Authors: Stephanie M Singe, Julio Hernandez, Alexandrya Cairns

Department of Kinesiology, University of Connecticut, USA

Corresponding Author:

Stephanie M. Singe, PhD, ATC, FNATA
Director, Teaching and Learning
Department of Kinesiology
University of Connecticut
2095 Hillside Road, U-1110, Storrs, CT 06269-1110
860-608-4184
@StephanieSinge
stephanie.m.singe@uconn.edu

Stephanie M. Singe is an associate professor in the Department of Kinesiology. Her research focus is on work-life balance and other factors that influence the job satisfaction and quality of life of an athletic trainer. She is lead author of the position statement on Facilitating Work-Life Balance in Athletic Training Practice Settings.

Julio Hernandez, BS is a graduate student at the University of Connecticut, studying physical therapy. He earned his BS in Exercise Science and completed this project as part of his senior capstone project.

Alexandrya H Cairns is a second year PhD student in the Department of Kinesiology at the University of Connecticut. Her research interests include work-life balance among athletic trainers, and more specifically perceptions of patient care and clinician well-being.

A Cross-sectional Study—Examine the Relationship Between Work Interference with Family Conflict and Burnout Among Athletic Trainers

ABSTRACT
Objective: Work-family conflict and burnout are reported among college athletic trainers, and a recent systematic review found work-family conflict has been found to be a contributor to burnout. Much, however, is to be explored on the relationship between the two constructs. Therefore, the purpose of this study is to explore the relationships between burnout, work-family conflict, and engagement in self-care practices.
Methods: We had 984 (370 men, 605 women, 9 did not disclose) college athletic trainers participate in our survey. Of those 984, 564 were employed in the NCAA Division I setting, 187 in the NCAA Division II setting, and 233 in the NCAA Division III setting.
Data analyzed included basic demographic information, the Copenhagen Burnout Inventory, a Work-Family Conflict Scale, and 4 questions pertaining to self-care.
Results: Athletic trainers scored a mean of 39.51 ± 8.88 on the work and family conflict scale and a moderate burnout score of 61.59 ± 12.55. A moderate negative correlation resulted between the work to family subscale, and the work-related subscale, rs (984)= -.535, p<.001. A significant regression equation was present, F(1, 982)= 424.93, p<.001, with an R2 of .302. A Kruskal-Wallis H test revealed statistically significant differences (𝒳2[2]= 212.89, p<.001) between these three groups (always/often, sometimes, seldom/never) regarding feeling fatigued at work within the CBI, and significant differences (𝒳2[2]=91.21, p<.001) between the same groups on the WFC. A Kruskal-Wallis H test revealed a statistically significant difference between groups regarding availability to engage in self-care practices on both the CBI (𝒳2[2]=212.89, p<.001), and the WFC (𝒳2[2]=110.66, p<.001).
Conclusions: Athletic trainers who experienced higher levels of work interference with family conflict reported higher levels of personal and work-related burnout. Family interference with work conflict was not found to be associated with higher levels of personal burnout. Fatigue was associated with experiences of burnout but not work family conflict. Engagement in self-care practices was shown to help manage burnout, but wasn’t shown to lower levels of work family conflict.

Key words: workplace issues, stress, role strain, self-care, burnout

INTRODUCTION

The collegiate setting receives considerable attention when it comes to workplace dynamics such as work-life balance, burnout, and retention factors (11,24,25). Working in collegiate athletics is viewed as a demanding career, as individuals must endure workweeks that surpass 40 hours, often over weekends and night time hours (21). Research suggests that enduring long work hours, limited time for non-work activities, and constant job stressors can lead to burnout (4, 15).

Burnout is a condition that is hallmarked by emotional, mental and physical fatigue that can arise due to unresolved or prolonged stress (8). Burnout has been linked to work-family conflict (WFC) where burnout is positively predicting WFC among athletic trainers (12,15). Work-family conflict is a stressor that occurs when an individual devotes too much time, energy or resources to one life role, which causes a conflict in meeting the responsibilities in other life roles. Conceptually, WFC can be divided into two directions, family responsibilities limiting work time (FIWC), and work responsibilities limiting time at home (WIFC). Most research studies do not distinguish the directionality of the conflict (e.g., work to family, or family to work); a key piece of the literature that is missing. While the concepts of burnout and WFC have similarities, they are distinctive and can lead to a reduction in job satisfaction (12,15), and have also been linked to departure from the profession (15). 

Time is not the only causative factor to burnout, as part of the framework recognizes that individuals who work in the human sector (teaching, healthcare); are more likely to experience burnout due to the demands placed on them in their professional roles (16). Additionally, those who neglect their own emotional well-being, are more susceptible to experiencing burnout. Additionally, those who do not prioritize their own physical and mental wellness, are at risk to experiences of burnout (19). Athletic trainers are described as agreeable, conscientious healthcare providers, who at times will put their own needs and self-care ahead of their patients and student-athletes (1). In fact, athletic trainers recently report having no availability for self-care, and their dissatisfied with their work-life balance (3, 4).

Burnout is the result of unmanaged, prolonged stress that causes an individual to feel physically and emotionally fatigued (8). Experiences of role strain and WFC have been identified as antecedents for athletic trainers (4, 15), as the demands and time necessary to fulfill the duties of an athletic trainer are overwhelming.  Burnout and WFC have been found to be proportionally related, as an individual experiences burnout they also are likely to report higher levels of work-family conflict (12). Although organizational factors (e.g., hours worked) contribute largely to burnout and WFC, how an individual perceives and manages their life stressors can also contribute to both (1, 6, 24). Engaging in self-care practices has been shown to alleviate workplace stress as well as improve work-life balance for athletic trainers (3, 4).

There is significant literature on both burnout and WFC, however much more can be explored. Although a recent systematic review (15) suggests that WFC is a causative factor to burnout, the directional nature of WFC has yet to be explored or linked to the sources of burnout. We also know that burnout is more than just a consequence to occupational stress, and that an individual can experience stress independent from their work lives (8). Moreover, engagement of self-care strategies (3) has yet to be quantitatively connected to experiences of burnout and WFC.  There is some preliminary data suggesting that self-care practices can positively contribute to work life balance for the athletic trainer, but has yet to be directly linked to it (3). Therefore, we decided to use a cross-sectional survey to explore the relationships between burnout, WIFC, FIWC, and engagement in self-care practices.

H1: Athletic trainers who self-report higher levels of WIFC they will also report increased levels of personal and work-related burnout.

H2: Athletic trainers who self-report higher levels of FIWC will also report higher levels of personal and work-related burnout.

H3a: Athletic trainers who report feeling fatigued at work will report higher levels of burnout.

H3b: Athletic trainers who report feeling fatigued at work will report higher levels of WFC.

H4a: Athletic trainers who engage in more self-care practices will report lower levels of burnout.

H4b: Athletic trainers who engage in more self-care practices will report lower levels of WFC.

METHODS

Study design

We used an online (Qualtrics, Provo, UT) cross-sectional survey to collect data on WFC and burnout among certified athletic trainers who were employed within the NCAA collegiate setting. We gained Institutional Review Board approval prior to data collection and the study occurred during the Fall of 2022 over a 4-week period, with 2 reminders for participation after the initial email was sent.

Participants

In 2022, we found 1030 institutions that are sponsoring NCAA athletic programs (Sports Index, 2022). Using this list of institutions, we accessed the athletics staff directories to obtain email addresses for athletic trainers employed in the NCAA setting. The process yielded 6, 243 emails, of which 6,148 were deliverable. We had 1, 373 completed surveys (22% response rate), before screening for inclusion criteria and completed surveys. Once that process was complete, we had 984 (72% response rate) who met the inclusion criteria and completed the WFC and CBI scales.

Questionnaire

The survey was separated into 4 distinct sections: 1) demographic information, 2) self-care practices, 3) WFC, and 4) burnout. We asked participants to provide demographic information such as age, gender, years of Board of Certification (BOC), hours worked per week, and NCAA level (e.g. I, II, III). Participants were then asked 4 questions about their self-practices: 1-open-ended question (# of hours of sleep per night), and 3-Likert scale questions 1 (always) to 5 (never/seldom). Table 1 provides self-care questions.  We used 2 reliable and validated scales within the athletic training population (3, 11, 12) to measure WFC and burnout and chose not to alter either scale.   

WFC. To measure the bidirectional nature of WFC, we chose the WFC scale first developed and validated by Netermeyer et al. (13). The 10-item scale has been used within athletic training previously (3, 11,12) and is reported to be reliable (ɑ=.84). The scale is broken down into 2 main sections: WIFC, and FIWC. Using a 7-point Likert scale, 1 (strongly disagree) to 7 (strongly agree), participants rated their level of agreement with questions directed at the challenges of balancing work and family life.

Burnout. The Copenhagen Burnout Inventory (CBI) (8) was used to evaluate participant’s experiences with burnout. The scale has been used before to measure burnout among athletic trainers (3) and is reliable (ɑ=.85-87). The scale includes 3 subscales: personal, work-related, and client-based burnout. The scale itself can be summed for an overall score of burnout, with a higher score indicating a higher level of burnout (0 is low, 100 is severe). The CBI uses a 5-point Likert scale: 100 (always/high degree), 75 (often/high degree), 50 (somewhat or sometimes), 25 (seldom/low degree), and 0 (never/almost never/low degree). In total, participants responded to 19-items related to their experience of burnout (6-items, personal; 7-items work-related; 6-items client-related). (8)

Statistical Analysis

Demographics variables collected from our population were age, gender, marital status, NCAA division and years of experience. The dependent variables collected were burnout and WFC via their respective validated scales.

Data was extracted into Excel (Microsoft Corporation), it was then filtered where respondents who left the scales incomplete or completed less than 80% of the entire survey were excluded. The responses remaining were then analyzed using IBM SPSS Statistics for Macintosh (version 24.0). Frequency and descriptive statistics were utilized to determine means and standard deviations for demographic information.

The CBI, WFC, and respective subscales were investigated for relationships utilizing Spearman correlations. Correlations were determined using the following categories; .1-.39 were considered weak, .40-.69 moderate, .7-.89 strong, and .9-1.00 very strong (19). Moderate correlations were revealed between the work to family subscale, and the work-related subscale. A linear regression analysis followed once correlations were determined, and linearity assumption was met.

A Kruskal Wallis H test (non-parametric ANOVA) was utilized to identify differences within groups regarding feeling tired at work, and engagement in self-care practices. Dunn’s post hoc analysis was then utilized to determine where the statistical difference lies between groups. An a priori value for significance was set at p<.005 prior to all analyses.

RESULTS

We had 984 (370 men, 605 women, 9 did not disclose) college athletic trainers participate in our survey. Of those 984, 564 were employed in the NCAA Division I setting, 187 in the NCAA Division II setting, and 233 in the NCAA Division III setting. Participants report an average of 6.77 (± .95) hours of sleep per night. More demographic statistics are represented in Table 2. Athletic trainers scored a mean of 39.51 ± 8.88 on the work and family conflict scale, a mean of 12.59 ± 5.83 on the work to family subscale, and 26.91 ± 5.74 on the family to work subscale. Athletic trainers reported moderate burnout score of 61.59 ± 12.55, a reported mean of 66.48 ± 13.40 on the personal-related sub scale, a mean of 63.96 ± 13.34 on the work-related sub scale, and a mean of 53.97 ± 12.55 on the client-related subscale.

Spearman correlation was utilized to identify correlation between the CBI, WFC, and respective subscales. A moderate negative correlation resulted between the work to family subscale, and the work-related subscale (rs (984)= -.535, p<.001) and between the work to family subscale and the personal-related burnout subscale (rs (984)= -.523, p<.001). The work to family subscale of the WFC predicted the work-related subscale of the CBI (b=79.80, t983= 94.21, p=.000). A significant regression equation was present, F(1, 982)= 424.93, p<.001, with an R2 of .302. The work to family subscale of the WFC also predicted the personal-related subscale of the CBI (b=81.53, t983=93.70, p=.000). A significant regression equation was present F(1, 982)= 363.20, p<.001, with an R2 of .270. Further, a very weak negative spearman correlation resulted between the family to work subscale, and the personal burnout subscale (rs (984)= -.073, p=.022) and a very weak negative and insignificant correlation between WIFC and the work-related subscale (rs (984)= -.054, p=.091).

Athletic trainers report feeling fatigued at work, and engagement in self-care practices on a 5-point Likert scale (1: always, 5: never). They were then grouped based on these answers; always/often, sometimes, seldom/never. Those who report always/often feeling fatigued at work scored a mean of 66.08 ± 10.47 on the CBI, and a 37.17 ± 7.83 on the WFC. Those who report sometimes feeling fatigued at work scored a mean of 56.17 ± 10.51 on the CBI, and a 42.13 ± 8.53 on the WFC. Those who report seldom/never feeling fatigued at work scored a mean of 46.89 ± 16.00 on the CBI and a mean of 48.03 ± 10.37 on the WFC. A Kruskal-Wallis H test revealed statistically significant differences (𝒳2[2]= 212.89, p<.001) between these three groups within the CBI. Pairwise comparison utilizing Dunn’s post hoc analysis resulted in those who report always/often feeling fatigued at work scored significantly higher (p=.001) on the CBI, than those who report sometimes (p=.001), and seldom/never (p<.001). Within the WFC a Kruskal-Wallis H test revealed a significant difference (𝒳2[2]=91.21, p<.001) between these three groups. Dunn’s post hoc analysis revealed that athletic trainers who report always/often feeling fatigued at work scored significantly lower (p<.001), and those who report sometimes (p=.001), and seldom/never (p=.001).

Athletic trainers who report always/often having the availability to engage in self-care activities scored a mean of 66.08 ± 10.47 on the CBI, and a mean of 37.17 ± 7.83 on the WFC. Those who report sometimes having the availability report a mean of 56.17 ± 10.51 on the CBI, and a mean of 42.13 ± 8.53 on the WFC. Athletic trainers who reported seldom/never having availability reported a mean of 46.89 ± 16.99 on the CBI, and a mean of 48.03 ± 10.52 on the WFC. A Kruskal-Wallis H test revealed a statistically significant difference between groups on both the CBI (𝒳2[2]=212.89, p<.001), and the WFC (𝒳2[2]=110.66, p<.001).

Pairwise comparisons utilizing Dunn’s post hoc analysis determined that athletic trainers who report always/often having availability to engage in self-care practices scored significantly lower (p=.001) than those who report sometimes (p<.001), and those who report seldom/never (p=.001) on the CBI. Dunn’s post hoc then revealed that athletic trainers who report always/often scored significantly higher (p=001), than those who report sometimes (p<.001) and seldom/never (p=.001) on the WFC.

DISCUSSION

Burnout and WFC receive considerable attention in athletic training, and recently WFC has been linked to burnout as a precipitating factor (4,15). The goal of our study was to better understand the relationship between WFC and burnout, as well as the impact of self-care on experiences of each. Overall, our sample of athletic trainers was experiencing moderate levels of burnout, and was averaging less than the recommended 7 or more hours of sleep per night by the National Institute of Health (5). Athletic trainers, however, do sleep similarly to other healthcare providers such as nurses and physicians (18, 19).

Work-family conflict and Burnout

We found that athletic trainers who were experiencing WIFC, also experienced higher levels of personal and work-related burnout. Work-related burnout attributes experiences of burnout to fatigue by the nature of their job (i.e., long working hours, patient load, etc.) (8). Personal burnout is a recognition of one’s overall burnout independent of their work expectations or demands (8). Although working can contribute to experiences of burnout, our results do suggest that exhaustion and fatigue can be perceived when WIFC is present, as it can drain one’s energy, but also limit time for their nonwork interests (26). Although there are many work-related variables that could contribute to experiences of burnout and WIFC, our participants reported working on average 55 hours per week. Past research has shown that as WFC happens, so does burnout (12,15), and a major contributor to these experiences is long working hours (15).

Past literature, as previously mentioned, has not examined FIWC and burnout. We did not however, find a relationship between experiences of personal and work-related burnout and WIFC. We were surprised by this finding, as we believed that the spillover effect from nonwork requirements (e.g., household chores, parenting duties, etc.) would create fatigue and exhaustion for our sample. Half of our participants were single, and 70% of the participants did not have children. So, perhaps burnout and FIWC occur when an individual has more obligations at home, such as a spouse or children. Family stress has been linked to FIWC and burnout (9), thus our sample may not have family stress. Additionally, individual variables not measured here such as personality, perceived stress, and resiliency have been found to influence experiences of burnout (1, 7).

Fatigue, Work-family conflict, and Burnout

We found that athletic trainers who reported frequently feeling fatigued at work also experienced higher levels of burnout than those who sometimes, or almost never feel fatigued at work. In contrast, we did not find that perceptions of fatigue at work translate to experiences of work-family conflict. The hallmark characteristic of burnout is fatigue, and disenchantment with one’s work (2); so, this finding makes sense. Additionally, a majority of our participants were sleeping less than 7 hours per night, which can explain feelings of fatigue at work. Moreover, the landscape working in college athletics is described as demanding (4, 11, 24), and thus if the athletic trainer is not recovered by restorative sleep, then fatigue can be present. Most research around burnout in sport or healthcare finds emotional exhaustion as the most prevalent (10, 17). This is the first study to our knowledge that measured perceptions of fatigue at work, with burnout or WFC.

Although we did not connect fatigue at work to WFC, we do believe this suggests that the stress experienced in balancing work and life roles does not produce feelings of fatigue at work. Early work around WFC suggested that psychological strain, increased stress, and depression were a result of experiences of work-family conflict. The possibility for fatigue at work would be likely due to the strain experienced by WFC; however, we did not find this true. Perhaps the athletic trainer has effective strategies that limit the spillover at work, or the strain felt by balancing both roles is not exhaustive. Athletic trainers have used disengagement and work-life separation to help reduce the spillover from family to work, so that may limit feelings of fatigue at work (21). Work-family conflict does predict burnout, but recent results find this to be a small percentage for the athletic trainer (15, 21). So, future research needs to explore the outcomes of WFC.

Self-care, Burnout, and Work-family conflict

Self-care is a commitment to one’s overall health and well-being through daily care activities, which can include exercise, healthy food choices, sleep, and social relationships (14). Engaging in daily self-care practices is often individualized, and reflects the person’s identity, interests, and needs. Engaging in self-care for our sample was found to produce lower levels of burnout. Self-care helps promote mental health and well-being, and when burnout is occurring it can have a negative impact on one’s mental health (4). Our results indicate that those athletic trainers who participate in self-care practices are not correlated with their satisfaction with work-life balance. We did not ask our participants to indicate what self-care activities they were engaged in, or the frequency of those activities; thus, future research should gather this information. We believe that this is important, as our results contradict a research study that found self-care practices promote work-life balance (3). Perhaps, other strategies such as social and spousal support help manage conflicts with work and family rather than self–care (16, 20). Moreover, sleep is considered a self-care practice, yet many of our participants slept less than the daily recommendation.

Self-care has been shown to mitigate burnout in physicians, when practiced personally and professionally (18). Though our results contradict recent conclusions in the athletic training profession, it is becoming more apparent that self-care is an overarching concept (3). One could question whether different forms could potentially create positive impacts in different areas of one’s personal and professional lives. The concept of self-care positively impacting the over-all wellbeing of health-care providers in general and currently athletic trainers may seem blatant, further investigation into forms of self-care and its relationships to burnout and WFC should be completed to make these determinations.

LIMITATIONS and FUTURE DIRECTION

The nature of a cross-sectional study means the participant responses only represent one moment in time, and therefore future studies should explore these constructs longitudinally. Our data was collected in the fall semester of the academic year, and therefore by conducting the study at multiple time points we can determine if there is a cyclic nature of these constructs. The data collected only represents athletic trainers working in the college setting, future studies should isolate each of the practice settings in athletic training, but also include all employment settings in one study. We did not explore individual practices of self-care on burnout and work-family conflict, so future studies should be more expansive of the individuality that can account for self-care practices, such as exercise, yoga, and meditation.

CONCLUSIONS

Athletic trainers who had higher levels of WIFC also reported higher levels of personal and work-related burnout. Interestingly, we did not find that FIWC was related to higher levels of personal burnout. Feeling fatigued at work was associated with experiences of burnout, but not work-family conflict for our sample. Having time to engage in self-care activities was a way to manage burnout, but not associated with lower levels of WFC.

APPLICATION TO SPORT While this study is not one directly related to sports performance it is known that athletic trainers play a significant role in the prevention of injury as well as supporting athletes through their return to play protocols after an injury. If the quality of care given by athletic trainers is directly affected by their own feelings of both personal and work-related burnout, we can assume that those who are experiencing more WIFC and therefore higher levels of burnout will likely distribute a lower quality of care likely leading to longer time spent in the rehabilitation process or less work being done on injury prevention leading to higher rates of injury among their athletes. As discussed in the limitations and future direction section we did not explore individual self-care practices, but we know that those who engaged in more self-care practices experienced lower levels of burnout meaning these trainers would theoretically distribute a higher quality of care than those not as engaged in self-care practices. This should lead to lower injury rates and a smoother rehabilitation process. This research should lead to the encouragement of finding methods to decrease WIFC and encourage the practice of self-care to ensure trainers can manage their stress in order to prevent burnout and keep quality of care as high as possible.

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