The Workplace Experiences of Athletic Trainers in the Professional Sports Setting

Authors:

Katelyn A. Zweigle DAT, LAT, ATC
Neuromechanics, Interventions, and Continuing Education Research (NICER) Laboratory Department of Applied Medicine and Rehabilitation
Indiana State University
Terre Haute, IN
E-mail: kzweigle@sycamores.indstate.edu

Stephanie M. Mazerolle Singe PhD, ATC, FNATA
Department of Kinesiology
University of Connecticut
Storrs, CT
E-mail: Stephanie.mazerolle@uconn.edu

Zachary K. Winkelmann PhD, SCAT, ATC
Neuromechanics, Interventions, and Continuing Education Research (NICER) Laboratory Department of Applied Medicine and Rehabilitation
Indiana State University
Terre Haute, IN
E-mail: zwinkelmann@indstate.edu

Elizabeth R. Neil PhD, LAT, ATC
Neuromechanics, Interventions, and Continuing Education Research (NICER) Laboratory Department of Applied Medicine and Rehabilitation
Indiana State University
Terre Haute, IN
E-mail: eneil@sycamores.indstate.edu

Nicholas J. Spangler DAT, LAT, ATC
Neuromechanics, Interventions, and Continuing Education Research (NICER) Laboratory Department of Applied Medicine and Rehabilitation
Indiana State University
Terre Haute, IN
E-mail: nspangler@sycamores.indstate.edu

Lindsey E. Eberman PhD, LAT, ATC*
Neuromechanics, Interventions, and Continuing Education Research (NICER) Laboratory Department of Applied Medicine and Rehabilitation
Indiana State University
Terre Haute, IN
E-mail: lindsey.eberman@indstate.edu

Corresponding Author:
Lindsey Eberman, PhD, LAT, ATC
Department of Applied Medicine and Rehabilitation
Indiana State University
567 North 5^th Street,
Terre Haute, IN 47809
E-mail: lindsey.eberman@indstate.edu
Phone: 812-237-3961

The Workplace Experiences of Athletic Trainers in the Professional Sports Setting

ABSTRACT:

Purpose: Previous literature has reported that athletic trainers in the professional sports setting (PSS) experience role strain from extreme organizational expectations and demands, resulting in perceived limitations in patient care and work-life balance.Therefore, the purpose of this study was to explore the experiences of athletic trainers working in the PSS.

Methods: We recruited 18 participants from various professional sports who partook in a semi-structured, one-on-one phone interview. A 3-person data analysis team used a multi-phased process to identify emerging domains and core ideas, ultimately developing a consensus codebook. Trustworthiness was established with member checking, multiple researcher triangulation, and external auditing.

Results: Three domains emerged: 1) job attractors, 2) feeling valued, and 3) characteristics of the workplace environment. Participants reported being attracted to athletic training in the PSS to work with elite athletes, because of supportive coworker relationships, having a network of athletic trainers, and increased access to resources and education. Athletic trainers reported feeling valued by employers through increasing professional responsibilities and increasing compensation or recognition. They also reported having trusting relationships with their patients. Participants described mutual organizational and employee loyalty in their workplace environment. Participants detailed examples of inappropriate behaviors and a sub-culture of acceptance, whereby these workplace experiences were accepted as a byproduct of the PSS. Participants discussed common coworker tensions related to miscommunication. Although participants were overall positive about their workplace’s experiences, they acknowledged sacrifices to acquire and retain their positions, including significant time commitments, regular travel expectations, family compromises, and fewer opportunities for promotion.

Conclusion: Athletic trainers in the PSS feel valued for their work despite the long hours, family and promotional sacrifices. Positive coworker environments and access to resources continue to attract athletic trainers to the PSS. A sub-culture of accepting inappropriate workplace behavior within the PSS should be further explored.

Application in Sport: Athletic trainers in the professional sports setting feel that they have added job attractors that may include access to resources and education. The professional sports setting may include a sub-culture of acceptance, where inappropriate behavior is overlooked as a result of the setting.

Key Words: worth, harassment, payment, consensual qualitative research

INTRODUCTION

Health care professionals in all settings are predisposed to work-life imbalances due to the nature of healthcare, and athletic trainers are no exception. Athletic trainers in various settings have reported working on average forty plus hours a week that does not include traveling.(20) These long hours are brought on by attending to patient needs, administrative duties, athlete supervision, and travel to contests.(26,27) Due to the long hours, athletic trainers in various settings are succumbing to burnout in the workplace. The burnout is often attributed to role overload, stress, and personal perception of being undervalued or underappreciated in the workplace.(19)

Previous research has been completed exploring the secondary school and college/university athletic trainers’ work experiences; however no such investigation has occurred within professional sports setting (PSS). Although only 3% of the National Athletic Trainers’ Association (NATA) membership database identifying as working within the PSS, it is a setting that many athletic training students and young professionals’ may be drawn into the profession, simply based on its media exposure.(28) Settings have such variability, it is important for future athletic trainers to have a better understanding of each. The athletic trainers that work in a rehabilitation or clinical setting seem to have a more consistent schedule (about 40 hours per week); however those in the secondary school, college/university, and PSS are reporting working more than 40 hours a week accompanied by frequent travel.(30) The role of the athletic trainer in the collegiate setting can be very demanding due to the travel requirements, obligations to multiple teams, teaching duties, supervision of students, and various other administrative duties.(4) Literature has also revealed that finances at institutions play a role in the access to, expectations of, and priorities for athletic training services.(29)

The culture of college/university and PSS has typically focused on the athletic team’s success rather than high-quality, independent health care to athletes. When patient care and sport performance are misaligned, which is not always the case but often is in competitive athletics, athletic trainers face conflicting priorities.(36) Previous literature stated that athletic trainers in the PSS indicate they experience moderate to high levels of role strain and role overload, which create work-life imbalances.(40,41) Athletic trainers have also become accustomed to the time demands which have become “long-standing” within competitive athletics and seen as indistinguishable with commitment and productivity.(3) A recent NATA Position Statement further elaborated on the work-life balance that is associated with an increase in quality of life for athletic trainers and the various outcomes which include burnout, job satisfaction, professional commitment, health and wellness, and career intention.(30) Therefore, we sought to evaluate the experiences of athletic trainers working in the PSS.

METHODS

Design

We used a qualitative design with one-on-one interviewing to describe the workplace experiences of athletic trainers in the PSS. The Institutional Review Board approved this study.

Recruitment and Participants

We used a criterion sample of athletic trainers that were practicing in the PSS athletic trainers between August to October 2018. We recruited the sample of PSS athletic trainers through word of mouth, social media, snowball sampling, and the NATA membership database. We posted 66 tweets on Twitter through the XXX Twitter^® page (@XXX). The tweets were addressed to 66 different professional sports associations, state athletic training associations, as well as individuals. We selected these individuals based off presence in the PSS and activity on social media. Current literature supports utilizing social media as a feasible way to target specific populations for the recruitment of studies.(8)

A total of 18 participants (15 male, 3 female; age = 38 ± 8 years; credentialed experience = 14 ± 7 years; experience in the PSS = 11 ± 9 years) from various professional sports leagues [Major League Baseball (MLB; n = 8), National Football League (NFL; n = 1), National Basketball Association (NBA; n = 1), Major League Soccer (MLS; n = 2), National Hockey League (NHL; n = 4), Major League Rugby (MLR; n = 1), Women’s National Basketball Association (WNBA; n = 1)] volunteered for the study. Table 1 describes the demographics of the participants.

Table 1. Participant Demographics

Pseudonym	Age	Sex	Years BOC Certified	Years of Experience in PSS	Ethnicity	Professional Affiliation
Adam	34	Male	11	1	East Asian	MLS
Charlie	30	Male	8	6	Caucasian	NFL
Edward	28	Male	6	5	Caucasian	MLB
Everett	29	Male	5	4	Caucasian	MLS
Kane	42	Male	20	20	Hispanic/Latino	MLB
Johnathan	30	Male	7	3	Caucasian	MLB
Iris	29	Female	2	2	Caucasian	MLB
Maverick	33	Male	11	10	Caucasian	MLB
Kayden	41	Male	19	11	Caucasian	NHL
Dylann	49	Male	22	22	Caucasian	NHL
Beverly	38	Female	12	1	Caucasian	MLR
Kyle	47	Male	24	24	Caucasian	NHL
Glenn	44	Male	21	10	Caucasian	MLB
Jean	33	Female	10	4	Caucasian	WNBA
Robert	39	Male	15	15	Caucasian	MLB
Christopher	39	Male	17	5	African-American	NBA
Corey	44	Male	21	21	Caucasian	MLB
Trent	53	Male	23	29	Caucasian	NHL

Abbreviations: BOC, Board of Certification; MLB, Major League Baseball; MLR, Major League Rugby, MLS, Major League Soccer; NBA, National Basketball Association; NFL, National Football League; NHL, National Hockey League; WNBA, Women’s National Basketball Association

Instrumentation

The primary investigator (AAA) developed the interview protocol (Table 2) based on existing literature related to athletic training in the PSS. The interview protocol included 10 semi-structured questions. Following development, the interview protocol was reviewed by the co-authors (BBB, DDD) and two content and methods experts with minor edits to the final protocol. Next, the primary investigator conducted two pilot interviews with athletic trainers that had previous work experience in the PSS. The research team met to discuss the pilot interviews with final edits made to the interview protocol.

Table 2. Interview Script.

1. Describe you role as an athletic trainer in the professional setting.

What was your career path to prepare you for this position?
Can you describe what a typical day looks like? Is that all the time or seasonal?
What do you do in the “off season”?

2. Do you enjoy working in your career setting? Why or why not?

3. What is your relationship like with coworkers?

Have you experienced any difficulties with coworkers? If so, please tell me about that.

4. Do you have mentorship in or outside the organization? How does that influence you as a professional?

5. What are your prospects for job growth in this organization? Do you see yourself being able to get promoted? Why or why not?

6. Can you describe the methods in which you see yourself earning raises, praises, or promotion? Why or why not?

7. Describe your satisfaction with compensation.

Is it equitable to your peers? Why or why not?

8. What is your ultimate career goals? Do you have the resources to achieve that goal working within this organization or setting? Why or why not?

9. Describe your interactions with patients. For instance, how do you interact with patients? How frequently do you interact? What are the nature of those interactions?

What challenges, if any, have you experienced providing patient care in the professional setting?

10. How would you describe the term workplace harassment? Based upon your definition and understanding of harassment, have you ever experienced any workplace harassment? What about bullying? Or discrimination? Can you describe those experiences for me?

Following interview protocol development, a demographic survey using a web-based platform was created including the electronic informed consent. Once participants clicked on the link, they were then transferred to the web-based, demographic survey (Qualtrics^®, Provo, UT). As part of the demographic survey, the participant provided their contact information to schedule the interview.

Data Collection and Analysis

All interviews and verbal consent were audio recorded using a video conferencing platform (Zoom, San Jose, CA). Each interview was performed by the primary investigator (AAA). The interviews were audio recorded and field notes were taken. We used participant numbers to protect the identities of the contributors, and then coordinated pseudonyms to represent each. The primary investigator then reviewed the interview transcripts between 48 and 72 hours after conducting the interview and then transcribed using a web-based transcription company (Temi, San Francisco, CA). Once the interview was transcribed, it was then sent back to the participant to allow for “member checking” where the participant was allowed to read the transcript and ensure that everything stated was correct.(15,16,17)

Interview data was analyzed using the consensual qualitative research (CQR) approach.(15,16,17) The CQR approach has 5 essential components: 1) open-ended questions in semi-structured data collection that allows for a consistent collection of data across all participants and a more in-depth investigation of individual experiences; 2) a 3-member code team to analyze the data using individual perspectives; 3) the data analysis team meets to come to a consensus on the meaning of the data; 4) the use of an auditor to check the work of the data analysis team; and the 5) development of domains, categories, core ideas, and cross analyses.(15,16,17)

To begin the data analysis process, the transcriptions were deidentified before being sent to the other two members of the data analysis team. The CQR approach specific to the code team included: 1) identifying initial code domains; 2) extracting core ideas from each domain; 3) cross-analysis of multiple participant interviews to create a code book; and 4) establishing the frequency of data presented in the determined categories.(15,16,17). The three members (AAA, BBB, and DDD) of the data analysis team met to review four participant interviews to discuss emerging concepts. Once the domains were agreed upon the initial codebook was created. Following that initial code book, the data analysis team coded the first four transcripts independently and assigned the data to the domain as they saw fit. The data analysis team met again to discuss the four transcripts and edit the codebook based on findings to reach a consensus on the core ideas. We used an external auditor (CCC) who is a qualitative researcher to verify the interpretation made by the three researchers. The roles and experience of the data analysis team are detailed in Table 3.

Table 3. The Roles and Experience of the Research Team

Researcher	(AAA)	(BBB)	(CCC)	(DDD)
Role	Principal investigator; Data analysis team member	Data analysis team member	External reviewer	Data analysis team member; Senior investigator
Research Experience	Novice qualitative researcher	Experienced qualitative research	Expert qualitative researcher	Expert qualitative researcher

The cross-analysis comprised of putting all the categories into separate documents. Which was then followed by distinguishing those categories into a frequency count. The transcripts were individually reviewed for each category and counted for frequency counts of appearance. Trustworthiness was established using a 3-person data analysis team combined with a multi-phase process to identify emerging domains, categories, and core ideas. The domains and categories were then discussed collaboratively to minimize the potential of individual researcher bias with the use of an external audit. The data trustworthiness was also established using peer review.

RESULTS

Three primary domains emerged from the interviews: (1): job attractors, (2) feeling valued, and (3) characteristics of the workplace environment (Figure 1). During the coding process and external review, we determined the need to supplement the workplace environment domain with sub-categories. Additionally, the CQR process places frequency labels on the domains and categories that was established from the number of interviews (n=18) with general labeled as a category that appeared in all (n=18) or but one (n=17), typical labeled as a category that appeared in more than half (n=9) but less than 17 transcripts, variant labeled if the category appeared between 2 to 9 of the transcripts, and rare labeled if the category appeared 2 or less times in the transcripts.(15,16,17) Table 4 provides a frequency count of the coded data per interview transcript that allowed each participant to be counted per domain and/or category.

Figure 1. Domains and Themes

Table 4. Participant Cases by Category (n=18)

Domains, Categories, and Subcategories	Frequency*	No. of Participant Cases
Job Attractors
Elite Athlete Coworker Relationship/Support Network Access	Variant Typical Typical Typical	7/18 17/18 15/18 9/18
Feeling Valued
Increased Responsibilities Compensation and Recognition Trusting Relationships with Patients Loyalty	Typical Typical Typical Typical	11/18 18/18 15/18 12/18
Characteristic of The Workplace Environment
Sacrificing personally Time Travel Family	General Variant Typical	18/18 8/18 11/18
Sacrificing Professionally Promotion Progression	Typical Typical	14/18 14/18
Sacrificing Professionalism Inappropriate Behavior Coworker Tension Sub-culture of Acceptance Cultural Differences	Variant Typical Typical Variant	6/18 15/18 17/18 5/18

*General 18/18; Typical 9/18; Variant < 2 < 9; Rare ³ 2

Job Attractors

We identified that participants were attracted to working with elite athletes, having supportive coworker relationships, having a network of athletic trainers and mentors from the PSS community, and having increased access to resources and education due to their position. The participants identified that it is important to foster strong relationships so that everyone can achieve a common goal within the organization. Everyone under the medical team has a vision to provide the best quality health care for their athletes, being surrounded by forward thinkers, intelligent people, and clinicians of varying backgrounds and experiences, as well as winning games. The participants in this study were just as inclined as the athletes to pursue post-season play offs and hopefully a championship title. Furthermore, the participants were more willing to stay if the organization and the people who worked in it upheld a high quality of patient care, coworker relationships, and professional development. Supporting quotes from each of the categories including elite athlete, coworker relationships, network, and access are available in Table 5.

Table 5. Supporting Quotes for the Job Attractors Domain and Category

DOMAIN	CATEGORY	SUPPORTING QUOTES
Job Attractors	Elite Athletes	“I love it because I get paid to watch NHL games, the players really. We have elite level athletes competing at the top of their game…” – Kayden “They’re motivated to stay healthy [and] get better. Basketball is their job and so if they are hurt, it is their job to come in and do rehab. Their livelihood depends on it. So they have an extra level of motivation.” – Jean
	Coworker Relationships	“…the relationships and the people that you work with… I think that’s what makes my job most enjoyable. It’s really working with good people that are go getters and forward thinkers like myself…[we] found a way to collaborate with each other and work together. I think when someone has that forte that they’re very good at. We need to let them run with it. I think when someone has a weakness as well, we need to rely on our other colleagues that may have a strength in that and run with that as well.” – Christopher “You know bouncing ideas off each other, someone [may do something] a little bit different than someone else [and you] learn from each other. I think all veteran staff in our organization, are very involved in the development of the younger staff. The medical coordinator puts on a professional development [in-service]; a hands-on type of environment.” – Johnathan
	Network	“…if we hear of a new product…across the board in the NFL, we do a really good job of sharing information and having everyone at least be on the same playing field in terms of information…” – Charlie “I think in order to be successful you have to rely on certain people in the profession or even outside of the profession. From a clinical standpoint or from a leadership standpoint or even from a support standpoint. My mentorships come in different directions. Those that have been in the profession of a major league baseball that I see as a mentor certainly early in my career…I utilize him quite a bit from decision making, future plans from recommendation, from how he’s done things in the past. And then there is always the one that’s from a clinical standpoint to reach out to that you see as making you better as clinician so that individual, I know I can reach out to with case studies or difficult situations.” – Kane
	Access	“…forces us to continue to maintain a high level of education. I’m continuing every single day to try to find the newest thing that’s coming out…as a department [we] pride ourselves in being aggressive and progressive and so anything and everything that comes out that’s new, we’ve tried it…That’s my favorite part about this [setting] is having the access and ability to do just about anything.” – Charlie “A lot of our continuing education or in services during the off season… [as well as] receiv[ing] advance preparation, to use services and [conduct] in services. I do a lot of talks in the off season.” – Kane

Feeling Valued

Participants reported feeling valued by employers through increasing professional responsibilities within their current position and increasing compensation or recognition. They also discussed having trusting relationships with their patients that made them feel valued within their respective organizations. This studies participants stated that the time spent to get into their roles takes numerous years and personal dedication, almost guaranteeing a slow promotion, which results in the participants being satisfied with an increase in responsibilities. The participants revealed they were being recognized with awards within their organization or league, both as a medical staff or an individual. The PSS athletic trainers were largely satisfied with their salaries and stated that shortly after annual performance evaluations, they experienced an increase in salary or were awarded another contract. However, the athletic trainers also stated that even though they are pleased with their salaries they feel that they should earn a higher salary when compared to coaches and athletes. Supporting quotes from each of the categories including increased responsibilities, compensation and recognition, trusting relationships with patients, and loyalty are available in Table 6.

Table 6. Supporting Quotes for the Feeling Valued Domain and Category

DOMAIN	CATEGORY	SUPPORTING QUOTES
Feeling Valued	Compensation and recognition	“…[My organization] take[s] care of us they will fly our family out to visit you one time … ensure that you get a little break where you can see your family…minimally they have at least throughout the seasons been able to give raises. These are based on monetary inflation or through improvement of promotions. Or even trying to even a level the playing field of trying to be more on the line of competitive [salaries] with other organizations and how they pay [their athletic] trainers, as well as,] pay player development staff. [My organization offers a] fairly decent benefits and retirement package. So that’s one way they really try and take care of us and they really try and put us first in that regard…they’ve given bonuses for those who have worked extra camps here or there. They understand that beyond the standard contract job, even though this is part of the contract, if you’re asked upon the work this, they understand that it is another time [commitment] they take you away from your family. [So to respect the time the organization is] going to do monetary, compensate you a little bit. [Furthermore,] if the organization…is successful [and] makes playoffs because that in essence is successful…Oftentimes it will be a winter bonus depending on how the year goes…but not always…I know our directors have always tried to recognize those who have been doing a lot…I’ve found my organization is competitive…more money never hurts the situation all the time. And could often, depending on a certain amount, you know, lead to a possibly nicer family life in essence of allowing one spouse not to work if they wanted to.” – Maverick “…Maybe instead of just having a one-year contract offer or a two year to your deal, maybe you start getting to that three or four year raised contract that provides a sense of financial security… [however,] even though you reach that spot where there’s maybe no more growth upwardly because you’ve already reached that top level [position]. There’s always room to go upwards financially…” – Corey
	Trusting Relationships with Patients	“Some interactions with my players [pertain to my knowledge within the] athletic training profession [and we] discuss an injury that happens on the field. [However, if a] player has a question about nutrition. We have a nutritionist that they can contact and making sure that they have the advice that they need. There is also the social aspect like being in the dugout and just getting along with players, getting to know players, and getting a better understanding their mental status. Or just developing a great relationship with the player. At the rookie level, there’s a lot of different cultures, especially in a Latin American community. I interacted with a large amount of Dominican Republic players, Venezuela. So knowing the Spanish language as well as different cultural aspects of their background is always helpful. I think that players kind of respect that. Players can see and discuss certain things it creates more of a relationship with them.” – Johnathan “I interact at least daily with every patient a few times a day…I think it’s important for us to interact with our patients. Just as people. To see how they’re doing…If we don’t have that relationship, then there is no trust, if there is no trust, then we are no good to them…I believe no one cares of how much you know until they know how much you care. And because that is the case we need to understand who our athletes are as people first… When they know you have a vested interest in them and you treat them as if they were your family member.” – Christopher “…we’re interacting on a daily basis in season. [Some] interactions are in person [during the] season [they are] face to face…there’s also interactions… either by phone call or text message… the nature of those interactions I would say are…95 percent professional in respects to, related to injuries, their participation level or anything kind of on the medical side. The five percent is checking in on them or their families kind of in more of a personal manner.” – Jean
	Increased Responsibilities	“There’s an opportunity to oversee both sports medicine and strength and conditioning… we could [look] more globally because we know what goes on between equipment managing and strength and conditioning, sports medicine and nutrition, support side, we have an opportunity to serve in the assistant general manager role where we would be in charge of player health or in charge of performance…” – Christopher
	Loyalty	“People want to work here. People want to stay within the organization because they know what we have here is a very, very good thing. There’s definitely the potential for promotion because a lot of our athletic trainers are qualified and could easily go to other organizations and work at higher levels and do so. I would say that the positives outweigh that. I mean, you wouldn’t want to work in a place where you’re constantly looking over your shoulder. Your job’s in jeopardy if you make a mistake or something like that, dealing with players that are worth millions and millions of dollars on your team. You want to know that you have supporters It’s good to work in a family-oriented organization [instead of a] nasty professional athletic business.” – Edward “I know that my organization would be happy to give [another organization] permission to speak with me. They know what my ultimate goal is…” – Kane “I got a phone call from my boss, Orthopedic Group saying that they had found out that the team was going with another medical company and mentioned if I wanted to pursue staying with the team, they totally understand that even if it means me leaving the company…” – Everett

Characteristics of the Workplace Environment

Finally, the third domain described by the participants was characteristics of the workplace environment. Overall, the participants were positive. However, they also acknowledged that they made sacrifices to acquire and retain their current positions, including a high time commitment to the job and regular travel expectations, family compromises, fewer opportunities for promotion, and a long period to progress to their current position. They also described situations where inappropriate behaviors had been exhibited (e.g. patients in the athletic training facility in a towel or naked, offensive language) and a sub-culture of acceptance for behaviors that would otherwise be unacceptable (e.g. job duties outside the realm of healthcare, banter that would be otherwise unacceptable in a healthcare facility). Participants detailed common coworker tensions related to miscommunication and coworker conflict, and described challenges related to providing care to non-native language speakers. Supporting quotes from each of the categories including sacrificing personally, sacrificing professionally, and sacrificing professionalism are available in Table 7.

Table 7. Supporting Quotes for the Characteristics of the Workplace Environment Domain and Category

DOMAIN	CATEGORY	SUPPORTING QUOTES
Characteristic of The Workplace Environment	Sacrificing Personally	“It’s a grind…Half of a season away from home or your home base if you don’t live in that town all year…So my body finally breaks down because it’s a grind riding on buses all the time, sleeping in hotels, lugging hockey gear, all that kind of stuff.” – Kyle “Because you have to have friends and family who understand that you’re going to miss things and…don’t hold that against you and support you and give you those opportunities to succeed. Because if they’re draining on you and your personal life…then that’s when the burnout occurs…It occurs because there may not be a good support system personally.” – Edward “I got married and my wife was pregnant and I always thought that I could get back into baseball when my kids were a little bit older, but I could never see them grow up again…I left affiliate [baseball] after seven years [and] I took a job at a high school to give myself a little bit more consistent hours and the availability to be home more often… baseball season… I’m rarely home for dinner, I travel often, basically two weeks out of every month for six months…” – Glenn “… I’ve limited myself in [promotional sacrifices] capacity as well. Being that I’ve wanted to stay closer to my family. I have passed up, promotions that would have put me across country or made it more difficult for me to see my family at times.” – Maverick
	Sacrificing Professionally	“I’m the head athletic trainer right now. In my field there’s really not going to be anything else available within our organization. I’m okay with that…I’ve done this for 23 years with this team and things are going good so I think I’m just going to keep the run going and try to get maybe 10 more years out of it. Then that’ll be it.” – Trent “I did a five-month internship with the [said] organization and the rookie ball level…from there I spent the next 13 years in professional baseball at the minor league level…and then I just concluded my first year as the head athletic trainer.” – Corey
	Sacrificing Professionalism	“It’s hard to say how much is genuine and how much is it actual truthful or how much of it [is] horseplay. When you work in an environment of men from the ages of 23 to 35 [with a lot of] strong Alpha male mentality [there is going to be] a lot of joking around…[I do not think that I have] ever once felt that I was being strictly derogatory or offensive genuinely…there’s [going to] be some type of hazing or some type of rule…[however,] it’s definitely been decreased a lot lately since 2016 when Major League baseball implement[ed] that rule of no hazing or bullying policy.” – Kane “I have a feeling if you asked a female athletic trainer in my same position, they might have a different answer…I feel like for a female to be in a professional sport setting is a lot more difficult than it is for me and it’s been a barrier for female athletic trainers as far as getting into baseball, football, basketball, but you see that changing…I think they’re asked to be a little bit more understanding [of the culture of the game and] that it’s different.” – Glenn “…there’s always cultural difficulties…people from different countries that are not used to [the Western Medicine] healthcare system, whether it be an insurance difficulty, they don’t understand that they’re going to have to pay for things or why they have to do all these things first rather than get an MRI just right away. Or it could be a communication issue…there’s always things to navigate, language barrier, sometimes it’s a style of treatment…a lot of athletes are more familiar with physiotherapists and they’re mostly manual therapy and rehab based and not so much preventative.” – Beverly “The toughest part… you’re not only the athletic trainer, but you’re also kind of a road secretary and travel secretary. A lot of your responsibilities lie outside the realm of athletic training… you’re making hotel reservations, bus reservations, flight reservations. You’re handling baggage stuff for flights, you control player transfers. You’ll get calls from the operations director to have a player fly from one city to another or you’re getting another player and you need to work out picking them up.” – Glenn

DISCUSSION

Athletic trainers have been known to take on many roles and responsibilities related to their jobs as healthcare providers.(40,41) However, the additional roles and job requirements may contribute to the role strain commonly cited in the PSS.(40,41) Role strain can cause a decrease in job satisfaction and performance which may lead to retention concerns, as well as burnout.(29,30) The NATA has published a Position Statement on facilitating work-life balance in athletic training to provide guidance for athletic trainers to successfully manage job stressors.(30) The findings for the study confirmed the stressors, but also helped to appreciate why athletic trainers in the PSS are willing to continue working in the setting regardless of the various strains.

Job Attractors

The participants in this study noted numerous reasons for being attracted to working in the PSS including working with elite athletes, coworker relationships and support, network, and access to professional development. Additionally, they stated personal enjoyment while working with highly motivated individuals who were determined to return to sport. The participants stated that being able to partake in the culture and establish relationships with their patients is what made the work place exciting and fun to come to everyday. The study findings are similar to previous research that identified the creation of a supportive work environment helps to foster work-life balance.(26,27,28,30,36,37) As a result, there has been a decrease in athletic trainers that leave their positions who work within the collegiate setting(11) and we found this to be similar with the PSS.

Previous research identified that athletic trainers in the PSS stressed the importance of having mentors from within and outside the PSS to help decrease role strain and acclimate the athletic trainer to the profession by providing on the job learning and guidance.(30) This study revealed that participants stated that in PSS they value the family bond that is created over the duration of the season and years spent with these individuals. Specifically, the role of the mentor provided them advice on handling situations that may arise during the season or their career. Informal and formal workplace mentors should be considered during the onboarding process in the PSS.

The participants also mentioned they obtained their positions within the PSS due to the connections they had with those already working in the profession. Literature shows that networking behaviors lead to job satisfaction and commitment. However, networking is different between male and females. When networking is explored between female and males; females positively relate job satisfaction to professional networking, males positively relate job satisfaction to peer networking. Furthermore, based on these methods males are more inclined to encourage strength, independence, competitiveness, task oriented, goal oriented and get-to-business; while females are more likely to along with a nurturing, relational, sensitivity to others, and building a relationship.

Most athletic trainers described that organizations throughout the PSS provided feedback throughout the season or at least at the end of the season. Feedback has been described as one of the most important characteristics to improving clinical performance.(25) During the off season is when most athletic trainers were provided professional development opportunities through in service educational, national conferences, the specific sport conference (PBATS, NBATA, PFATS, or PSATS), and attending any other interesting continuing educational opportunities. Most athletic trainers in our study described having an unlimited or easy access to the newest cutting-edge modalities because their budgets afforded them. There is lack of research on the resourcing of organizations; a lack of healthcare resources can negatively influence patient outcomes, but there lacks research on over resourcing to state it leads to the implementation of best practice standards and how it influences the clinical philosophy of the clinician.(22,44)

However, literature otherwise states that there is often an inaccessibility to continuing education units (CEU) due to location, employers unaware of the CEU needs, family commitment restricts flexibility and availability, staffing shortages, or even having to self-fund or partially pay for CEU.(9,18,34,35,43) The MLR organization was the only PSS that had complained of access to modalities due to not having the budget or lack of space.(32) However, this was one athletic trainer and may not be the same for all athletic trainers within the league. However, with it being a new sport within the United States, the growth within the league is promising as stated from the athletic trainer and with that comes more money and more opportunities.

Feeling Valued

In order for companies to have successful goals and interest that will drive employees, it is important to define and measure value. Value is essential to understanding the performance of any organization and driving continuous quality improvement.(38) An athletic trainer may assess his or her value through respect, importance, worth, and usefulness of the athletic trainer in a particular position, organization, or setting.(30,31) Our research aligns with previous literature which shows how work-family conflict can be additional stress which can reduce psychological and physical wellbeing.(5) The athletic trainers described that organizations that had an invested interest in them, as well as had a family-oriented atmosphere, made them more inclined to stay with the organization.(24) Furthermore, the job expectations of athletic trainers and other healthcare providers with increased responsibilities and or demands of the job, emotional involvement with the workplace, as well as, inflexible requirements(30) are all responsible for retention rates within the athletic training profession.

Athletic trainers preferred to have supervisors that would advocate for them, provide recognition, allow for some degree of autonomy in the work place and not be micromanaged.(10) Literature supports that athletic trainers like to be respected and recognized for their skills and contributions to their organization and patients.(30) Participants in our research agreed that promotions or advancements had favorable effects on job satisfaction, organizational commitment, and intentions for staying.(39) Retention rates have been researched and shows that keeping employees happy requires the company to offer work-life balance, organizational commitment, developmental programs, appropriate salaries, career advancement opportunities, tangible rewards and high-quality leadership.(6,21) Those who stay in the place of employment but are not satisfied with their position explain the reasons why they stay are because they are too old to start over, financially dependent on the companies benefit program, have family responsibilities, working to make ends meet and cannot risk seeking a new job, and or the company has been good to them, and they do not believe in leaving the organization. Our participants either had the right social support, respect and loyalty from their employer or they decided that it was too much on their personal life and left the PSS.

Our research revealed that our participants across all PSS agreed that having a personal and professional relationship with their patients was important in gaining their trust.(13) In healthcare, there are two components to patient-clinician relationships: 1) the emotional care that can include mutual trust, empathy, respect, genuineness, acceptance and warmth and 2) the cognitive care which includes information gathering, sharing medical information, patient education, and expectation of the management of care.(23) Furthermore, honesty and genuineness to earn the athletes’ trust was also important to building the clinicians reputation and relationship.(1,2) Athletic trainers are in a unique position that affords them the ability to create trusting relationships that other health care providers may not have because they do not have daily patient interactions. However, patients describe that having a clinician that shows compassion, engagement, and a caring relationship provide healing, hope, and strength during vulnerable situations. The ability to be easily accessed by their athletes allowed for our participants to have check-ups with their patients in the comfort of their location. Having the capability to perform telemedicine efforts allows for efficient and quick access to healthcare for a flow of communication, however it will lack the hands on portion of the interaction as well as full observational access.

Nonetheless in the PSS, athletic trainers and athletes have the ability to interact daily allotting a special relationship that exists where the athletic trainer is viewed as safe, approachable, care-taking individuals and feel comfortable disclosing personal information.(33) Furthermore, the athletic trainer shows an invested genuine interest in the athlete. Some of the participants in our study discussed having both professional and personal relationships with their athletes which included going out to eat or going to the movies. While outside the scope of this study, we recommend that that employees in the PCC review human resource policies related to workplace relationships to ensure they are protecting themselves legally and ethically.

Characteristics of the Workplace Environment

Americans are showing an increased interest in obtaining work-life balance. The work place environment looks into the personal, professional and professionalism sacrifices that athletic trainers are making in the PSS. However, healthcare providers have a natural tendency to work more than 40 hours a week, especially athletic trainers.(30) Our study is consistent with previous literature that athletic trainers are working 80 hours or more,(30) 10 to 14 hour days, during the season and more “regular” 40 to 50 hour days in the offseason. Additionally, these subtleties with organizational factors of long working hours, work schedules, and job dynamics such as travel and flexibility were commonly seen as added stressors with participants in our research as well as previous literature.(3,7)

Work-life balance is defined as the individual’s ability to successfully balance work, personal, and family roles happily.(12) The work-life balance can be seen as a benefit or a unfavorable consequence which is why it is separated into work-family balance; being positive outlooks, and work-family conflicts; being negative outlooks. The underlying causes to work-life conflicts include employee schedule, hours worked, and job demands. However, athletic trainers in each PSS, depending which level in the organization, should expect varying demands and roles expectations. Participants identified that off-season duties consisted of checking in with athletes, working with long term rehabs, working camps, working winter ball leagues (MLB athletic trainers), and finally getting some down time to recuperate and spend time with family and friends. Athletic trainers may perceive that because the profession has always been this way that they need to be available and present 24 hours per day, 7 days a week.(30) Despite the long hours spent at work, the athletic trainers were happy working within the PSS. Recent literature on athletic trainers working in the PSS stated that regardless of the average in-season workweek of more than 70 hours, they accepted the workload, associated stress that was placed on them due to competing demands of the job, and the added non-athletic training duties; they were willing to stay working in the setting.(26)

Furthermore,athletic trainers described that traveling was tedious and that it can cause them to become sluggish. The extreme time and travel loads that are expected of an athletic trainer pose challenges to performing everyday job responsibilities while allocating time for leisure and family.(30) However, athletic trainers showed gratitude for the excessive traveling as well stating that they would never otherwise visit a majority of destinations if it were not for working in the PSS.The time spent traveling conversely means theathletic trainers reported having a strong family support was really important to their success in working in the PSS and the fact their family understood the demands the job required of their time. However, the athletic trainers are accept the mentality that missing family functions and holidays is an unwritten expectation in their respective setting. Those who respectively saw family as more important than work or did not have the right family support left the PSS.

Athletic trainers stated that when the organization shows loyalty to their employees the promotion process is even slower because people do not want to leave the organization. It was even stated that once an athletic trainer finally obtains the top of the totem pole position that they stay as long as possible which makes promotion for those lower on the hierarchy chain harder to attain promotions. Athletic trainers in the PSS described promotion as a long process because they either wait for someone to get fired, quit, or retire. The same promotional advancements up the hierarchy chain is also seen in NCAA Division 1 settings, which pose for athletic trainers seeking other job opportunities or retiring.(30) The athletic trainers within the WNBA and MLR stated that with the growth of their settings they hope to have opportunity for promotions. A majority of our participants had a similar progression of undergraduate and then graduate athletic training programs before obtaining internships or positions within the PSS. The progression was cited to be slower for MLB athletic trainers as they had to experience an internship first then affiliate ball within one of the six affiliate leagues prior to bring promoted to the MLB. MLS athletic trainers stated having somewhat of a similar progression with internships, academy teams, NASL, and MLS. Then the NFL athletic trainers stating having to complete internships first. Regardless of the sport setting, the athletic trainers were slow to progress due to the lack of available positions within the PSS.

The participants commented that verbal harassment was being witnessed within their settings. The female participants experienced comments that they could not do certain activities or job duties because they were a female or not strong enough, having inappropriate comments said to them, or athletes and or coaches going to other staff members who were below them just because they were a female. These barriers for female athletic trainers have been associated with gender equity and work-life balance challenges, particularly those in the Division 1 setting.(11) Athletic trainers in the PSS setting may be responsible for interrole conflict; which is defined as “a situation in which a role occupant simultaneously has more than one role and the demands of one role conflict with the demands of another role;” due to the health care provider roles and non-athletic training duties.(14,26) Our participants stated that having added responsibilities that are outside their role as an athletic trainer which included handling meal money, hotel rooming lists and arrangements, scheduling bus or plane times, transporting players, coordinating player transfers, pre/post-game meal(s), and even cleaning laundry or performing equipment duties.

The majority of the PSS have an intimate setting that is in close corridors. In some of the settings, the locker room and athletic training facility are in the same room. The players are often walking through shirtless, just in their underwear, or walking in a towel and that is just normal of the setting. Most athletic trainers stated that they have become numb to cursing and some forms of verbal harassment and state that it is due to the unique setting. However, some of organizations have a fining system in place if they fall out of line of the organizations standard. Bullying and “rookie” hazing of both athletes and the medical staff was often mistaken as friendly banter and taking things light hearted. However, in 2016 the MLB specifically cracked down and implemented and anti-hazing and anti-bullying policy. It is vital that all athletic trainers, but those specifically in the PSS, have access to and have read their organizational policies related to anti-hazing and anti-bullying while also being mindful of hostile work environment labor laws in the United States that protect all employees from discriminatory behaviors or comments that make it difficult or unwelcoming to work.

In the PSS there are varying nationalities, ethnicities, and cultures that are all housed under the same roof. Athletic trainer’s discussed having a challenging time communicating with their athletes if they did not speak the same language. However, communication was more accessible with an improved connection for those athletic trainers that were bilingual primarily in speaking English and Spanish. The athletic trainers struggled to explain medical care differences between western techniques and those of other countries of their athletes. The athletes from other countries did not understand the process of the western medicine, insurance issues, or the steps needed to receive diagnostic imaging. Overall, each sport setting saw the importance of fostering an environment where everyone, regardless of cultural differences, could feel comfortable. Communication amongst health care providers and patients that relate to culture-related communication issues involved similarities seen in our study; cultural differences in the treatments of health and illness, varying cultural values, and linguistic barriers.(42)

CONCLUSIONS

Athletic trainers in the PSS feel valued for their work despite the long hours, family and promotional sacrifices. The work environment, as cited by our participants, created positive coworker interactions, mutual loyalty, and access to resources is what continues to attract them to this setting. Positive coworker environments and access to resources continue to attract athletic trainers to the PSS. Despite feeling valued, some athletic trainers in PSS reported leaving the profession altogether because they regarded family time more than the time spent at work. A sub-culture of accepting inappropriate workplace behavior within the PSS should be further explored.

APPLICATION IN SPORT

Our study had three female participants, which is consistent with the representation of females employed in the setting itself. During the interviews, male participants expressed that their responses may have been different if they were a female in the PSS or had female coworkers in the PSS. This finding was especially evident during the workplace environment questions. The participants, of both genders, expressed numerous times that inappropriate behavior was deemed acceptable in the PSS. As such, professional sports administration including executive management and human resources should collaborate with the medical staff, specifically the athletic trainers, to create inclusive workplace environments, which will likely improve the talent acquisition and employee retention for those healthcare providers. Lastly, athletic trainers should be proactive in navigating the workplace to improve career longevity and work-life integration within this job setting. Specifically, athletic trainer should gain confidence in immediately addressing and reporting inappropriate behaviors in the workplace, because of the potential impact it has on other patients, not just other healthcare providers. We suggest exploring mindfulness and self-help applications, connecting with human resource personnel before an incident occurs to establish workplace boundaries, and negotiating their roles and responsibilities that afford career advancement and continued positive interactions.

ACKNOWLEDGEMENTS

None

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