as a defensive coping mechanism.
Strain and self-evaluation occur during cognitive appraisal, putting emotional exhaustion
and feelings of decreased personal accomplishment largely in this component of the
Smith’s model. Depersonalization fits into the last stage as a type of behavioral
responses.

Burnout is not a personality trait or characteristic, but a complex interaction
between reciprocally related personal and situational factors that can perpetuate itself in a
never ending cycle (Gould, 1996). Smith’s model has been instrumental in the study of

burnout in sport because it is one of the most widely used and explored theories in this

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body of literature to date (Dale & Weinberg, 1990). Though this theory has been explored
among athletes and coaches, it only occasionally appears in the athletic training literature,
prompting the subsequent review of research on stress and burnout in athletic training.
2.4 Stress and Burnout in Athletic Training

2.4.1 Overview

In 1985, Campbell, Miller, and Robinson reported that 60.3% of 221 surveyed
athletic trainers were experiencing burnout as defined by their measurement scale.
Though the reliability and validity of their instrument was not proven by today’s
standards, a few telling results of the study cannot be denied. Their research showed a
magnitude of physiological problems related to burned out athletic trainers, as well as a
high desire of those classified as bumed out to change their employment setting.

Contemporary research has shown burnout in athletic training to be just as
complex as in other professions (Scriber & Alderman, 2005). Increased supervisory
responsibilities due to educational changes, heightened pressure to provide more
comprehensive care because of technological advances, and the increase in litigation due
to the deaths of high profile athletes have all been extrinsic factors suggested that may be
increasing the stress on athletic trainers of today (Clapper & Harris, 2008). Because
burnout research has evolved to focus on situational and environmental influences,
Smith’s Cognitive Affective Model of Athletic Burnout coincides with the literature on
the subject in athletic training. In the subsequent sections, the research available related
to each component of the model will be discussed, culminating in the examination of

prevention and intervention strategies that may be used to mediate stress and burnout.

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2.4.2 Situational Characteristics: Demands Versus Resources

Smith’s (1986) model begins with situational characteristics in which an
individual perceives the resources available to meet the demands of a situation. Research
on burnout in athletic training has identified many situational factors that influence
athletic trainers. Commonly identified demands are role complexities such as role
overload, role ambiguity, and role conflict (Clapper & Harris, 2008). Resources, such as
social support and family, can aid in lessening the stress caused by imposed demands.
However, there are instances when the conflict between family and work lead to
increased demands and subsequent feelings of increased imbalance between the demands
and resources available to mediate them.

2.4.2.1 Role Overload. Role overload occurs when individuals feel that they have
too much to do and not enough time to do it all or to do it all well (Brumels & Beach,
2008). Scriber and Alderman (2005) estimated that most athletic trainers worked greater
than 50 hours per week. Similarly, Mazerolle, Bruening, and Casa (2008a) found the
average weekly workload of 587 Division 1 athletic trainers to be 62 i 14 hours per in-
season week and 46 i 11 hours per out-of-season week. On top of regular clinical hours
in which athletic trainers cover practices, evaluate injuries, and rehabilitate injured
athletes, travel may consume a significant amount of time. For this same group of
athletic trainers, average travel time per month was reported to be 8 :L- 4 in-season days
and 2 i 2 days out-of-season (Mazerolle et al., 2008a). Athletic trainers may also have
other job responsibilities outside of the clinical setting, such as teaching in undergraduate
programs, administrative duties, and research obligations (Brumels & Beach). One

athletic trainer stated in an interview, “It is kind of hard to have a life with the long hours

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you wor ” (Mazerolle et al., 2008a). While this profession is known for long work hours,
many athletic trainers feel stressed because of these time demands.

Factors that increase role overload include staffing issues and an incongruence
between the hours worked and money earned. Mazerolle et al. (2008a) found that the
Division I athletic trainers in their sample were responsible for an average of 3 i 3
athletic teams per year. Many institutions do not have enough staff to cover all the teams
in order to provide adequate healthcare to the level which athletic trainers are taught to
give. In many cases there is only one athletic trainer for two or more in-season teams
(Scriber & Alderman, 2005). In 1986, Capel determined the average number of athletes
under the care of one athletic trainer to be 263; however, there was quite a distribution of
data in the sample. Twenty-seven percent had less than 100 athletes, while 28% had
more than 300 athletes. More recent research by Kania, Meyer, and Ebersole (2009)
found that 55.3% of 206 athletic trainers surveyed cared for more than 70 athletes.
Unfortunately, the numerical breakdown past 70 athletes was not provided, and this
sample was restricted to clinical athletic trainers at NCAA institutions. The number of
direct contact hours per week with athletes has also been shown to correlate with burnout,
with a higher number of hours increasing levels of burnout (Capel, 1986). The 332
athletic trainers in Capel’s survey reported an average of 41.3 contact hours. The
majority of these subjects had less than 40 hours of direct patient contact per week; 35%
had between 41 and 60 hours per week, and the remaining 8% had greater than 60 hours
per week. However, this research was conducted over 20 years ago. Therefore, further

investigation is warranted to determine if these hours and factors have changed over time.

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Lastly, inadequate salary in proportion to hours worked is frequently cited as a
factor in role overload (Capel, 1986; Gieck, Brown, & Shank, 1982). The average salary
for a full time athletic training position is between $30,000 and $40,000 per year
(Mazerolle et al., 2008a). Athletic trainers have reported that they would feel better
about working the long hours if the pay matched the effort they put into their jobs. One
subject stated, “It is hard for people to imagine successfully having a career and a home
and a family while working all those hours and having such low pay” (Mazerolle et al.,
2008a, p. 509). Those who enter this profession understand that the time demands are
intense; however, competitive escalation, fiscal restrictions, and the elevating costs of
healthcare have all influenced work overload (Brumels & Beach, 2008). Ultimately,
Brumels and Beach found that 38% of athletic trainers experienced moderate to high
stress levels due to role overload. Regardless of the reasons that may cause it, role
overload is a definite demand experienced by athletic trainers.

2.4.2.2 Role Ambiguity. Role ambiguity is a stressor that occurs when
expectations of a job are vague and unclear (Clapper & Harris, 2008). There may be a
lack of clear information regarding role expectations, methods of fulfilling these
expectations, and/or consequences of performance (Capel, 1986). Many athletic trainers
lack specific job descriptions or written contracts delineating their roles and
responsibilities (Mensch, Crews, & Mitchell, 2005). Furthermore, the expectations that
are provided may never be adequately explained to the athletic trainers or those who
work with them, creating uncertainty. For example, Mensch et a1. (2005) found
discrepancies between high school basketball coaches’ expectations of their athletic

trainers and the actual athletic trainers’ expectations of their duties. The 20 coaches in

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this study could not correctly identify the athletic trainers’ direct supervisors; two
coaches actually referred to themselves as their athletic trainers’ direct supervisors. The
coaches also expected their athletic trainers to “be available” but did not articulate what
they expected their athletic trainers to be doing while they were “available” (Mensch et.
al, 2005). The coaches’ lack of clarity in describing their needs and desires and
subsequent lack of communication with the athletic trainers who worked with them
resulted in the athletic trainers’ experience of role ambiguity. Furthermore, the role
ambiguity created here has most likely resulted from inadequate explanations of job
expectations as well as inadequate or lack of communication about these expectations to
the athletic trainers and/or coaches by the athletic trainers’ direct supervisors. Individual
colleagues may interpret common expectations differently: Insufficient communication
creates incongruity for athletic trainers (Brumels & Beach, 2008). The athletic trainers
may come to believe the ambiguity is a demand that they cannot control.

2.4.2.3 Role Conflict. Role conflict occurs when role ambiguity is combined with
conflicting expectations by multiple authorities (Brumels & Beach, 2008). The demands
placed upon athletic trainers may be contradictory or mutually exclusive, creating
situations in which the athletic trainers may feel stuck in the middle. For example,
athletic trainers are commonly responsible for being at practice in case of an emergency.
Coaches expect athletic trainers to be at every practice, including non-traditional
“captain’s” practices, while administrations tell their athletic trainers that they should not
cover those practices. This situation is created out of a common expectation that is
interpreted differently by those with whom the athletic trainers work. The perception that

individual athletic trainers have “multiple bosses” is common due to role ambiguity and

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lack of communication. More often than not, coaches perceive their athletic trainer as
solely responsible for their group of athletes. These coaches do not realize that their
particular medical professional has a variety of other obligations outside of caring for one
specific team (Mensch et a1., 2005). Both of these hypothetical but common situations of
role conflict can create interpersonal conflict, another frequently cited demand of athletic
trainers’ jobs (Clapper & Harris, 2008).

2.4.2.4 Social Interaction and Support. Social interaction can either increase
feelings of perceived stress and burnout because of interpersonal conflict or help buffer
these feelings through strong social support. Disagreements with coaches, dissent among
staff members, or conflict between the organization and the sports medicine staff are
commonly cited stressors among athletic trainers (McLaine, 2005). These issues may
increase demands by exacerbating role conflict and overload.

Despite interpersonal conflicts, a good social support network has been shown to
buffer the effects of stress. Collegiality and teamwork within a sports medicine program
and positive relationships with administrators encourages productivity and can be a good
resource used to limit stress (McLaine, 2005). Though harmony at work may not always
be possible, Hendrix et a1. (2000) showed that social support outside of the workplace
negatively correlated with perceived stress and is influential in relieving work-related
stress. However, many athletic trainers feel that they struggle to maintain an active social
life outside of work (Brumels & Beach, 2008). Mazerolle et al. (20083) reported that
many athletic trainers felt that their social support networks were diminished because of
the significant time commitment to work. One of their subjects stated, “some of the

ATCs here laugh and say, “What social life?” You do not have time to go out and meet

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people. You can’t do things consistently. You know you can’t plan a date because you
do not know if you have to work that night because the schedule is so inflexible and can
change at any time” (p. 510). Hendrix et al. also found that athletic trainers with
decreased social support had the tendency to make poor lifestyle choices and exhibit
negative behavior. Though McChesney and Peterson (2005) identified social needs as
critical to job satisfaction, it seems that athletic trainers may struggle to maintain
adequate social support outside of the workplace, causing more stress and perhaps
decreasing their abilities to cope with the demands of their jobs.

Role overload, role ambiguity, role conflict, and interpersonal conflict are all
demands which athletic trainers encounter and must effectively manage to avoid stress.
Though the current body of literature discusses many of these factors, there is a marked
absence of data that illuminates the prevalence, frequency, and intensity of these
stressors. Deeper investigation into the causes of role complexities and interpersonal
difficulties may further our understanding of this component of Smith’s model.

2.4.3 Cognitive Appraisal

Everyone, regardless of their profession, desires appreciation, recognition, and
reward for their efforts at work. If these do not happen, especially over a long period of
time, feelings of frustration may ensue (McLaine, 2005). The way individuals appraise
or interpret the demands, resources, and consequences inherently involved in any
circumstance produces overall feelings and opinions about the situation. Two of the
dimensions of burnout described by Maslach (1986) are illustrated here in the cognitive
appraisal component of Smith’s model. Athletic trainers who are emotionally over-

extended due to long term stressors may display emotional fatigue and perhaps negative

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attitudes (Hendrix et a1., 2000). Appraisal of the stress may also lead to a perception of
decreased personal accomplishment, including feelings of inadequacy or incompetence
and magnification of worry (McLaine). These feelings as a whole can be grouped into a
few sub-concepts of cognitive appraisal, such as job satisfaction, work-family conflict,
and intention to leave a position or the profession.

2. 4.3.1 Job Satisfaction. Job satisfaction is definitely linked to burnout, but it is
not the same entity (McLaine, 2005). Job satisfaction is defined by McChesney and
Peterson (2005) as a positive emotional response evoked from employees about their job
expectations being met or exceeded. Stressors may cause athletic trainers to question
their initial motives for obtaining certain jobs and if their positions are really worth the
time and effort required in order to be successful (McChesney & Peterson). Commonly
acknowledged stressors such as a large number of patients, long work hours, travel
requirements, among others are part of the occupational subculture considered when
athletic trainers enter the profession. As these professionals continue on their career
paths, these stressors may cause enough negative influence to make the athletic trainers
feel unsatisfied by their line of work (McChesney & Peterson). Other stressors such as
the incongruence between the administration, coaches, and athletic training staff may also
influence cognitive appraisal and decrease job satisfaction. Mensch et al. (2005)
postulated that discrepancies between the coaches’ expectations of their athletic trainers
and the actual expectations held by the athletic trainers in regard to their duties may
jeopardize job satisfaction through feelings of discontent, role ambiguity, and role
conflict. Lastly, the next facet of cognitive appraisal, work-family conflict, produced a

statistically significant explanation of the variance in job satisfaction among collegiate

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athletic trainers (Mazerolle, Bruening, Casa, & Burton, 2008b). Time constraints,
inflexible schedules, and lack of staff also influenced these findings (Mazerolle et al.,
2008b). So while stressors may influence perceptions of job satisfaction, different facets
of cognitive appraisal may also interact among each other, reflecting the reciprocal and
cyclical nature of stress and burnout described by Gould (1996).

2.4.3.2 Work-Family Conflict. Work-family conflict, a product of the cognitive
appraisal of job stressors’ influence on family life, is also of concern to athletic trainers
experiencing burnout. Mazerolle, Bruening, and Casa (2008a) defined work-family
conflict as discontent that develops when time spent working interferes and/or limits time
available for family. They found that work-family conflict correlated with long work
hours and travel, as well as with job satisfaction, job burnout, and intention to leave a
position or the profession in a group of 587 certified athletic trainers (Mazerolle et al,,
2008b).

The challenge of playing multiple roles may influence the experience of work-
family conflict (Pitney, 2006). With obligations to work, family, and fiiends pulling
athletic trainers in different directions, distinct separations among each of the roles can
occur, potentially causing internal conflict because the individuals may feel torn between
each of their different role responsibilities. Competition amongst these different “selves”
may eventually lead to one role becoming more dominant while others are de-emphasized
(Pitney, 2006). If the dominant role becomes the work role, the athletic trainers may
neglect family and fi'iends which may create interpersonal issues. If the dominant role is
focused on family and friends, the athletic trainers will experience unhappiness with

work’s interference with their personal obligations, perhaps leading to a job or career

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change that better accommodates these needs. Pitney’s idea about role responsibilities
and dominance is an intriguing one but requires more research and investigation.

2.4.3.3 Intention to Leave Position or Profession. As athletic trainers appraise
unhappy situations, they may begin to harbor feelings about leaving the position in which
they work for another or to leave the profession of athletic training entirely. Campbell et
al. (1985) reported that 60.3% of athletic trainers were “burned out” as measured by the
survey scale they implemented Of those who were burned out, 65% had considered
changing jobs or leaving the profession, compared to only 15% of those who were not
burned out. Twenty-seven percent felt this way because of better job opportunities or
advancement prospects elsewhere and better pay in other positions or professions.
Feelings of being underpaid and over-worked composed 17.5% of opinions, while 10.9%
complained of having too many job restrictions in their current position. Similarly,
athletic training education program directors reported that they considered changing jobs
or leaving the profession because of family responsibilities, low pay, health issues, and
burnout (Judd & Perkins, 2004).

Brumels and Beach’s (2008) more recent study found differences among feelings
of attrition and the particular employment positions the athletic trainers held. Role
overload predicted intentionsto leave among faculty athletic trainers, whose
responsibilities primarily included directing the athletic training education program and
teaching. Role ambiguity and role overload were correlated with intentions to leave
among joint appointees, who had multiple educational, clinical, and/or administrative
responsibilities. Analysis of the entire sample, composed of faculty, dual appointees, and

clinicians, revealed that role overload was most associated with intention to leave a

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current position or the profession (Brumels & Beach). Note that the thoughts about
leaving a job or the profession are highlighted here; the action of leaving — attrition — is
discussed in the behaviors and outcomes section.

Results of studies in the area of cognitive appraisal leave many questions
unanswered. It would be interesting to see the Campbell et al.’s 1985 study on the
desires of athletic trainers to leave the profession repeated in a sample of present day
athletic trainers. Back in 1985 when their study was published, women were still
struggling to achieve equal employment opportunities and to perform similar skills in
athletic training as men do, which may have influenced the 10.9% reporting that they felt
the urge to leave because of too many job constraints. Results may be different in the 21”t
century as women now have a more equal footing and also because the profession has
changed immensely due the evolution of medical technology and knowledge. Brumels
and Beach’s (2008) research on job satisfaction in athletic trainers revealed that though
many had thought about changing jobs or leaving the profession, largely those sampled
were satisfied with their jobs. Future research should investigate the reasons unsatisfied
athletic trainers feel the urge to leave the profession and compare the results to Brumels
and Beach’s original research. Lastly, the interactions between burnout, work-family
conflict, and job satisfaction have not been thoroughly researched in a population of
athletic trainers. As multiple individuals may appraise the same situation differently, the
cognitive interpretation phase of Smith’s model emphasizes the thoughts and feelings
individuals have about the variables influencing their lives. These thoughts and feelings

subsequently affect physiologic functioning.

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2.4.4 Physiological Reactions

Hendrix, Acevedo, and Hebert (2000) adeptly stated that the physiologic
component of Smith’s model has often been ignored or forgotten in athletic training
burnout literature. Indeed, this facet of the burnout phenomenon yields the least amount
of discoveries and insights. Early research by Campbell et al. in 1985 revealed that
65.1% of the 221 athletic trainers surveyed reported at least one medical condition related
to stress and burnout. Fatigue was the most prevalent, composing 40.7% of the sample,
followed by irritability (30.3%), weight management problems (24.9%), and
sleeplessness (19.5%). Depression, nervousness, gastrointestinal disturbances, and
frequent headaches were among the other problems reported A case study by Gieck
followed in 1986 describing an athletic trainer who experienced many of these same
signs and symptoms, and had become so psychologically distraught that he almost
became hospitalized and needed intense psychotherapy. Another of Gieck’s studies
examined the cases of a dentist, nurse, and athletic trainer who were all defined as burned
out and showed that all of their symptoms were similar as they experienced emotional
exhaustion, depersonalization, and decreased feelings of personal accomplishment
(Gieck, Brown, & Shank, 1982).

Frequently the signs and symptoms of burnout resemble other conditions.
Differential diagnoses for burnout include post-traumatic stress disorder, chronic fatigue
disorder, and depression (McLaine, 2005). Interestingly, many reports of burned out
athletic trainers who have received treatment for depression found that this treatment was
unsuccessful in relieving all of their signs and symptoms (Gieck et a1., 1982). Therefore,

though burnout and clinical depression are linked, burnout may be a more complex

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condition inside of which depression may manifest. Since the 19805, research on burnout
specific to the athletic training profession has tended to rely on the notion that the signs
and symptoms of burnout mimic those of chronic stress. However, fiuther research is
needed to reveal the relationships between physiologic manifestations and chronic stress
and burnout.

Differentiation between the signs and symptoms of each of Maslach’s
components of burnout has begun to emerge. The emotionally exhausted individual is
said to become irritable, detached, and cynical, while the person facing feelings of
decreased personal accomplishment may be excessively worried, withdraw from others,
feel incompetent or inadequate, or have difficulty unwinding (McLaine, 2005). There are
no signs and symptoms specific to the depersonalization component because it is a
coping mechanism and not a type of cognitive appraisal.

Because there is little research investigating the physiologic component of
Smith’s model in athletic trainers, there are many questions that have been left
unanswered. First, Smith’s model explains that physiologic responses to stress can and
often perpetuate the stress cycle (Smith, 1986). However, this has not been proven in a
sample of stressed athletic trainers. Furthermore, any physiologic differences between
genders among burned out athletic trainers have not been thoroughly investigated, nor
has the correlation of the differences in job setting with certain physiologic reactions.
Lastly, the effect of the physiologic and emotional changes on the individuals’ overall
well-being, specifically in regards to long-term stress and the resultant sequelae, has yet

to be established. Though under-investi gated, the physiologic responses to stressors and

32

cognitive appraisal seem to have a profound influence on behaviors and outcomes in
those experiencing burnout.

2.4.5 Outcomes and Behavior

Burnout tends to result in decreased performance but the magnitude of this
decrease has not been quantified in the literature. Gieck et al. (1982) reported that burned
out professionals tend to cut corners and may lack attention to detail. Furthermore, they
may only do what is necessary and rarely go above and beyond what is required
(McLaine, 2005). Other behavioral changes, some of which are coping mechanisms,
have been identified in those who are classified as burned out. However, decreases in
productivity and actual attrition are also included in this facet of Smith’s model (1986).
Unfortunately, many of these identified behaviors have not been well studied past
observation and anecdotal report.

There are a wide variety of coping mechanisms that bumed out athletic trainers
may employ to attempt to lessen the feelings of stress. Gieck (1984) reported observing
rigidity and inflexibility in behavior, pessimism, cynicism, and irritability as potential
outcomes. Social withdrawal is also a very commonly cited behavioral change associated
with burnout. Burned out individuals reportedly may avoid social gatherings with fellow
colleagues or with personal friends outside of work (McLaine, 2005). They stop seeking
outside activities and meaningful relationships with others (Gieck et a1., 1982).
Depersonalization is the most highlighted type of social withdrawal, as it is one of
Maslach’s three dimensions of burnout (Maslach & Jackson, 1981). McLaine
anecdotally reported that athletic trainers who depersonalized their patients treated them

“by the book” and did not go to great lengths to individualize and tailor treatment to their

33

specific needs. Depersonalization and social withdrawal may help burned out athletic
trainers decrease their emotional involvement with their patients and therefore aid in
decreasing emotional overextension. However, no research in the athletic training
literature is available to prove or disprove this idea.

Coping mechanisms as a whole are difficult to study, and thus few research
articles have been published specific to athletic trainers. One particular study of interest
by Reed and Giacobbi (2004) delineated the coping mechanisms graduate assistant
athletic trainers employed to assist them with the stresses of their jobs. The authors were
able to divide these coping mechanisms into two distinct types: problem-focused and
emotion-focused coping. Problem-focused coping, or methods used to find a solution to
the problem at hand, included planning (scheduling, time management, organization),
social support (through conversation and seeking advice), adjustment to the job (seeking
information and adaptation mechanisms), and outside activities (such as exercise and
recreation). The graduate assistant athletic trainers also used emotion-focused coping
techniques such as emotional support from others, humor, venting through discussion,
and positive evaluations. Surprisingly, many seemingly negative coping mechanisms,
such as social withdrawal and substance abuse were not mentioned, both behaviors which
have been largely cited as occuning in burned out athletic trainers (Capel, 1990; Gieck et
a1., 1982; McLaine, 2005). This was perhaps due to a small sample size of six
interviewees, or a lack of recognition on the interviewees’ part that these are forms of
coping. Interestingly, of the six interviewees, two left the profession entirely after the
study was completed, Two others began teaching in athletic training because they

perceived this branch of the profession to be less stressful. The final two remained true

34

clinical athletic trainers. More investigation is needed with a larger sample size to
determine the prevalence of social withdrawal and substance abuse in bumed out
individuals, as well as on coping mechanisms in other populations of athletic trainers.

Lastly, if the experience of burnout results in unhappiness, the thoughts athletic
trainers’ may have about leaving their job or the profession may become actions. The
only literature addressing attrition in athletic training was written by Capel in 1990.
Capel surveyed 82 former athletic trainers, asking them why they wanted to be athletic
trainers and why they chose to leave the profession. Twenty-eight percent chose to leave
so that they could pursue practice as physical therapists, 14% had returned to school, and
12% because they had moved and no job was available in their area. Other reasons
included low salary, limited opportunities, and long hours. Along with reasons for
attrition, Capel asked her subjects to identify what they thought were the least enjoyable
aspects of the athletic training profession. Thirty-seven percent said that the long hours
and no personal time was the worst part of the job, followed by salary (12%) and
interpersonal conflicts (12%). Though she found that there were a variety of reasons for
attrition, many of those who chose to leave were young. Seventy-five percent of the
subjects were less than 36 years old and 75% had been certified for ten years or less. One
must consider the time in which this survey was administered, as it was almost twenty
years ago. If this study were to be repeated, it would be fascinating to discover if those
reasons are the same or if different reasons have arisen due to proliferation and
maturation of the profession.

Through a wide variety of coping mechanisms including problem- and emotion-

focused methods, depersonalization, withdrawal, and others, athletic trainers who are

35

burned out may neglect their jobs, a product of lost passion. Whether bumed out athletic
trainers cope effectively or choose to leave the profession, it is clear that athletic training
is facing difficult issues when it comes to keeping these medical professionals happy and
productive.

2.4.6 Personality and Motivational Influences

Capel (1986) stated that though individual factors such as personality and
motivational differences may determine the onset and severity of burnout, the likelihood
and incidence of this phenomenon is probably determined by other factors. The available
body of literature specific to burnout in athletic training includes mention of factors such
as “type-A personality”, hardiness, and locus of control, but these are presented as
portions of experimental research and not as the foci.

Gieck (1982) identified individuals with “type-A personality” as “ideal candidates
for burnout”. He described this personality type as being excessively focused on time
and urgency, so much that the individuals are over-sensitive, impatient, compulsive, and
may suffer from anxiety due to their exclusive focus on deadlines. While this personality
type has been mentioned in the general literature, it has not been extensively studied.

Locus of control has also been identified as a personality difference among
individuals that influences chronic stress and burnout. Capel (1986) defined locus of
control as individuals’ general interpretations of the relationship between their actions
and subsequent events. Those with an internal locus of control believe that their actions
almost always influence events that follow, whereas those with an external locus of
control believe that this connection is infrequent. Capel found through use of the Rotter

Intemal-Extemal Locus of Control Scale that 78% of 332 athletic trainers had an internal

36

locus of control, versus 22% with a tendency toward an external point of view. Though
Capel found the type of locus of control and the combination of four other factors as a
collectively significant predictor of burnout, the specific analysis of the relationship
solely between locus of control and burnout was not reported. Capel did postulate that
those with an external locus of control probably were more susceptible to burnout, but
this is only anecdotal.

Hardiness is another personality factor related to locus of control that may
influence the experience of burnout. Hendrix et a1. (2000) described hardy individuals as
those who feel that they have an internal locus of control and act as if they have power to
face certain life events. These people view work as challenging rather than threatening.
Through the use of the Hardiness Test, Hendrix and colleagues reported that athletic
trainers tended to score higher on the hardiness scale than those in other health
professions, leading them to conclude that athletic trainers must believe that they have
some sort of control over their work environment. They also discovered hardiness to be a
significant predictor of perceived stress, as this concept explained 40% of the variance in
perceived stress. This was the only published study that investigated the effects different
personalities have on stress and burnout among athletic trainers.

Lack of research specific to athletic training in this component of Smith’s (1986)
model leaves many questions unanswered. For instance, though Capel (1986) found the
overall burnout levels in her sample to be low, it would be interesting to discover if these
results were related to the internal locus of control displayed by 78% of her sample.
There is little doubt that these individual factors do have an influence on the experience

of burnout, but we do not know to what extent this occurs.

37

Overall, this review of literature has shown that while there are many factors,
components, and variables that influence athletic trainers’ experiences of burnout, many
are in need of further questioning and study. Future discoveries in this line of research
will promote the development of prevention and intervention techniques that may help
solve the problem of burnout.

2.5 BURN OUT PREVENTION AND INTERVENTION

While the five components of Smith’s (1986) model seek to explain the burnout
phenomenon, they do not consider how to alleviate or prevent this syndrome. There is a
plethora of literature suggesting the efficacy of positive coping mechanisms, behavioral
changes, and environmental changes, but there is no proof that these methods actually
work. Changing the amount of time spent working by determining coverage priorities
and employing time management strategies may allow an increase in leisure time and
subsequent increase in social life outside of work, strategies which may alleviate or
prevent burnout. Increasing communication between members of the sports medicine
team, coaching staff, and administration may also prevent conflict and therefore decrease
stress and burnout. Lastly, improving health behaviors, education on stress management
techniques, and other personal changes to cognitive appraisal all have been cited as
potential resources used to manage burnout (Scriber & Alderman, 2005).

The time commitment required in this profession has been the most cited demand
in research (Capel, 1986; Hendrix et a1., 2000; Kania et al,, 2009), so proper time
management and prioritization are keys in reducing role overload and subsequent feelings
of stress and burnout. This may be accomplished through changing the work

environment by conducting a needs assessment and devising a priority coverage plan, as

38

well as through changing personal habits to promote effective time management and
delegation of tasks.

It is a challenge to attempt to modify the amount of hours worked in a profession
where time is dictated by others’ schedules. However, re-prioritization of coverage by
the employer may be able to reduce the number of work hours required by the athletic
trainers. Scriber and Alderman (2005) described a “priority coverage plan” that they
implemented in their institution that redistributed the workload among their athletic
trainers so that each was responsible for only one in-season athletic team per season.
Priority coverage was determined and though some non-traditional practices and games
were without medical coverage, it allowed the athletic trainers to decrease their patient
loads and work hours. Furthermore, they also divided off-peak athletic training room
hours amongst the staff which gave each person a few mornings off per week. The
authors reported that this added leisure time allowed the athletic trainers to take care of
personal and family needs more effectively. The communication of role overload to
administration was a key factor in making these changes. McChesney and Peterson
(2005) recommend using documentation and data, such as hours worked, number of
patient contacts per day, and athlete satisfaction ratings to build an argument for
organizational and program change that can be presented to administrators to reinforce
desired changes. Though this example is only from one institution, similar plans applied
in other settings may be quite valuable in reducing role overload and in turn may reduce
stress and burnout.

Priority coverage plans such as the one discussed above added leisure time for

those involved. Many athletic trainers listed a desire for family happiness as one of their

39

highest priorities and yet actual time spent with family was not listed as a high priority
(Scriber & Alderman, 2005). More time spent away from work allows athletic trainers to
partake in family activities, social gatherings, and personal leisure preferences related to
their religion, interests, and hobbies. Reed and Giacobbi (2004) hypothesized that strong
workplace and familial support systems can help mediate stress. Pitney (2006) suggested
that the development of interpersonal relationships with colleagues and the use of
mentorship may also promote positive coping mechanisms and help to decrease stress.
The time to enhance social support through an active life outside of athletic training may
be one of the best modifications athletic trainers can make to their lifestyles. Similarly,
increased time off would allow for athletic trainers to also focus more on good health
behaviors. Multiple authors reported stress management techniques such as daily
exercise, proper nutrition, and adequate sleep as tools athletic trainers can use to decrease
and/or prevent stress burnout (Hendrix et a1., 2000; Scriber & Alderman, 2005; McLaine,
2005). Time is required, though, to partake in these activities. Unfortunately, the .
magnitude of the effect these behaviors have on stress and burnout has not been
established among athletic trainers. No research to date has proven a correlation between
increased leisure time and decreased stress and burnout, but it can be hypothesized from
the results that increased leisure time may negatively correlate with stress and burnout.

Organization and prioritization are also important components of time
management. Organized individuals may feel more in control of their situations than
those who are disorganized and fi'ustrated. Therefore, prioritizing activities and tasks are
vital to effectively managing the little time available to complete them (Scriber &

Alderman, 2005). Goal setting can help athletic trainers create and control portions of

40

their environments, which may help to alleviate or prevent stress (McChesney &
Peterson, 2005). Through assessing and. changing coverage plans, increasing leisure
time, and using time more effectively, athletic trainers can successfirlly mediate role
overload while enhancing social support and health behaviors, all of which can
potentially decrease stress and eliminate or prevent burnout.

Another prevention and intervention strategy employed in managing burnout is
effective communication between colleagues, coaches, and administration. Mensch et a1.
(2005) found that coaches did not understand athletic trainers’ roles and responsibilities,
leading to role ambiguity and role conflict for the athletic trainers. Athletic trainers must
communicate their roles and responsibilities clearly to coaches to alleviate ambiguity and
reduce potential interpersonal conflicts (Brumels & Beach, 2008). More importantly,
communication between athletic administration, coaching staff, and athletic training staff
may also help to reduce role conflict and ambiguity. Opening the lines of communication
in efforts to enhance clarity of performance expectations and role responsibilities will
allow athletic trainers to function more optimally within an athletic program (Mensch et
al.).

Education has also been suggested as an important component that may influence
burnout. Some authors suggest integrating stress management techniques and processes
into undergraduate curriculum programs to make newly certified professionals more
prepared to manage stress (Stilger et a1., 2001). In their research on graduate assistant
athletic trainers’ coping mechanisms, Reed and Giacobbi (2004) suggested that students
and younger professionals’ perceptions of stress are very malleable. Preparing young

athletic trainers with realistic expectations may decrease perceptions of stress and

41

burnout (Stilger et al.). Mentorship can also promote stress management skills as well as
the formulation of a strong social support system (Reed & Giacobbi). Continuing
education opportunities on topics such as stress management and conflict resolution may
also benefit already practicing athletic trainers by helping them maintain low stress levels
and passion for their jobs (Pitney, 2006).

Lastly, though many of the factors that produce stress and burnout are external,
altering internal factors and cognitive appraisals of the situation may also help to
decrease burnout. For instance, cognitive restructuring through having realistic
expectations would allow athletic trainers to more accurately perceive their environments
as well as effectively communicate expectations to others with whom they work.
Promoting self awareness (especially awareness of personal stress triggers) as well as
critical reflection will help in the identification and proper management of the feelings
that arise from different situations and environments (Reed & Giacobbi, 2004). Re-
examination of personal and career desires, goals, and purpose may also help athletic
trainers define what they are seeking through their work (Gieck et a1., 1982).

Early research focused much on the individual’s role in stress and burnout. The
literature is now exploring the roles that organizational and environmental factors play,
which has led to the realization that these external factors are just as much a part of this
phenomenon as the personal variables. More research should be conducted to investigate
whether the stress relief methods discussed here actually result in the desired outcomes.
Ultimately, individuals may do all they can to change their attitudes and behaviors to fit

the situation, but sometimes it is the situation that is in need of change.

42

2.6 CONCLUSION

Gieck et a1. (1982) explained that humans need stress to function. There becomes
a time at which stress becomes too much, and researchers are inching closer to defining
this point and its components. The literature on stress and burnout in athletic training has
expanded in recent years but much is still undiscovered. A subject in one of the studies
stated, “combination of the hours, lack of personal life, coaches always riding you, when
there is an injury a coach thinks you have magical powers and control it, but realistically
you do not at all. Basically, your life is affected by everyone, and most of the time
coaches and athletes do not realize it” (Mazerolle et al., 2008b, p. 517). It is a bleak
perspective. McChesney and Peterson (2005) counter this thought with the idea that
allowing others to have a negative impact on one’s job only disempowers the self.
Perhaps changing the cognitive appraisal of athletic trainers will help to empower those
in the profession to make change for the betterment of their quality of lives and the lives

of those who choose to follow their footsteps.

43

CHAPTER 3
METHODS
3.1 PURPOSE

This section will discuss the methodology used to investigate the time
commitments and leisure choices of graduate assistant athletic trainers and the
relationships between the hours these professionals spent working or at leisure with levels
of perceived stress, emotional exhaustion, depersonalization, and feelings of personal
accomplishment.

3.2 RESEARCH DESIGN

This study was a one time non-experimental survey. The demographic
descriptive variables that were investigated included age, gender, institutional
demographics, and position demographics. Institutional demographics included NCAA
division, NATA district, and year in educational program. Position demographics
described the athletic trainers’ jobs at the time they filled out the survey. This section
asked them about the components of their job descriptions, occupational settings, and
team and patient loads.

The independent variables studied were the number of hours the athletic trainers
spent on their school and work responsibilities and the number of hours spent on leisure
and non-work-related activities. The demographic independent variables considered
were patient load, occupational setting (on- or off-campus), and the NCAA Divisions of
the institutions of their educational enrolhnent. The dependent variables included levels
of perceived stress, emotional exhaustion, depersonalization, and personal

accomplishment.

44

3.3 SAMPLE POPULATION AND PARTICIPANT SELECTION

The studied population was composed of graduate assistant athletic trainers who
were members of the National Athletic Trainers’ Association (NATA). The NATA’s
2007 year end records indicated a total of 2,878 members were a part of the “student-
certified” category, a subdivision formed specifically for certified athletic trainers who
are working on higher degrees. The maximum number of e-mail addresses that a student
member of the NATA can obtain is 1,000, so this study polled 1,000 members of the
“student-certified” category who had not opted out of e-mail surveys. Unfortunately, the
NATA was not able to randomly stratify the sample in order to achieve equal numbers of
participants in various categories such as gender, NCAA Division of institution, etc.
Participation was voluntary and only those who were current graduate assistant athletic
trainers at the time of administration were asked to participate.
3.4 INSTRUMENTATION

The questionnaire was composed of four different sections: demographics, time
allocation, the Perceived Stress Scale (PSS), and the Maslach Burnout Inventory (MBI).

3.4.1 Demographic Survey. The demographic survey (Appendix A) was created
to assess various aspects of the lives of the participating athletic trainers. Along with age
and gender, this section also included questions about the NCAA divisions and NATA
districts of their educational institutions. The delineation of job responsibilities was
broken into five main categories: clinical, research, teaching, administrative, and clinical
instructor/approved clinical instructor. Clinical responsibilities were defined in the
survey as “working directly with athletes/patients”. Research responsibilities included

“assisting with/conducting research, writing grants, analyzing data, assisting with the

45

publication process, etc.” This category did not include capstone projects, theses,
dissertations, and other research projects required for degree completion. Teaching
responsibilities included teaching or assistant teaching in courses. Budgeting, insurance
management, and other specifically assigned administrative duties not connected with
typical clinical patient care defined administrative responsibilities. Lastly, those graduate
assistants who marked the clinical instructor or approved clinical instructor category had
responsibilities of clinically supervising, teaching, and mentoring undergraduate athletic
training students. Participants were able to select multiple job responsibility categories.

The occupational setting (on- or off-campus) of the athletic trainers’ employment
as well as the specific setting in which they worked was also reported here. On-campus
settings included varisty, club, and intramural athletics. Off-campus settings included
middle school, high school, private school (k-12), junior or community college, clinic,
hospital, or another college or university. If their specific setting division was not listed,
the athletic trainers were able to mark other and specify. The participants also indicated
how many athletes and athletic teams for which they were responsible.

3.4.2 Time Allocation Survey. The time allocation survey (Appendix B) allowed
for exploration of the independent variable. This portion was divided into three sections:
professional responsibilities, leisure, and miscellaneous. The professional responsibilities
section included eight items that allowed the athletic trainers to type in how much
average time they spent doing various activities in a specified unit of time. The
obligations listed included coursework, capstone experience/thesis/dissertation work,
clinical athletic training, travel, administrative duties, teaching, studying and homework,

and professional development. The leisure section included nine items such as watching

46

television and/or movies, using electronic devices such as video games and computers,

using a cell phone, exercising and playing sports, hanging out with friends, religion,

recreational non-exercise activities, family events, and attending performances. Lastly,
the miscellaneous section included questions about the average number of hours the
athletic trainers slept each night, if they had an athletic training job during the summer
prior to the current school year, and the average number of alcoholic beverages consumed
per week. The section ended with seven opinion questions to which the respondents
could choose a response on a four-point Likert scale ranging from strongly disagree to
strongly agree.

3.4.2.1 Time Allocation Operational Definitions.

C OURSEWORK - hours spent in class (lecture, lab) or other formal meetings relating to
coursework.

CAPSTONE EXPERIENCE —— time spent on a major project, thesis, or dissertation,
including research, writing/revising/editing, meetings, grant/scholarship
applications, data collection/analysis, etc.

CLINICAL ATHLETIC TRAINING — time at practice, home games, treatments,
rehabilitation, normal patient paperwork, meetings with coaches/administrators.

TRAVELING -- the actual hours spent away from central athletic training room traveling
with athletic teams, including transit time, practice, game, and down time, but not
including time spent sleeping.

ATHLETIC TRAINING ADMINISTRATIVE DUTIES — hours separate from assigned
coverage or patient specific duties, including general budgeting or supply

ordering, insurance, responding to departmental/admin email etc.

47

TEACHING - actual teaching, planning, grading, office hours, student meetings,
responding to student e-mails, etc.

STUDYING or DOING HOMEWORK - reading, studying, writing, researching,
assigned field experiences, etc.

PROFESSIONAL DEVELOPMENT - attending seminars/ conferences or other meetings
that are CEU eligible, reading professional journals (not assigned in classes),
volunteering on a board/committee, and other related activities.

WATCHING TV AND/OR MOVIES — at home, at a fiiend’s, or going to the theater.

ELECTRONIC DEVICES - using computers and video games, including non
school/work related intemet browsing, chatting online, playing computer or video
games, etc.

A TELEPHONE or CELL PHONE - time spent using for non-work/professional calls.

EXERCISIN G OR PLAYING SPORTS — time spent in organized sports or fitness
classes, informal games, workouts, weight lifting, home fitness videos, etc.

HANGING OUT WITH FRIENDS — time spent “hanging out” at your place or theirs
doing non-school/work activities and going out.

RELIGION OR SPIRITUAL BELIEFS - attending church/synagogue/mosque/etc.,
studying religious texts, choral or choir group participation, youth/religious group
involvement.

RECREATIONAL NON-EXERCISE ACTIVITIES - shopping, attending places of
entertainment such as zoos, museums, travel, reading for leisure, arts/crafts, and

other hobbies, etc.

48

PLANNED FAMILY EVENTS - formally arranged meetings with family for events
such as parties, celebrations, etc.

ATTENDING PERFORMANCES AND/OR OTHER EVENTS - including anything in
which the participants were part of an audience, such as sporting events, concerts,
performances in theater or dance, etc.

3.4.3 Perceived Stress Scale. The Perceived Stress Scale (PSS) (Appendix C)
was used to assess perceived stress among graduate assistant athletic trainers. The PSS
was specifically designed to measure how respondents cognitively appraise their stress
(Cohen, Kamarck, & Mermelstein, 1983). The instrument has been used since the mid-
19805 to assess perceived stress levels in a variety of populations including smokers,
college students, and athletic trainers (Cohen et al,, 1983, Hendrix et a1., 2000). The PSS
measured perceived, non-specific stress that the respondents experienced over the past
month of their lives, delineating how uncontrollable, unpredictable, and overloaded they
felt (Cohen & Williamson, 1988). Participants responded to 14 items using a Likert scale
ranging from “never” to “very often”. Sample questions included, “in the last month,
how often have you been upset because of something that happened unexpectedly?” and
“in the last month, how often have you felt on top of things?” The Likert scale was then
assigned a point value, “0” corresponding to “never” and “4” corresponding to “very
often”. Positively worded items were reversed (0:4, l=3, etc.) and then the numbers
correlating to each of the responses were summed. The scores can range from “O” or “no
stress” to “56” or “extreme stress”. Scores were relative to the population being studied.

Psychometric Properties of PSS. Research has shown the PSS to be both valid

and reliable (Cohen, Kamarck, & Mermelstein, 1983; Cohen & Williamson, 1988).

49

Construct validity and factor analyses have been established. in studies investigating the
samples of college students, participants in a smoking-cessation program, and in a sample
of 2,387 American citizens (Cohen et al., 1983; Cohen & Williamson, 1988). The PSS
has been shown to better predict health outcomes than stressful life-event scores do. For
instance, correlations of stress measures with depressive symptomatology were moderate
to high (r=.7 6, p<.001) as compared to the number of life events (F. 18) or impact of life
events (r=.29) in a sample of college students (Cohen et a1., 1983). Correlations of stress
measures with physical symptomatology were moderate with the PSS (r=.52 p<.001) as
compared to the number of life events (r=.3 l) or impact of life events (r=.23) in this
sample (Cohen et a1., 1983). Similar results have been found in other samples (Cohen et
a1., 1983), illustrating that the PSS better predicted psychological and physical problems
than other life-event scales.

The PSS has also shown an association between self-reported physical illness and
increased stress (Cohen & Williamson, 1988). Perceived stress was positively correlated
with reported symptoms of potentially serious illness (r==.27, p<.0001), non-serious
symptoms (r=.3], p<.0001), and flu symptoms (r=.32, p<.0001) (Cohen & Williamson,
1988). F urtherrnore, PSS results have been shown to independently measure stress and
not psychological distress (Cohen & Williamson, 1988). Lastly, the PSS was moderately
correlated with life dissatisfaction (r=.47, p<.0001) (Cohen & Willaimson, 1988). The
PSS’s predictive validity declines rapidly after four weeks due to the transient and ever
changing nature of stressors and the levels of stress associated with them (Cohen et a1.,
1983; Cohen et a1., 1988). Reliability has also been established, ranging from coefficient

alphas of .75 (Cohen & Williamson, 1988) to .85 (Cohen et al,, 1983).

50

 

3.4.4 Maslach Burnout Inventory. The human services version of the Maslach
Burnout Inventory (MBI) (Appendix D) was used to assess the cognitive appraisal of
burnout. The MBI was first designed over 50 years ago to measure burnout in people
working in human services professions (Maslach, Jackson, & Leiter, 1996). Since then,
the survey has evolved and has become the leading measurement tool for burnout. The
questionnaire is designed to measure three constructs: emotional exhaustion,
depersonalization, and feelings of personal accomplishment. The first sub-scale,
emotional exhaustion (EE), delineates how emotionally overwhelmed respondents felt by
their work. The second sub-scale, depersonalization (DP), is a type of coping mechanism
shown through lack of caring about those with whom respondents work. The last
subscale, personal accomplishment (PA), is marked by how well respondents believed
they were achieving in their jobs (Maslach et a1., 1996). The MBI was presented to the
subjects as the “human services survey” in order to prevent the effects of personal
experience and the topic of burnout from becoming a factor in the participants’ responses.
It was explained as recommended by the MBI Manual (1996) as a “survey of job related
attitudes.”

The MBI-HSS had a total of 22 items: nine items for EE, five for DP, and eight
for PA. Participants chose a response to each question on a 6 point frequency of
occurrence scale. Participants believed they “never” experienced the item marked “”,0
while those who felt they experienced this “every day” marked 6. The scores for each
construct were then calculated separately by adding the numbers of the corresponding
answer of each question in that construct; the MBI is not designed to result in a total

burnout score. The categorical results of the data were compared as a determination of

51

 

the relative level of burnout. For medical professions, high burnout was classified as EE
scores equal to or above 27, DP equal to or above 10, and PA equal to or below 33.
Moderate burnout was classified by moderate values of all constructs, and low burnout
was signified by EE values equal to or below 18, DP equal to or below 5, and PA equal to
or above 40 (Maslach et a1., 1996).

Psychometric Properties of the MBI. Research has shown the MBI to be both
reliable and valid (Lee & Ashforth, 1996; Maslach et a1., 1996; Maslach & Jackson,
1981). Convergent validity was found through correlations with behavior ratings of close
friends or family of individuals who took the MBI. Coworkers who rated an individual
as being highly emotionally drained rated higher on EE (r=.41, p<.01) and DP (r=.57,
p<.0001) (Maslach & Jackson, 1991). Individuals who were also rated by their
coworkers as being physically fatigued scored higher on EE (r=.42, p<.01) and DP
(r=.50, p<.01). Convergent validity was also determined by a comparison of the MBI
scores to the presence of certain job characteristics and to measures of various outcomes
that were hypothesized to be related to burnout (Maslach et a1., 1996). Physicians who
spent most of their time in contact with patients rated higher on EE (r=.30, p<.03) than
those who spent more time on administrative work (r=-.36, p<.02) (Maslach & Jackson,
1991)

Discriminant validity has distinguished the MBI from other psychological
constructs such as job satisfaction and depression (Maslach et al,, 1996). Maslach and
Jackson (1991) found low to moderate correlations between job satisfaction and EE (r=-
.23, p<.05), DP (r=-.22, p<.05), and PA (r=.l7, p<.06). However, less than 6% of the

variance in job satisfaction was matched with any one of these burnout constructs,

52

signifying an undeniable difference between job satisfaction and burnout. Moderate to
high reliability has also been established for each construct of the MBI. Maslach et al.
(1996) reported chronbach alphas of 0.90 for BB, 0.79 for DP, and 0.71 for PA.

3.5 DATA COLLECTION AND MANAGEMENT

After obtaining Institutional Review Board approval, SurveyMonkey.com, a
website that allows researchers to post and distribute surveys via the intemet, was utilized
to collect responses. The link to the survey was dispersed by the NATA via electronic
mail (e-mail) to the 1,000 participants in the “student-certified” category that were
randomly selected from the NATA membership database. The e-mail correspondence
that was sent to participants also included an explanation of the study (Appendix E).
Those who completed and returned the survey implied consent to participate.

The questionnaire was a one-time, self-administered survey completed on a
computer with intemet access. It was composed of 88 total items divided into four
sections and took approximately 20 minutes to complete. The order of the sections was
demographic, time allocation, PSS, and MBI. Participants were allowed to skip questions
and could withdraw at any time. The questionnaire was available from October 15, 2009
at 11:00 AM to November 15, 2009 at 11:00 AM. Because of the nature of
SurveyMonkey.com, the instrument was available 24-hours per day for the one month
testing period. An e-mail reminder was sent on November 2, 2009 to encourage
participation.

SurveyMonkey.com stored the data, until collection was completed when it was
then downloaded and analyzed. The data were password protected and only accessed by

the primary researcher and the three members of the research committee. All responses

53

remained anonymous, as no identifying information was asked, and no IP addresses were
recorded by SurveyMonkey.com. Any printed data were placed in a locked file cabinet
in the primary investigator’s office.
3.6 DATA ANALYSIS
Demographic information and scores from the MBI and PSS were summarized
using descriptive data. All data collected were nominal data. There was no total sum of
the scores that resulted in an overall “burnout” score for the MBI. Therefore, descriptive
statistics for emotional exhaustion, depersonalization, and feelings of personal
accomplishment were calculated. The statistical significance level was set at p<.05. Data
were analyzed using the Statistical Package for the Social Sciences (SPSS) 18.0 software.
The following statistical analyses were used with the hypotheses:
H1: An independent t-test was performed to determine the differences between the time
committed to work responsibilities and the time committed to leisure activities.
H2-H4: Separate Pearson r correlations were used to determine the relationships
between the number of hours dedicated to work responsibilities and the three constructs
of burnout (emotional exhaustion (H2), depersonalization (H3), and personal
accomplishment (H4)).
H5-H7: Separate Pearson r correlations were used to determine the relationships
between the number of hours dedicated to leisure activities and the three constructs of
burnout (emotional exhaustion (H5), depersonalization (H6), and personal

accomplishment (H7)).

54

H8-H9: Pearson r correlations were conducted to determine the relationships between
perceived stress and the number of hours spent on work responsibilities (H8) and leisure
activities (H9).

H10-H11: Separate Pearson r correlations were conducted to determine the relationship
between the number of athletes for which the athletic trainers are responsible and their
levels of emotional exhaustion (H10) and depersonalization (H11).

H12-13: Separate one-way analyses of variance were conducted to determine the
differences between the NCAA Divisions of the athletic trainers’ educational institutions
and the number of hours spent on work responsibilities (H12) and leisure activities (1-113).
H14: One-way analysis of variance was conducted to determine the difference between
perceived stress and the NCAA Divisions of the athletic trainers’ current institutions.
H15: One-way analysis of variance was conducted to determine the difference between
the number of hours spent on work responsibilities and occupational setting (on- or off-
campus).

H16: One-way analysis of variance was conducted to determine the difference between
the three constructs of burnout and occupational setting.

H17: One-way analysis of variance was conducted to determine the difference between

perceived stress and occupational setting.

55

CHAPTER 4
RESULTS

4.1 OVERVIEW

This research was conducted to investigate graduate assistant athletic trainers’
cognitive appraisals of their work environments and to delineate their levels of perceived
stress and burnout. The following chapter will describe the demographics of the sample
and depict the relationships between work, leisure, perceived stress, and burnout.
4.2 DEMOGRAPHIC DATA

4.2.1 General Demographics. Three-hundred and four participants began the
survey; however 99 of these were not current graduate assistant athletic trainers and
therefore did not continue with the survey. Twenty-eight of the 205 remaining were
excluded because they did not complete the survey past the demographic section. A total
of 177 participants completed the survey for a response rate of 17.7% (because the
participants were allowed to skip questions, the total sample sizes may vary from item to
item). More female graduate assistant athletic trainers (117/176 [66.5%]) participated
than males (59/ 176 [33.5%]). The majority of the participants were Caucasian (155/ 176
[88.1%]), followed by Asian (including Hawaiian and Pacific Islander) (10/176 [5.7%]),
and Hispanic/Latin American (5/176 [2.8%]). The average age of the participants was
23.7 $2.02 years. Eighty-percent (142/ l 77) of participants graduated with their
undergraduate degree in 2008 or 2009. Almost 12% (21/1 77) of participants graduated in
2006 or 2007; the remaining 8% (14/177) graduated between 2001 and 2005.
Participants had been certified for an average of 12.51 $12.14 months at the time of

survey administration.

56

An overwhelming majority (126/175 [72%]) of participants were working toward
their degrees at NCAA Division 1 institutions in a wide variety of NATA districts (see
Tables 4-1 and 4-2). Most of the respondents were first year graduate students (103/175
[58.9%]), although almost 38% (66/175) were in their second year of graduate school and
3.4% (6/175) were in their third year. Almost the all participants expected to complete

their degrees in 2010 (79/175 [45.1%]) or 2011 (86/175 [49.1%]).

Table 4-1

Percentage of NC AA Divisions Represented by Graduate Assistant Athletic Trainers

 

 

 

NCAA Number of Percent
Division Participants
1 126 72.0
11 29 16.6
111 16 9. 1
NAIA 4 2.3
Total 175 100

 

57

Table 4-2

Percentage of NA TA Districts Represented by Graduate Assistant Athletic Trainers

 

 

 

District Number of Percent
Participants
District One 4 2.3
District Two 18 10.2
District Three 31 17.5
District Four 28 15.8
District Five 24 13.6
District Six 14 7.9
District Seven 1 1 6.2
District Eight 10 5.6
District Nine 29 16.4
District Ten 8 4.5
Total 177 100

 

4.2.2 Position Demographics. Seventy-four percent (13 1/1 77) of respondents
reported being assigned to duties on-campus. An overwhelming majority in this group
worked solely with varsity athletics (118/131 [90.1%]) (see Table 4-3). The average
number of teams assigned to on-campus participants was 3.08 3522 (see Table 4—4). The
average number of patients/athletes for this group ranged from zero to 250, with the mean

at 68.69 i50.90.

58

Table 4-3

Percentage of On-Campus Settings for Graduate Assistant Athletic Trainers

 

 

 

On-Campus Assignment Number of On- Percent
Campus Participants
Varsity athletics only 118 90.1
Club sports only 2 1.5
Other 1 0.8
Varsity and other 6 4.6
Club and intramural sports 2 1.5
Intramural and other 1 0.8
Club, intramural, and other 1 0.8
Total 131 100.0

 

59

Table 4-4

Percentage of Teams Assigned to On-Campus Graduate Assistant Athletic Trainers

 

Number Number of On-Campus Percent

 

 

of Teams Participants

0 3 2.3

1 44 33.8
2 35 26.9
3 20 15.4
4 to 6 17 13.1
7 to 9 7 5.4

10 and 4 3.1

above

Total 130 100

 

Of the remaining 26% (46/ 1 77) of participants assigned off-campus,
approximately half (22/46 [47.8%]) worked solely in the high school setting (see Table
5). In addition, the majority of the off-campus participants only worked at one institution
(37/46 [80.4%]), although 19.6% (9/46) had responsibilities at two or more institutions.
The average number of teams assigned to off-campus graduate assistant athletic trainers
was 16.26 3:12.14. The average number of patients/athletes for the off-campus group

ranged from 25 to 900, with the mean at 269.05 i221.39 (see Table 6).

60

Table 4-5

Percentage of Ofl-C ampus Settings for Graduate Assistant Athletic Trainers

 

 

 

Off-Campus Assignment Number of Off-Campus Percent
Participants

High School only 22 47.8
Middle School only 1 2.2
Private School (K-l2) only 5 10.9
Community College only 2 4.3
Another college/university different 7 15.2
from degree granting institution

High School and Middle School 3 6.5
High School and Clinic 4 8.7
Another College and Clinic 1 2.2
High School, Middle School, and Clinic 1 2.2
Total 46 100.0

 

61

Table 4-6

Percentage of Teams Assigned to Ofl-Campus Graduate Assistant Athletic Trainers

 

 

 

Number of Number of Off- Percent
Teams Campus Participants
1-5 5 10.9
6-10 3 6.5
11-15 15 32.6
16-20 13 28.3
20-25 8 17.4
26 and above 2 4.3
Total 46 100

 

4.3 TIME ALLOCATION DATA

The time allocation portion of the survey instrument was constructed to delineate
the amount of time graduate assistant athletic trainers spent on work responsibilities and
leisure activities. A summary of the total amount of time the participants committed to

work and leisure activities can be found in Table 4-7.

Table 4-7

Means, Standard Deviations, and Ranges for Work and Leisure Time

 

 

Total Time Mean Standard Min Max
JHrs/Wk) Deviation

Work Responsibilities 79.20 27.62 30 212

Leisure Activities 53.39 29.34 0 219

 

62

4.3.1 Work Responsibilities. Overall, the graduate assistant athletic trainers
spent a mean of 79.20 $27.62 hours per week on work responsibilities (see Table 4-7).
Clinical athletic training responsibilities (defined as the time at practice, home games,
treatments, rehabilitation, normal patient paperwork, meetings with
coaches/administrators) consumed the majority of work time (37.99 i16.58 hours/week),
followed by traveling (12.59 3:14.46), coursework (11.15 i632), and homework (9.05
$6.55) (see Table 4-8). Participants did not spend as much time on capstone project

work, teaching, administration, or professional development.

Table 4-8

Means, Standard Deviations, and Ranges for Work Time Categories (n= 1 7 7)

 

 

Work Time Mean Standard Min Max
Category (Hrs/Wk) Deviation

Coursework 1 1.15 6.32 0 40
Capstone 3.63 4.72 0 25
Clinical AT 37.99 16.58 0 90
Traveling 12.59 14.46 0 85
Admin Duties 2.36 3.40 0 24
Teaching 1.94 4.47 O 30
Homework 9.05 6.55 0 50
Professional 0.72 0.85 0 5
Development

 

4.3.2 Leisure Activities. The participants spent 53.39 $29.34 hours per week on

leisure activities (see Table 4-9). Electronic devices (defined as time spent using

63

computers and video games, including non-school/work related intemet browsing,
chatting online, playing computer or video games, etc.) composed the majority of these
hours (17.40 £14.46), followed by watching television (12.94 3:10.43) and non-work or
school-related telephone conversations (9.37 i7 .09). These three categories alone

constituted 74.4% of the hours per week spent at leisure (39.71 hours of the mean 53.39).

Table 4-9

Means, Standard Deviations, and Ranges for Leisure Time Categories (n=1 7 7)

 

 

Leisure Time Mean Standard Min Max
Category (Hrs/Wk) Deviation

Television 12.94 10.43 0 56
Electronic Devices 17.40 14.46 0 84
Telephone 9.37 7.09 0 42
Exercise 3.84 3.23 0 16
Friends 7.06 7.34 0 18
Religion 0.82 1.32 0 7
Non-physical l .9 l 2.32 0 15
Recreation
Planned Family 0.50 0.80 0 5
Events
Spectator Events 0.86 1.23 0 9

 

4.3.3. Comparisons between Occupational Settings. There was a significant

difference found in the number of hours devoted to leisure activities between on- and off-

campus graduate assistant athletic trainers “0.175): -3.11 p=.002] (see Table 4-10). On-

64

campus participants spent an average of 49.42 hours at leisure, whereas off-campus

participants had 64.70 hours of leisure per week. There was also a significant difference
in the number of hours devoted to work responsibilities between the groups “(1,128): 3.28

p=.000] (see Hypothesis 15).

Table 4-10

Independent T- Test Analyses of Total Leisure and Work Hours by Occupational Setting

 

95% Confidence Interval

 

 

Sig. Mean of the Difference
t df (2-tailed) Difference Lower Upper
Total Leisure -3.11 175 .002* -15.28 -24.97 -5.59
Hours
Total Work 3.28 128 .000* 15.06 7.73 22.38
Hours

 

*p__<_0.()5; test assumed variances were equal.

Significance between occupational settings was also found in two of the work
responsibility categories and one leisure category (see Tables 4-11 and 4-12). First, on-
campus participants devoted significantly more time to clinical athletic training

responsibilities than their off-campus counterparts (40.83 vs. 31.17 hours per week
respectively) [T(1,1(,0_07)=4.57, p=.000]. The on-campus group also had significantly
more travel hours (14.88 vs. 6.22) [T(1.154,56)=4.83, p=.000]. The only leisure activity

category to reveal statistical significance was the television category. Off-campus
respondents watched significantly more television than on-campus respondents (17.33 vs.

11.35) [T(1.171)=-3.43, p=.001]. No other categories showed significant differences

between the two groups.

65

Table 4-11
Independent T -Test Analyses of Work Hour Categories by Occupational Setting

 

 

 

t df Sig. Mean 95% Confidence
(2- Difference Interval of the
tailed) Difference
Lower Upper
Coursework -1.73 175 .079 -1.86 -3.98 .13
Capstone -1.70 64.09 .094 -l.55 -3.38 .27
Clinical
Athletic 4.57 160.07 .000* 9.21 5.23 13.19
Training
Traveling 4.83 154.56 .000* 8.67 5.12 12.21
Admin Duties 1.82 164.66 .071 .80 -.07 1.68
Teaching .81 174 .418 .62 -.89 2.13
Homework -. l 7 175 .862 -.20 -2.42 2.03
Professional -1.61 62.14 .113 -.27 -.61 .07
Development

 

$50.05,“ test assumed variances were equal.

66

Table 4-12

Independent T - T est Analyses ofLeisure Hour Categories by Occupational Setting

 

 

 

t df Sig. Mean 95% Confidence
(2-tailed) Difference Interval of the
Difference
Lower Upper
Television -3.43 171 .001 * -5.97 -9.41 -2.537
Electronic -.61 171 .540 -1.53 -6.45 3.39
Devices
Telephone -1.76 56.87 .084 -2.68 -5.72 .37
Exercise -1.08 171 .284 -.60 -1.69 .50
Friends -1.43 55.87 .159 -2.29 -5.51 .93
Religion 1.14 170 .256 .26 -.19 .71
Non-Physical -1.79 170 .076 -.68 -l .44 .07
Recreation
Planned -.80 171 .428 -.11 -.38 .16
Family Events
Spectator -.18 171 .860 -.04 -.46 .38
Events

 

*pg 0. 05; test assumed variances were equal.

4.3.4 Miscellaneous. The participants in this study slept an average of 6.35 $1.07

hours per night. Participants reported consuming an average of 5.20 $7.79 alcoholic

beverages per week (range 0-60). Eighty percent (139/ 1 72) of respondents believed they

would still be working as a certified athletic trainer in ten years.

Table 4-13 shows the percentage of participants’ responses to the seven

miscellaneous opinion questions. In general, respondents felt appreciated by their

coaches (80.3% agreed or strongly agreed), patients/athletes (91.3% agreed or strongly

67

agreed), and colleagues (86.6% agreed or strongly agreed). Eighty-nine percent agreed
or strongly agreed that their jobs were worthwhile and 84.8% agreed or strongly agreed
that others recognized the importance of their work. Sixty-seven percent disagreed or
strongly disagreed that they got enough time for themselves, and 68% agreed or strongly
agreed that their jobs frequently stressed them. Ahnost sixty-percent agreed or strongly

agreed that they spent too much of their time working.

68

Table 4-13

Miscellaneous Opinion Questions (n =1 72)

 

 

Question Strongly Disagree Agree Strongly Mean
Disagree Agree
(1) (2) (3) L4)

Most of the time, I feel
appreciated by the coaches with 1.7% 18.0% 54.7% 25.6% 3.04
whom I work.
My job frequently stresses me. 3.5% 28.5% 43.0% 25.0% 2.90
Most of the time, I feel 0.0% 8.7% 59.9% 31.4% 3.23
appreciated by the
patients/athletes with whom I
work.
Most of the time, I feel 0.6% 12.8% 61.0% 25.6% 3.12
appreciated by my colleagues and
coworkers.
I spend too much of my time 3.5% 37.2% 41.3% 18.0% 2.74
working.
Most of the time, I feel that doing 1.2% 9.9% 59.1% 29.8% 3.18
this job is worthwhile.
I feel I get enough time for 16.4% 50.9% 26.9% 5.8% 2.22
myself.
Most of the time, I feel that others 1.2% 14.0% 64.5% 20.3% 3.04

recognize the importance of my
job.

 

4.4 PSS and MBI Data

The means, standard deviations, and ranges for the perceived stress scale and each

construct of the Maslach Burnout Inventory can be found in Table 4-14.

69

Table 4-14

Means, Standard Deviations, and Ranges for PSS and MBI Data

 

 

Mean Standard Min Max
Deviation

PSS 24.55 7.07 10 44
MBI Emotional 23.10 10.44 1 46
Exhaustion

MBI 7.44 5.29 0 24
Depersonalization

MBI Personal 37.93 5.98 18 48

Accomplishment

 

*Note: n=167 for PSS values. For all MBI values, n=l64.

4.5 Assessment of Hypotheses
H1: Graduate assistant athletic trainers will contribute more time to work
responsibilities than to leisure activities. This hypothesis was supported as graduate

assistant athletic trainers did contribute significantly more time to work responsibilities

than to leisure activities [t(1.176):8-1 1,p=.000] (see Table 4-15).

Table 4-15

Dependent T - Test Analysis of Total Work Hours Versus Total Leisure Hours

 

 

 

t df Sig. Mean 95% Confidence Interval
(2-tailed) Difference of the Difference
Lower Upper
Total Hours 8.11 176 .000* 25.81 19.53 32.09

 

*p50. 05

7O

H2: There will be a positive relationship between the number of hours dedicated to work
responsibilities and emotional exhaustion. This hypothesis was supported as results
revealed a significant, positive relationship between work hours and emotional
exhaustion (r=. 161 , p=.039).

H3: There will be a positive relationship between work hours and depersonalization.
This hypothesis was not supported as results revealed a positive but non-significant
relationship between work hours and depersonalization (r=.102, p=.194).

H4: There will be a negative relationship between work hours and personal
accomplishment. This hypothesis was not supported as results revealed a positive but
non-significant relationship between work hours and personal accomplishment (r=. 120,
p=. 125).

H5: There will be a negative relationship between the number of hours dedicated to
leisure activities and emotional exhaustion. This hypothesis was supported as results
revealed a significant, negative relationship between leisure hours and emotional
exhaustion (r= -.233, p=.003).

H6: There will be a negative relationship between the number of hours dedicated to
leisure activities and depersonalization. This hypothesis was not supported as results
revealed a non-significant negative correlation between depersonalization and leisure
hours (r= -.102,p=.194).

H7: There will be a positive relationship between the number of hours dedicated to
leisure activities and personal accomplishment. This hypothesis was not supported as
results revealed that personal accomplishment had a non-significant relationship with

leisure hours (r=.081, p=.305).

71

H8: There will be a positive relationship between the number of hours dedicated to work
responsibilities and perceived stress as measured by the perceived stress scale (PSS)
among graduate assistant athletic trainers. This hypothesis was not supported as results
revealed a non-significant relationship between work hours and perceived stress (F068,
p=.3 83).

H9: There will be a negative relationship between the number of hours dedicated to
leisure activities and perceived stress as measured by the PSS among graduate assistant
athletic trainers. This hypothesis was not supported as results revealed a non-significant
negative relationship between leisure hours and perceived stress (r= -. 133, p=.085).

H10: There will be a positive relationship between the number of athletes for which the
athletic trainers are responsible and their levels of emotional exhaustion. Due to data
organization, results for this hypothesis were split by occupational setting (on- and off-
campus groups). The hypothesis was not supported in on-campus participants, as results
revealed a non-significant negative relationship for emotional exhaustion (r= -.O76,
p=.415). The hypothesis was supported in off-campus participants, as results revealed a
significant positive relationship for emotional exhaustion (r=.372, p=.018).

H11: There will be a positive relationship between the number of athletes for which the
athletic trainers are responsible and their levels of depersonalization. Again, results for
this hypothesis were split by occupational setting. The hypothesis was not supported in
on-campus participants, as no relationship was found for depersonalization (r=.000,
p=.994). The hypothesis was supported for off-campus participants, as results revealed a

significant positive relationship for depersonalization (r=.330, p=.03 8).

72

H12: Graduate assistant athletic trainers at NCAA Division I institutions will spend
significantly more time on work responsibilities than those at Division II and III
institutions. This hypothesis was not supported as results of a univariate analysis of

variance revealed no significant difference between NCAA Divisions and hours spent on

work responsibilities [F(1_1(,g)=2.33, p=.101] (see Tables 4-16 and 4-17).

Table 4-16

Descriptives for Work Hours by NCAA Division

 

N Mean Std. 95% Confidence Interval For
Deviation Mean
Lower Bound Upper Bound

 

 

 

 

Division I 126 81.95 28.00 77.01 86.88
Division II 29 73.78 22.89 65.08 82.49
Division III 16 68.58 34.01 50.46 86.70

Total 171 79.31 28.04 75.08 83.54
Table 4-17

Univariate Analysis of Variancefor Work Hours and NCAA Division

 

 

Sum df Mean Square F p
of Squares
Between Groups 3603.97 2 1801.99 2.33 .101
Within Groups 130040.38 168 774.05

 

*p_<_0. 05

73

H13: Graduate assistant athletic trainers at NCAA Division I institutions will have
significantly higher levels of emotional exhaustion and depersonalization and lower
levels of personal accomplishment than the athletic trainers at NCAA Division II or [11
institutions. Hypothesis 13 was not supported as results of a univariate analysis of

variance revealed no significant difference between NCAA Division and emotional

exhaustion [F(1,155)=1.86, p=. 159], depersonalization [F(1‘]55)=1.34, p=.266], or personal

accomplishment [F(1‘]55)=.380,p:.685] (see Tables 4-18 through 4-23).

Table 4-18

Descriptives/or Emotional Exhaustion by NCAA Division

 

N Mean Std. 95% Confidence Interval For
Deviation Mean
Lower Bound Upper Bound

 

 

 

 

Division I 120 24.07 10.49 22.17 25.96
Division II 27 19.78 10.37 15.68 23.88
Division III 1 l 23.73 10.34 16.78 30.67
Total 158 23.31 10.52 21.66 24.96
Table 4-19

Univariate Analysis of Variance for Emotional Exhaustion and NCAA Division

 

 

Sum df Mean Square F p
of Squares
Between Groups 407.49 2 203.74 1.86 .159
Within Groups 16960.32 155 109.42

 

74

Table 4-20

Descriptives for Depersonalization by NCAA Division

 

N Mean Std. 95% Confidence Interval For
Deviation Mean

 

Lower Bound Upper Bound

 

 

 

Division I 120 7.80 5.38 6.83 8.77
Division II 27 6.04 4.49 4.26 7.81
Division III 1 1 8.27 6.21 4.10 12.45

Total 158 7.53 5.31 6.70 8.37
Table 4-21

Univariate Analysis of Variance for Depersonalization and NCAA Division

 

 

Sum df Mean Square F p
of Squares
Between Groups 74.50 2 37.50 1.34 .266
Within Groups 4354.35 155 38.09

 

*p50. 05

75

Table 4-22

Descriptives for Personal Accomplishment by NCAA Division

 

N Mean Std. 95% Confidence Interval For
Deviation Mean

 

Lower Bound Upper Bound

 

 

 

Division I 120 37.77 5.95 36.69 38.84
Division II 27 38.85 6.56 36.26 41.45
Division III 11 37.55 5.80 33.65 41.44

Total 158 37.94 6.02 36.99 38.88
Table 4-23

Univariate Analysis of Variance for Personal Accomplishment and NCAA Division

 

 

Sum df Mean Square F p
of Squares
Between Groups 27.78 2 13.88 .38 .685
Within Groups 5669.60 155 36.58

 

*p _<_ 0. 05

76

H14: Graduate assistant athletic trainers at NCAA Division I institutions will have
significantly higher levels of perceived stress (as measured by the PSS) than the athletic
trainers at NCAA Division II or [11 institutions. This hypothesis was not supported as

results of a univariate analysis of variance revealed no significant difference between

Divisions for levels of perceived stress [F(1,160)=.20, p=.818] (see Tables 4-24 and 4-25).

Table 4-24

Descriptives for Perceived Stress by NCAA Division

 

N Mean Std. 95% Confidence Interval For
Deviation Mean
Lower Bound Upper Bound

 

 

 

Division I 123 24.67 6.89 23.44 25.90
Division II 28 23.93 6.44 21.43 26.43
Division III 12 25.33 9.30 19.43 31.24

Total 163 24.60 6.98 23.52 25.67
Table 4-25

Univariate Analysis of Variance for Perceived Stress and NCAA Division

 

 

Sum df Mean Square F p
of Squares
Between Groups 19.76 2 9.88 .20 .818
Within Groups 7865.52 160 49.16

 

*p g 0. 05

77

H15: Graduate assistant athletic trainers working in on—campus positions will spend
significantly more time on work responsibilities than those in off-campus positions. This

hypothesis was supported as results of a univariate analysis of variance revealed a
significant difference between occupational setting [F (1,175)=10.67, p=.001] (see Tables

4-26 and 4-27). Specifically, on-campus graduate assistant athletic trainers spent more

time on work responsibilities (83.1 1 $29.33) than those off-campus (68.05 $18.13).

Table 4-26

Descriptives for Work Hours by Occupational Setting

 

N Mean Std. 95% Confidence Interval For
Deviation Mean

Lower Bound Upper Bound

 

 

 

 

On-Campus 131 83.11 29.33 78.04 88.18

Off-Campus 46 68.05 18.13 62.67 73.44

Total 177 79.20 27.62 75.10 83.30
Table 4-27

Univariate Analysis of Variance for Work Hours and Occupational Setting

 

 

Sum df Mean F p
of Squares Square
Between Groups 7719.78 1 7719.78 10.67 .001*
Within Groups 126582.14 175 723.33

 

*p 5 0. 05

78

H16: Graduate assistant athletic trainers working in on-campus positions will have
significantly higher levels of emotional exhaustion and depersonalization and lower
levels of personal accomplishment than those working in ofl-campus positions. This
hypothesis was partially supported as results of a univariate analysis of variance revealed
a significant difference between occupational settings and emotional exhaustion
[F(19162)=4.22, p=.041] (see Tables 4—28 and 4-29). Specifically, on—campus graduate
assistant athletic trainers had higher levels of emotional exhaustion (24.11 $10.26) than
their off—campus counterparts (20.36 $10.55). However, no significant differences were

found between occupational settings and depersonalization [F(1,162)=1.40, p=.240] or

personal accomplishment [F(1,163)=.28 p=.598] (see Tables 4-30 through 4-33).

Table 4-28

Descriptives for Emotional Exhaustion by Occupational Setting

 

N Mean Std. 95% Confidence Interval For
Deviation Mean
Lower Bound Upper Bound

 

 

 

On-Campus 120 24.11 10.26 22.25 25.96
Off-Campus 44 20.36 10.55 17.16 23.57
Total 164 23.10 10.44 21.49 24.71

 

79

Table 4-29

Univariate Analysis of Variance for Emotional Exhaustion and Occupational Setting

 

 

 

Sum df Mean Square F p
of Squares
Between Groups 451.46 1 451.46 4.22 .041 *
Within Groups 17315.77 162 106.89
*p_<_0.05 F
Table 4-30 1
a

Descriptives for Depersonalization by Occupational Setting

 

N Mean Std. 95% Confidence Interval For
Deviation Mean
Lower Bound Upper Bound

 

 

 

 

On-Campus 120 7.73 5.41 6.75 8.71

Off-Campus 44 6.64 4.90 5.15 8.12

Total 164 7.44 5.29 6.62 8.25
Table 4-31

Univariate Analysis of Variance for Depersonalization and Occupational Setting

 

 

Sum df Mean Square F p
of Squares
Between Groups 38.74 1 38.74 1.39 .240
Within Groups 4517.65 162 27.89

 

*p_<_0. 05

80

Table 4-32

Descriptives for Personal Accomplishment by Occupational Setting

 

N Mean Std. 95% Confidence Interval For
Deviation Mean
Lower Bound Upper Bound

 

 

 

On-Campus 120 37.78 6.21 36.66 38.91

Off-Campus 44 38.34 5.34 36.72 39.96

Total 164 37.93 5.98 37.01 38.86
Table 4-33

Univariate Analysis of Variance for Personal Accomplishment and Occupational Setting

 

 

Sum df Mean Square F p
of Squares
Between Groups 10.01 1 10.01 .28 .598
Within Groups 5820.25 162 35.93

 

*pg 0. 05

81

H17: Graduate assistant athletic trainers working in on-campus positions will have
significantly higher levels of perceived stress than those working in off-campus positions.
This hypothesis was not supported as results of a univariate analysis of variance revealed

no significant difference between occupational settings for levels of perceived stress

[F(1,1(,7)=3.43, p=.069] (see Tables 4-34 and 4-35).

Table 4-34

Descriptivesfor Perceived Stress by Occupational Setting

 

N Mean Std. 95% Confidence Interval For
Deviation Mean 1
Lower Bound Upper Bound

 

 

 

 

On-Campus 124 25.15 7.12 23.88 26.41

Off—Campus 45 22.91 6.75 20.88 24.94

Total 169 24.55 7.07 23.48 25.62
Table 4-35

Univariate Analysis of Variancefor Perceived Stress and Occupational Setting

 

 

Sum df Mean Square F p
of Squares
Between Groups 164.79 1 164.79 3.34 .069
Within Groups 8233.03 167 49.30

 

*ng. 05

82

CHAPTER 5
DISCUSSION

5.1 OVERVIEW

This study found that work and leisure hours correlated with only one construct of
burnout. Specifically, emotional exhaustion was positively correlated with work hours
and negatively correlated with leisure hours among graduate assistant athletic trainers.
Results also showed that NCAA Division had no effect on work or leisure hours, or
perceived stress or burnout. However, patient load and occupational setting revealed
significant correlations with hours and constructs of burnout. This section will therefore
discuss the relevant findings and relationships between work, leisure, perceived stress,
and burnout among the graduate assistant athletic trainers who participated in this study.
5.2 GENERAL DEMOGRAPHICS OF TIME ALLOCATION AND BURNOUT

The data fiom this study revealed the amounts of time graduate assistant athletic
trainers spent on work and leisure. Participants in this study averaged more work hours
(79 $ 28) than those in a sample of 118 NCAA Division I certified athletic trainers (62 $
14 hours/in-season week and 46 $ 11 hours/out-of-season week) and those in a sample of
206 collegiate certified athletic trainers (48.6% worked more than 60 hours/week in-
season') (Hendrix, Acevedo, & Hebert, 2000; Kania, Meyer, & Ebersole, 2009).
However, the total work hours in this study included those related to coursework as well
as clinical athletic training, so it was difficult to make a true comparison. The same can
be said for leisure hours, as only the Kania et a1. study reported values: Almost 60% of

their respondents reported having between one and ten hours per week of leisure and

83

almost 37% reported 11 to 20 hours. Unfortunately, the researchers did not operationally
define leisure time, which causes difficulties in comparing data.

This study’s MBI values were in the moderate range for each construct and can be
compared with MBI results from other studies using athletic trainers as participants (see
Table 5-1). A “high” level of burnout for medical professions was defined as emotional
exhaustion values equal to or above 27, depersonalization equal to or above 10, and

personal accomplishment equal to or below 33 (Maslach, Jackson, & Leiter, 1996). None

417ng

of the studies in Table 5-1 had MBI averages that qualified as “high” levels of burnout.

Ln..-

Therefore, the results from the present study coincide with those prior to it in determining
that athletic trainers are, in general, less burned out than those in other medical

professions (Hendrix et al,, Giacobbi Jr., Walter et al.).

Table 5-1

Comparison of MBI Results in Athletic Training Literature

 

 

 

MBI Construct MBI Average Present study Hendrix et a1., Giacobbi Jr., Walter et
Value for Medicine 2000 2009 8.1., 2009
Participants 1,104 medical 164 graduate 118 NCAA 934 ATCs 249 athletic
providers assistant Division I ATCs from the training
(Maslach, athletic (separated by collegiate, education
Jackson, & trainers football and non- secondary program
Leiter, 1996) football school, clinic, directors
assignments) and industrial
settings
Emotional 22.19 $9.53 23.10 $10.44 FB 20.24 $9.03 16.94 $10.44 18.11 $9.89
Exhaustion Non 20.06 $8.77
Depersonalization 7.12 $5.22 7.44 $5.29 FB 10.83 $6.24 6.35 $5.20 6.05 $4.80
Non 8.44 $5.20
Personal 36.53 $7.34 37.93 $5.98 FB 37.15 $6.10 36.77 $7.06 38.29 $5.68
Accomplishment Non 38.82 $4.60

 

84

The present study’s MBI values also provided some contrast when compared to
the other studies. The present study’s results were higher in emotional exhaustion than
all others and higher in than Giacobbi et a1. and Walter et al.’s values in
depersonalization. Levels of personal accomplishment varied only slightly among the
four studies considered. Such a large difference in emotional exhaustion and
depersonalization may indicate inherent differences between certified athletic trainers and
graduate assistant athletic trainers’ cognitive appraisals of their work conditions.

5.3 TIME ALLOCATION, PERCEIVED STRESS, AND BURNOUT

Results of this research indicated that there was statistical significance between
only one construct of burnout and work and leisure hours. As hypothesized, emotional
exhaustion was positively correlated with work hours and negatively correlated with
leisure hours. Emotional exhaustion is a cognitive appraisal of working conditions and
stressors; one of these stressors can be the number of hours spent at work. As these hours
increased for participants in this study, emotional exhaustion increased; whereas when
leisure hours increased, emotional exhaustion decreased. Those who work more hours
may be more prone to emotional exhaustion because of the nature of the profession.
Athletic trainers generally spend much of their working hours in direct contact with
patients, coaches, colleagues, and other medical professionals. More time at work likely
increases the time in contact with people and also increases the chance for conflict to
arise. Conflict may create stress, which, over time, may promote the development of
emotional exhaustion.

The responses to two of the miscellaneous questions also may indicate why

emotional exhaustion correlated positively with work hours. Two-thirds of participants

85

strongly agreed or agreed that they spent too much time working, and two-thirds also
strongly agreed or agreed that they did not get enough time for themselves. These
negative cognitive appraisals of work time may have directly influenced their responses
to the emotional exhaustion items on the MBI.

Though relationships between work and leisure hours were found with emotional
exhaustion, no significance was found between work or leisure hours and the remaining
two constructs of burnout. The amount of hours worked likely did not affect the
participants’ responses to the depersonalization items on the MBI because
depersonalization is a coping mechanism, not a cognitive appraisal of work conditions.
The amount of hours at work or leisure therefore did not directly influence use of this
coping mechanism.

Personal accomplishment is a cognitive appraisal but was not found to relate
significantly to work and leisure hours. Personal accomplishment is not a cognitive
appraisal of working conditions (unlike emotional exhaustion), which may provide a
possible explanation of the weak relationship between the sheer number of hours worked
and personal accomplishment found in this study. An individual can work an exorbitant
amount of hours and feel accomplished, or work few hours and feel the opposite.
Furthermore, the results from the miscellaneous questions indicated that the majority of
participants in the study felt appreciated by their coaches, colleagues, and patients. This
positive feedback from others likely increased their feelings of accomplishment. They
also largely believed that their jobs were worthwhile, and 80% believed that they would
still be in the profession of athletic training in ten years. The participants’ expectations of

their worth and success are more likely facilitated by feelings of appreciation than time at

86

work or leisure, which may explain the lack of relationship between hours and personal
accomplishment.

Lastly, there was a lack of significance between work or leisure hours and
perceived stress. The participants’ perceived stress levels (M=24.6) were comparable
with the 118 NCAA Division I-A athletic trainers that Hendrix et a1. (2000) surveyed.
using the same instrument (M=24.6 for those assigned to football, 23.8 non-football).
However, 68% of graduate assistant athletic trainers in this study strongly agreed or
agreed that their job frequently stressed them. The lack of significance between hours
and perceived stress indicated that the stress they reported was not a result of the number
of hours they spent working. Time may, in some instances, serve as a stressor. However,
because stress is the result of the cognitive appraisal of perceived demands exceeding
resources, factors such as conflict with coaches, complicated injury scenarios, financial
concerns, and others could have been the sources of reported stress rather than the
amount of hours at work or leisure.

5.4 THE INFLUENCE OF SETTING ON TIME ALLOCATION, PERCEIVED
STRESS, AND BURNOUT

Much of the prior research on burnout in athletic training used participants from
the Division I or collegiate settings because the stressors at these levels of sport were
deemed to promote burnout (Hendrix et a1., 2000; Kania et a1., 2009). Contrary to the
hypotheses, NCAA Division was not related to the number of work or leisure hours
reported by the graduate assistant athletic trainers in this study. Furthermore, there were
no differences in any construct of burnout or perceived stress among Divisions. The lack

of effect of NCAA Division on the results may be due to the similarity of graduate

87

 

assistant athletic trainers’ responsibilities: all participants were students and all were
responsible for some sort of clinical patient care. The commonalities in responsibilities
may transcend the Divisional differences of their educational institutions.

Though NCAA Division had no effect on any of the variables, there was a
difference between occupational settings in this study. On-campus graduate assistant
athletic trainers worked significantly more hours and had significantly less leisure time
than those assigned off-campus because on-campus participants spent more significantly
more time in clinical hours and traveling. These results illustrate that there are inherent
differences in work responsibilities between the collegiate and youth sports settings.

How much these differences may have effected cognitive appraisal was also
illustrated in this study. On-campus graduate assistant athletic trainers were found to be
more emotionally exhausted than their off-campus counterparts. This significance may
be explained by the increased number of work hours (and thus decreased leisure time)
reported by the on-campus participants. These results mirrored the positive correlation
between work hours and emotional exhaustion already reported for the entire sample.
The results between these two groups also reflected the overall study results: No
significant differences were found between the groups and depersonalization or personal
accomplishment.

Other settings have been relatively unexplored until Giacobbi (2009) found that
athletic trainers in the college/university setting displayed significantly higher levels of
emotional exhaustion and depersonalization than those at the secondary school, clinic, or
industrial levels. His results, paired with the data from this study which revealed no

significant differences in burnout between NCAA Divisions, suggest that the Divisional

88

differences in the collegiate setting may not be as noteworthy as those among differing
occupational settings. A comparison between Giacobbi’s data with the present study can
be found in Table 5-2. Though the present study did not use the same occupational
categories as Giacobbi, the data were comparable because the on-campus group was
composed only of graduate assistant athletic trainers working in the college/university
setting. The off-campus group can be compared with Giacobbi’s youth sports category
because the majority of participants in the off-campus group worked in secondary

schools.

Table 5-2

Comparison of MB] Results by Occupational Setting with Data from Giacobbi (2009)

 

 

 

MBI Construct Present Study Giacobbi, 2009
Setting On-Campus Off-Campus College/ Youth Sports
n=1 20 n=44 University n=276
=293

Emotional 24.11 $10.26 20.36 $10.55 19.13 $10.71 15.56 $10.53

Exhaustion

Depersonalization 7.73 $5.41 6.64 $4.90 7.71 $5.71 5.95 $4.95

Personal 37.78 $6.21 38.34 $5.34 35.98 $6.96 36.50 $6.91

Accomplishment

 

The differences between the on- and off-campus MBI results and the differences
between the college/university and youth sport MBI results may further reinforce a
relationship between occupational setting and burnout. The college/university
participants in Giacobbi’s study scored almost four points higher in emotional exhaustion

than those working with youth sports. A numerically similar gap was found between

89

those on- and off-campus in the present study, and both studies found significant
differences between the levels of emotional exhaustion in their groups.
Depersonalization levels were lower and personal accomplishment levels higher in the
off-campus and youth sports groups when compared to their respective counterparts.
Giacobbi left speculation of reasons that these two MBI constructs were higher in the
college and university setting to his readers. However, given the other findings in the
present study, it seems that the differences in the amount of work and leisure time may be
one of the causes for the increased emotional exhaustion found in the
collegiate/ university setting. More studies are warranted to explore this trend.
5.5 PATIENT LOAD AND BURNOUT

Patient load also had an effect on emotional exhaustion and depersonalization in
this study. Prior research anecdotally suggested that the number of patients for which
athletic trainers are responsible correlated with higher levels of emotional exhaustion and
depersonalization (Capel, 1986). There was a large difference in patient load between
groups in this study: Off—campus participants were responsible for an average of 269
$221 patients, while on-campus participants averaged only 69 $51 patients. Results
indicated that emotional exhaustion and depersonalization were both significantly
positively correlated with the number of patients among off-campus participants. These
relationships should be considered with caution because of the relatively low number of
off-campus respondents (n=44).

Higher numbers of patients (athletes) may often correspond with more teams for
which the athletic trainers were responsible. In this study, off-campus participants

claimed responsibility to an average for 16 $12 teams per academic year, while on-

90

campus participants only had 3 $5 teams. As the number of patients and teams increased,
so do the number of people with whom the athletic trainers must interact. Not only must
the athletic trainers take care of a large volume of patients, but they also must disseminate
relevant information about these patients to coaches, parents, and other healthcare
providers. Emotional exhaustion may be created solely from caring for a large number of
patients or may be elicited from the vast amount of communication in which the athletic
trainers must invest time and effort. Increasing numbers of interactions with different
people also may create more opportunities for conflict to arise due to personality,
organizational, and ethical differences, all of which may further the development of
emotional exhaustion. Furthermore, large patient and team loads also can limit the time
spent with each injury and make it difficult for athletic trainers to emotionally extend
themselves to each person with whom they interact. Athletic trainers may use
depersonalization to reduce their emotional exhaustion. Whether depersonalization is
used to combat already existent emotional exhaustion or used to prevent emotional
overextension is unclear.
5.6 LIMITATIONS

There were a few limitations in this research. Perhaps the largest limitation was
the sampling procedure. First, the sample size was limited to 1,000 e-mail addresses.
When consulted about paying for additional addresses, the NATA told the researcher that
this was not possible due to the researcher’s student status. Using the NATA for
sampling eliminated a few different groups of graduate assistant athletic trainers: those
not members of the NATA, those not in the “student-certified” membership category, and

those who elected. not to receive surveys when they paid their membership dues. Though

91

 

the sample was representative of many NCAA Divisions and NATA districts, the small
size may prevent the results from being generalized to all graduate assistant athletic
trainers. Also in regards to sampling, the primary researcher received a few undeliverable
e-mails, two of which came from old e-mail addresses of her current classmates. When
asked, the classmates told the researcher that they had listed their current e-mails in their
NATA profiles, indicating that the database the NATA used may have been outdated.

Another limitation to the study was participant dropout. The sample size was
listed as 177 but as the survey progressed only 156 respondents completed the entire
survey. Incomplete data were used if the participants proceeded past the demographic
section; those who did not were eliminated.

Self-reporting bias also limited the results of the time allocation portion of the
survey. The researcher selected units in each question (hours per week, per month, etc.)
that were believed to be easily determined by respondents. Once the data were collected,
all of the hours were converted to hours per week. Because respondents were asked to
list how many hours they participated in an activity on average, participants could have
unknowingly over- or underestimated their actual time on the activity. A better method
would have been having participants keep a daily log of their hours for a week.

Lastly, two participants reported difficulties with the online survey administration
website either freezing or suddenly switching to a different page in the survey. The
researcher encouraged both respondents to attempt the survey again; one responded
saying he/she completed it successfully. The other did not reply. It is unknown how
many other participants had problems with the intemet-based administration of the

survey. These problems could have also led to the dropout rates noted above.

92

5.7 FUTURE RESEARCH CONSIDERATIONS

While it cannot be claimed from the results of this study that increased work
hours increased burnout overall, the relationships between the work and leisure hours and
emotional exhaustion warrant further investigation Researchers should explore work
responsibilities and leisure choices among certified athletic trainers in different settings to
discover if and how graduate assistants differ from other groups of athletic trainers.
Future research should also focus on how work and leisure hours contribute to the
cognitive appraisals of other constructs such as job satisfaction, work-family conflict, and
work-life conflict.

Participants in this study were not considered burned out when compared to the
MBI norms in medical professions. However, their MBI scores suggested higher levels
of burnout relative to other groups of certified athletic trainers. It is unclear if the scores
on the MBI reflect the potentially stressfiil change from student to certified status or other
factors unique to graduate assistant athletic trainers. More research is necessary to
determine if graduate assistant athletic trainers do have higher levels or burnout and why
this may occur.

Lack of effect of NCAA Division and the differences discovered between on- and
off-campus participants suggest that the focus of burnout research in athletic training
should look among occupational settings rather than within collegiate Divisions.
Knowledge of the different potential demands at the collegiate, youth sports, clinic, and
industrial levels would allow educators to prepare incoming certified athletic trainers

with reasonable expectations of their professional lives in each setting. Realistic

93

expectations of work environment may have an effect on the cognitive appraisal of
working conditions.

More studies are also warranted to clarify if the relationships between patient load
and the constructs of burnout because there are no other studies with which to compare
this study’s results. It is unclear if the higher emotional exhaustion and
depersonalization levels among the off-campus participants in this study are due to the
number of patients or because these participants were newly certified and learning how to
cope with job demands. If an increased number of patients does have an effect on
emotional exhaustion and burnout across all settings, then managing the number of
patients per athletic trainer could be a solution to reduce emotional exhaustion and
depersonalization.

Further investigation into depersonalization as a stress management technique is
warranted. Reed and Giacobbi (2004) found a first-order theme of “mental or behavioral
disengagement” when they investigated coping mechanisms among certified graduate
athletic trainers. While depersonalization was not explicitly mentioned, it should be
considered among the coping mechanisms that may be utilized by athletic trainers in this
study. Reed and Giacobbi recommended that graduate athletic trainers use positive,
emotion-focused and problem-focused coping to mediate their stress. Depersonalization
may not be a positive mechanism with which to do this. Ultimately, research involving
coping mechanisms for athletic trainers who have successfully navigated the profession
over the length of a career should be investigated to expose how to promote longevity

(and perhaps mediate or prevent burnout) in the profession. Discovery of the factors that

94

influence all sub-populations of athletic trainers’ cognitive appraisals may determine the
true causes of stress and burnout, and therefore allow us to successfully mediate them.
. 5.8 CONCLUSION

The results of this study revealed that there is indeed an interaction between work
and leisure hours and graduate assistant athletic trainers’ cognitive appraisals of their
work situations. Though perceived stress had no effect on any of the variables, burnout
construct levels were affected by work and leisure hours as well as on- and off-campus
setting. The differences discovered between on- and off-campus participants in levels of
burnout constructs and patient load suggest that the focus of burnout research in athletic
training should look among occupational settings rather than within collegiate Divisions.
Ultimately, the results of this study revealed the importance of further investigation into
athletic trainers’ cognitive appraisals of their working conditions in relation to levels of

stress and burnout.

95

 

APPENDICES

96

‘ 1...‘ I

1)

2)

3)

4)

5)

6)

7)

APPENDIX A
DEMOGRAPHIC QUESTIONNAIRE

Are you a current graduate assistant athletic trainer?
a) Yes
b) No

What is your current age?

Please select the race that best describes you:

a) Caucasian/White

b) African/African-American/Black

c) Hispanic/Latin-American

(1) American Indian/Eskimo

e) Asian (including Hawaiian and Pacific Islander)
f) 2 or more races

g) Prefer not to report

Gender:
a) Male
b) Female

Of which NCAA Division is your UNDERGRADUATE institution a member? (Pick
the division under which most sports compete)

a) LA

b) I-AA

c) I-AAA

d) 2

e) 3

f) NAIA

Of which NATA district is your UNDERGRADUATE institution a member?
a) 1 (CT, ME, MA, NH, RI, VT, Quebec, New Brunswick, Nova Scotia)
b) 2 (DE, NJ, NY, PA)

c) 3 (DC, MD, NC, SC, VA, WV)

d) 4 (IL, IN, MI, MN, OH, WI, Manitoba, Ontario)

e) 5 (IA, KS, MO, NE, ND, OK, SD)

1) 6 (AR, TX)

g) 7 (AZ, CO, NM, UT, WY)

h) 8 (CA, NV, HI, Guam)

i) 9 (AL, FL, GA, KY, LA, MS, TN, Puerto Rico, Virgin Islands)

j) 10 (AK, ID, MT, OR, WA, Alberta, British Colmnbia, Saskatchewan)

What year did you graduate from your UNDERGRADUATE institution?

97

8) Of the choices below, what best describes the duties that you are required to perform
by your job description as a GRADUATE ASSISTANT at your institution? (Check
all that apply.)

a)

Clinical (working directly with athletes/patients)

b) Teaching (assistant teaching and/or instructing courses)

c)

d)

6)

Administrative (insurance, budget management, etc. NOT INCLUDING normal
administrative work such as doctor’s visits, treatment logs, etc. for assigned
patients)

Research (assisting with/conducting research, writing grants, analyzing data,
assisting with the publication process, etc. NOT INCLUDING a capstone project,
master’s thesis, doctoral dissertation, or some other research project concurrent
with your degree to graduate)

Clinical instructor/approved clinical instructor (CI/AC1;

teaching/mentoring/ supervising undergraduate athletic training students)

9) How many MONTHS have you been certified as an athletic trainer?

10) In the past 2 months, were one or more of the athletic teams for which you were
responsible in-season? (This includes official pre-season training, in-season
competition, and post-season tournaments/championships)

a)
b)

Yes
NO

11) Of which NCAA Division is your GRADUATE institution a member? (Pick the
division under which most sports compete)

a)
b)
C)
d)
e)
0

LA
I-AA
I-AAA
2

3
NAIA

12) Of which NATA district is your GRADUATE institution a member?

a)
b)
C)
d)
e)
t)
8)
h)
i)
i)

1 (CT, ME, MA, NH, RI, VT, Quebec, New Brunswick, Nova Scotia)
2 (DE, NJ, NY, PA)

3 (DC, MD, NC, SC, VA, WV)

4 (IL, IN, MI, MN, OH, WI, Manitoba, Ontario)

5 (IA, KS, MO, NE, ND, OK, SD)

6 (AR, TX)

7 (AZ, CO, NM, UT, WY)

8 (CA, NV, HI, Guam)

9 (AL, FL, GA, KY, LA, MS, TN, Puerto Rico, Virgin Islands)

10 (AK, ID, MT, OR, WA, Alberta, British Columbia, Saskatchewan)

98

13) What is your current year in your GRADUATE educational program?
a) First year
b) Second year
c) Third year
(1) Fourth year
e) Fifth year or more

14) What is the estimated year of your GRADUATE degree completion?

15) Is your current graduate assistantship PATIENT CARE position ON-CAMPUS or
OFF- CAMPUS? (On- -campus positions include varsity, club, or intramural sports.
Off-campus positions include K-12 schools, clinics, hospitals, junior or community
colleges, or other sites separate from your educational institution.)

a) On-campus

b) Off-campus

*This question was a directive question. Those who selected on-campus answered
questions 16-19 and were then directed to question 23 and the rest off the survey.
Those who selected off-campus answered questions 20-22 and continued to the end.

16) With what group(s) do you primarily work? (Check all that apply.)
a) Varsity athletics
b) Club sports
c) Intramural sports

(1) Other (please specify )

17) Please list the teams for which you are responsible over the course of one academic
school year.

18) What is the total number of teams for which you are responsible? (Add the number
from the question above)

19) What is the total number of athletes/patients that are directly under your care/assigned
to you (over the course of one academic year)?

20) In what setting(s) do you primarily work? (Check all that apply.)
a) High school
b) Middle school
c) Private school (K-12)
(1) Junior or community college
e) Clinic
f) Hospital
g) Another college/university different from where you are currently enrolled

h) Other (please specify )

21) Please list the teams for which you are responsible over the course of one academic
school year.

99

 

22) What is the total number of teams for which you are responsible? (Add the number
from the question above)

23) What is the total number of athletes/patients that are directly under your care/assigned
to you (over the course of one academic year)?

100

APPENDIX B
TIME ALLOCATION QUESTIONNAIRE

INSTRUCTIONS: Completely read each question below. Thinking about your life in
the past month, place the average number of hours that you participate in the specified
activity in the space provided after each question. Please note that time units may be
different among questions and that each question has an explanation of what the category
includes. Please answer honestly and to the best of your ability. If you do not partake in
activities listed in a question, please insert ZERO (0).

Professional Responsibilities Section

24) How many HOURS/WEEK do you spend on COURSEWORK (including hours
spent in class (lecture, lab) or other formal meetings relating to coursework)?

Hrs/Wk

25) How many HOURS/WEEK do you spend working on a CAPSTONE EXPERIENCE
such as major project, thesis, or dissertation (including research, writing/revising/editing,
meetings, grant/scholarship applications, data collection/analysis, etc. )? Hrs/Wk

26) How many HOURS/WEEK do you spend doing CLINICAL ATHLETIC
TRAINING duties (including time at practice, home games, treatments/rehabilitation,
normal patient paperwork, meetings with coaches/administrators, etc. )? Hrs/W k

27) How many HOURS/W EEK do you spend TRAVELING (the actual hours spent
away from central A TR, including transit time, practice, game, and down time, but not
including time spent sleeping)? Hrs/ Wk

28) How many HOURS/WEEK do you spend on assigned ATHLETIC TRAINING
ADMINISTRATIVE DUTIES separate from assigned coverage or patient specific duties
(including general budgeting or supply ordering, insurance, responding to
departmental/admin email, etc. )? Hrs/Wk

29) How many HOURS/W EEK do you spend TEACHING (including actual teaching,
planning, grading, oflice hours, student meetings, responding to student e-mails, etc. )?
Hrs/Wk

30) How many HOURS/W EEK do you spend STUDYING or DOING HOMEWORK
(including reading, studying, writing, researching, assigned field experiences, etc. )?

Hrs/Wk

31) How many HOURS/MONTH do you spend on PROFESSIONAL DEVELOPMENT
(including attending seminars/conferences or other meetings that are CE U eligible,
reading professional journals (not assigned in classes), volunteering on a
board/committee, and other related activities)? Hrs/MONTH

101

Leisure Section

32) How many HOURS/DAY do you spend WATCHING TV AND/OR MOVIES
(Including at home, at a friend ’s, or going to the theater)? Hrs/DAY

33) How many HOURS/DAY do you spend using ELECTRONIC DEVICES such as a
computer and/ or video games (including non-school/work related intemet browsing,
chatting online, playing computer or video games, etc)? Hrs/DAY

34) How many HOURS/DAY do you spend using A TELEPHONE or CELL PHONE
(for non-work/professional phone calls)? Hrs/DAY

35) How many HOURS/W EEK do you spend EXERCISING OR PLAYING SPORTS
(including organized sports or fitness classes, informal pick-up games, workouts, weight

lifting, home fitness videos, etc)? Hrs/Wk

'1?

36) How many HOURS/W EEK do you spend HANGING OUT WITH FRIENDS and/or
SIGNIFICANT OTHER (hanging out at your place or theirs doing non-school/work
activities)? Hrs/Wk

37) How many HOURS/W EEK do you devote to RELIGION OR SPIRITUAL BELIEFS
(including attending church/synagogue/mosque/etc., studying religious texts, choral or
choir group participation, youth/religious group involvement, etc)? Hrs/Wk

38) How many HOURS/WEEK do you spend doing RECREATIONAL NON-
EXERCISE ACTIVITIES (including shopping, attending places of entertainment such as
200 ’s, museums, travel, reading for leisure, arts/crafts, and other hobbies, etc)?

Hrs/Wk

39) How many HOURS/MONTH do you spend at PLANNED FAMILY EVENTS
(Formally arranged meetings with family for events such as parties, celebrations, etc)?
Hrs/ MONTH

40) How many HOURS/MONTH do you spend ATTENDING PERFORMANCES

AND/OR OTHER EVENTS (Including anything that you are a part of an audience, such
as sporting events, concerts, performances in theater or dance, etc.) Hrs/MONTH

102

Miscellaneous Section

41) Over the past month, what is the average number of HOURS you have slept per
night? Hrs/NIGHT

42) During summer 2009 (defined as the time which you are not employed in your

current position), how many HOURS/WEEK did you spend doing athletic training

related activities (clinical, teaching, camps, professional development, etc)?
Hrs/Wk

43) What is the average number of alcoholic beverages you have per WEEK (Note:
beverage = 12 oz. beer, 1.5 oz. liquor, or 5 oz. wine or some equivalent)?
Beverages/Wk

44) Please answer these questions to the best of your ability.

Most of the time, I feel appreciated by the coaches with whom I work
Strongly Disagree Disagree Agree Strongly Agree

My job frequently stresses me.
Strongly Disagree Disagree Agree Strongly Agree

Most of the time, I feel appreciated by the patients/athletes with whom I work.
Strongly Disagree Disagree Agree Strongly Agree

Most of the time, I feel appreciated by my colleagues and coworkers.
Strongly Disagree Disagree Agree Strongly Agree

I spend too much of my time working.
Strongly Disagree Disagree Agree Strongly Agree

Most of the time, I feel that doing this job is worthwhile.
Strongly Disagree Disagree Agree Strongly Agree

I feel I get enough time for myself.
Strongly Disagree Disagree Agree Strongly Agree

Most of the time, I feel that the people with whom I closely work recognize the
importance of my job.
Strongly Disagree Disagree Agree Strongly Agree

45) In 10 years, do you still see yourself working as an athletic trainer? Yes No

103

APPENDIX C
PERCEVIED STRESS SCALE

46. INSTRUCTIONS: The questions in this scale ask you about your feelings and
thoughts during THE LAST MONTH. In each case, you will be asked to indicate your
response by marking the circle representing HOW OFTEN you felt or thought a certain
way. Although some of the questions are similar, there are differences between them and
you should treat each one as a separate question. The best approach is to answer fairly
quickly. That is, don’t try to count up the number of times you felt a particular way, but
rather indicate the alternative that seems like a reasonable estimate.

1. In the last month, how often have you been upset because of something that happened
unexpectedly?
Never Very Often Almost Never Sometimes Fairly Often Very Often

2. In the last month, how often have you felt that you were unable to control the
important things in your life?
Never Very Often Almost Never Sometimes Fairly Often Very Often

3. In the last month, how often have you felt nervous and “stressed”?
Never Very Often Almost Never Sometimes Fairly Often Very Often

4. In the last month, how often have you dealt successfully with day to day problems and
annoyances?
Never Very Often Almost Never Sometimes Fairly Often Very Often

5. In the last month, how often have you felt that you were effectively coping with
important changes that were occurring in your life?
Never Very Often Almost Never Sometimes Fairly Often Very Often

6. In the last month, how often have you felt confident about your ability to handle your
personal problems?
Never Very Often Almost Never Sometimes Fairly Often Very Often

7. In the last month, how often have you felt that things were going your way?
Never Very Often Almost Never Sometimes Fairly Often Very Often

8. In the last month, how often have you found that you could not cope with all the
things that you had to do?
Never Very Often Almost Never Sometimes Fairly Often Very Often

9. In the last month, how often have you been able to control irritations in your life?
Never Very Often Almost Never Sometimes Fairly Often Very Often

104

 

10. In the last month, how often have you felt that you were on top of things?
Never Very Often Almost Never Sometimes Fairly Often Very Often

1 1. In the last month, how often have you been angered because of things that happened

that were outside of your control?
Never Very Often Almost Never Sometimes Fairly Often Very Often

12. In the last month, how often have you found yourself thinking about things that you

have to accomplish?
Never Very Often Almost Never Sometimes Fairly Often Very Often

13. In the last month, how often have you been able to control the way you spend your
time?
Never Very Often Almost Never Sometimes Fairly Often Very Often

14. In the last month, how often have you felt difficulties were piling up so high that you

could not overcome them?
Never Very Often Almost Never Sometimes Fairly Often Very Often

105

APPENDIX D
MASLACH BURNOUT INVENTORY

SAMPLE ITEMS FOR THE
"Human Services Survey"
by Christina Maslach and Susan E. Jackson

Directions. The purpose of this survey is to discover how various persons in the human
services or helping professions View their jobs and the people with whom they work
closely. Because persons in a wide variety of occupations will answer this survey, it uses
the term' 'recipients" to refer to the peOple for whom you provide your service, care,
treatment, or instruction. When you answer this survey please think of these people as
recipients of the service you provide, even though you may use another term in your
work.

Please read, each statement carefully and decide if you ever feel this way about your job.
If you have never had this feeling, write a "0" (zero) before the statement. If you have
had this feeling, indicate how often you feel it by writing the number (from 1 to 6) that
best describes how frequently you feel that way.

 

 

How 0 1 2 3 4 5 6
Often:

Never A few Once a A few Once a A few Every
times a month times a week times a day
lyear or or less month week

ess

 

 

I. Depersonalization

5. I feel I treat some recipients as if they were impersonal objects.

II. Personal Accomplishment

9. I feel I'm positively influencing other people's lives through my work.
111. Emotional Exhaustion

20. I feel like I'm at the end of my rope.

Adapted and/or translated with permission of the Publisher, CPP, Inc. from the Maslach
Burnout Inventory - Human Services Survey by Christina Maslach and Susan E. Jackson.
Copyright 1988 by CPP, Inc. All rights reserved. Further reproduction is prohibited
without CPP’s written consent.

106

APPENDIX E
LETTER TO SURVEY PARTICIPANTS
Dear Fellow Athletic Trainer,

My name is Stephanie Carzoo and I am a graduate assistant athletic trainer at
Michigan State University. I am writing to ask for your participation in research for my
Master’s thesis, entitled “Graduate Assistant Athletic Trainers’ Time Commitments and
Cognitive Appraisals.” This student survey is not approved or endorsed by the
NATA. It is being sent to you because of NATA’s commitment to athletic training
education and research.

The survey in the link below is designed to assess how graduate assistant athletic
trainers spend their time, both during their work hours and at leisure, and their personal
feelings about their work environments. The survey will take approximately 20 minutes
to complete. Participation is voluntary and you must be 18 years or older to participate in
this research study. The current literature offers little investigation into this specific
population of athletic trainers, so while you will not directly benefit from participation in
this study, your participation may contribute to the understanding of the personal and
professional lives of graduate assistant athletic trainers.

Your confidentiality will be protected to the maximum extent allowable by law.
Information gathered from this research will not be used to identify you in any way.
Surveymonkey.com assigns a number to your response, so no identity information will be
linked to your questionnaire. Data will only be accessed by the primary researcher
(myself), three advisors, and the Michigan State University Institutional Review Board
and will be kept under double lock and key for seven years. You may decline
participation or withdraw at any time and you may also skip questions, all without
penalty. There are no known risks inherent in participation.

If you have any concerns or questions about this research study, such as scientific
issues, how to do any part of it, or to report an injury, please contact me, Steevie Carzoo,
at 105 IM Sports Circle, East Lansing, MI 48823, at (860) 908-4078, or at
carzoost@msu.edu. If you have questions or concerns about your role and rights as a
research participant, would like to obtain information or offer input, or would like to
register a complaint about this study, you may contact, anonymously if you wish, the
Michigan State University’s Human Research Protection Program at 517-355-2180, Fax
517-432-4503, or e-mail irb@msu.edu or regular mail at 207 Olds Hall, MSU, East
Lansing, MI 48824.

I thank you in advance for your contribution to this research and for your
willingness to share your experiences in hopes to better the lives of others that will follow
you in this profession. Please click on the link below to proceed to the survey. Doing so
will indicate your voluntary agreement to participate in this research. Please complete
your survey no later than November 15, 2009.

107

https://www.survevmonkeycom/s.aspx?sm==MPKGB3TGszMSFr 2behBuQ 3d 3d

 

Sincerely,

~ Steevie Carzoo, ATC, EMT-B Tracey Covassin, Ph.D., ATC
Graduate Assistant Athletic Trainer Thesis Advisor

Michigan State University Michigan State University
105 IM Sports Circle 105 IM Sports Circle

East Lansing, MI 48823 East Lansing, MI 48823
(860) 908-4078 (517) 353-2010
carzoost@msu.edu covassin@,msu.edu

 

Participants for this survey were selected at random from the NATA membership
database according to the selection criteria provided by the student doing the
survey. The student survey is not approved or endorsed by NATA. It is being sent
to you because of NATA’s commitment to athletic training education and research.

108

REFERENCES

109

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