Athletic Trainers' Influence on National Collegiate Athletic Association Division I Athletes' Basic Psychological Needs During Sport Injury Rehabilitation

We used convenience-sampling procedures²²  to recruit NCAA DI athletes who had (a) sustained an injury within 1 year of the interview and (b) been unable to fully participate in practices or competitions for at least 4 weeks. The sample comprised 10 athletes (7 women, 3 men) from DI institutions in the northwestern and southeastern United States who were between 19 and 24 years old (mean age = 20.9 ± 2.0 years) at the time of the interview. Nine participants self-identified as Caucasian and 1 as biracial (Caucasian and African American). Athletes had been involved in their sport for an average of 11.8 ± 4.8 years and represented 4 sports: cross-country and track and field (n = 4), swimming and diving (n = 4), basketball (n = 1), and softball (n = 1). Participants sustained a wide array of injuries to various parts of the body, including the foot and ankle (n = 4; ie, Achilles tendinitis, osteochondral lesion, torn Lisfranc ligament, and unknown torn ligament in the ankle), back (n = 2; ie, stress reaction, torn ligament in lower back), hip (n = 1; ie, torn labrum), upper leg (n = 1; ie, fractured femur), knee (n = 1; ie, degenerative cartilage), and shoulder (n = 1; ie, torn labrum). Three athletes were not fully recovered at the time of the interviews. Among the 7 who were fully recovered, recovery times ranged from 7 weeks to 1 year (mean recovery time = 35.9 ± 15.2 weeks).

The first and second authors (M.P.B., J.R.) developed a semistructured interview guide based on an extensive review of the literature on sport injury^3,19  and self-determination theory¹⁶  as well as interview guides previously used to explore athletes' perceived basic psychological needs.²³  The guide allowed for uniform data collection across individuals while also permitting probing.²⁴  Questions were developed to explore athletes' perceptions of (a) ATs' influence on their basic psychological needs of competence, autonomy, and relatedness and (b) how ATs' influence on these needs affected their motivations. Both positive (ie, satisfaction) and negative (ie, thwarting) influences on athletes' basic psychological needs were explored. Throughout the interview, probes were used as needed. Finally, questions regarding the nature of injury (eg, recovery time, concerns) and participant demographics (eg, sport, age, ethnicity) were asked. The interview guide was then sent to the third and fourth authors (R.A.Z., L.A.F.), faculty members with expertise in the psychology of sport injury and self-determination theory who provided feedback on the wording and flow of the questions. At the time of the study, the first author—who conducted all interviews—was a sport psychology doctoral student who had previous experience as an interviewer in a number of research studies and had ample coursework and training in qualitative research methods. Before the main study, a pilot interview was conducted with 1 former DI cross-country runner who had previously sustained a stress fracture. As a result, the interviewer learned how to ask more useful probing questions and tested the effectiveness of the guide in comprehensively exploring the constructs of interest; no changes were ultimately made to the interview guide.

Upon obtaining institutional review board approval, the first author e-mailed 24 athletes whose addresses were provided by ATs and mutual contacts of the authors. This e-mail informed them of the study's purpose and asked for their participation. In total, 10 athletes agreed to participate, and the other 14 athletes did not respond. Dates and times convenient for participants were then arranged for interviews; 8 took place in person, whereas 2 were conducted via telephone. Previous researchers²⁵  found no major differences between face-to-face and phone interviews. Before each interview, participants read and signed an informed consent form. Each person was assigned a pseudonym to protect confidentiality. Throughout the interview, the first author took notes to identify potential probes and themes to revisit during data analysis. Based on his experience as an interviewer, his notes, and a preliminary analysis of the data, the first author initially ascertained that data saturation occurred by the eighth interview. To ensure this assumption was accurate, 2 more interviews were carried out, and, as expected, no new themes emerged. Interviews lasted between 24 and 58 minutes (mean = 36.4 ± 10.9 minutes), were audio recorded, and were transcribed verbatim with transcripts averaging about 13 single-spaced pages.

The interview data were analyzed using consensual qualitative research (CQR)²⁴  procedures by a research team that consisted of 4 members (ie, the first 4 authors: 2 women, 2 men) with experience in qualitative research. Each member read through the transcripts and independently constructed preliminary themes. The team then met multiple times to arrive at a consensus regarding a table of domains (ie, themes), categories (ie, subthemes), and core ideas (ie, raw data themes) that comprehensively represented the participants' words. Although they contained both inductive and deductive elements, the domains were ultimately guided by a deductive approach because they reflected the interview guide topic areas.²⁴  The research team agreed that data saturation was achieved. Next, the first and second authors each conducted an independent cross-analysis to determine which and how many interview transcripts reflected each category. They then met to reconcile any differences. Per CQR,²⁴  these quantitative frequencies were translated into labels (ie, general = all or all but 1 of the cases, typical = more than half the cases, or variant = half the cases or fewer; Table). Thereafter, the interview guide, transcripts, and preliminary table of domains, categories, core ideas, and frequencies were sent to an external auditor (ie, the fifth author), who checked for biases and provided an outside perspective.²⁴  The external auditor provided feedback regarding how accurately the table represented the major findings from the transcripts. More specifically, the fifth author identified a number of instances in which a participant's comments should have been included or excluded from a specific category. The research team met once again to discuss how to incorporate the external auditor's suggestions and ultimately agreed with most of the proposed changes. Although this resulted in numeric frequency changes for some categories, they were not substantial enough to produce any changes in the labels (ie, general, typical, or variant).

A number of criteria (ie, credibility, transferability, dependability, and confirmability) were used to enhance the trustworthiness of the study.²⁶  For example, member checking was employed to augment the credibility, or the appearance of “truth,” in the study. Transcripts were sent to participants to give them the opportunity to modify their comments or contribute additional data.²⁴  Similarly, the preliminary table of domains, categories, and core ideas were sent to the participants before the cross-analysis to see if their words and main ideas were accurately represented. Ultimately, no changes were made to the interview transcripts or domains, categories, or core ideas. The dependability, or stability of observations, was cultivated through the consensus process and reliance on an external auditor. In other words, multiple researchers ensured that the most agreed-upon “truth” could be presented.²⁴ 

In addition, before the main study, the first author participated in a bracketing interview, which was conducted by an experienced qualitative researcher to examine any potential biases and presuppositions about the research topic. Research team members also discussed their personal biases and expectations before data analysis to enhance the confirmability, or the extent to which the findings were shaped primarily by participants' accounts. Although the idea of bracketing biases is grounded in phenomenology, CQR researchers also use this technique to enhance their awareness of “beliefs that researchers have formed on reading the literature . . . [and] personal issues that make it difficult for researchers to respond objectively to the data.”²⁷  The research team was composed of 2 doctoral students and 2 faculty members in sport psychology. Three researchers self-identified as Caucasian and 1 as biracial. All members had experience competing at a high level (eg, 1 member competed at the DI and 1 at the DIII level). Additionally, 3 of the 4 members had previously sustained serious sport injuries. With respect to their expectations, 1 member believed that participants would report negative experiences with ATs, whereas another member presumed that athletes would have low perceptions of autonomy. Multiple individuals assumed that participants who perceived satisfaction of their basic psychological needs would also report high levels of motivation during rehabilitation. When evaluating and presenting our findings, we frequently considered the research team's backgrounds and presuppositions.

As a result of the CQR procedures, 4 domains were constructed: (a) athletes' concerns about injury and rehabilitation, (b) ATs' feedback and athletes' perceptions of competence, (c) a person-centered approach from ATs and athletes' perceptions of autonomy, and (d) a connection between ATs' and athletes' perceptions of relatedness (Table).

Before discussing their perceptions of how ATs influenced their basic psychological need fulfillment and motivations, participants described their major concerns about injury and rehabilitation. This domain contained 2 categories: (a) physical concerns and (b) psychosocial concerns.

Participants discussed a number of physical concerns, which included lingering pain, immobilization, and flexibility. Several also expressed frustration with the lack of progress during rehabilitation. Mary, a softball player, said, “I was still in a lot of pain; I was really inflexible in my hip, so through the recovery process, I knew I wasn't where I was supposed to be and that started to really concern me.”

Similarly, Patrick, a cross-country and track and field athlete, mentioned concerns about weight loss and reduced strength due to atrophy of his lower body muscles. Participants also identified performance concerns. For example, Caleb, a cross-country and track and field athlete who experienced numerous setbacks, discussed missed opportunities: “Being injured means you're going to miss big races. . . . As a super senior, I had my mind set pretty firmly on trying to get to the big races to compete to try and get to regionals.” Tanya, a basketball player, added:

Scott, a cross-country and track and field athlete, felt his recovery was “a passive healing process” due to not having a rehabilitation regimen. Falling behind teammates in fitness level appeared to be salient concerns for multiple participants.

Additionally, athletes mentioned a myriad of psychological and social worries in response to their injuries (eg, depression, decreased confidence, disconnection from teammates). Mary noted, “I felt really disconnected from my team at the time . . . I felt like I wasn't even part of the team actually . . . like I was just sitting on my crutches in the dugout.” Multiple respondents also reported a lack of familiarity with their injury. In fact, for many athletes in the sample, this was their first major injury. Brittany, a diver, remarked:

Some participants also reported fears of disappointing their team. Dawn, a swimmer, who was injured before beginning her collegiate career, said, “Especially moving into college, I didn't know what the coaches would think and what the expectations of me were and if I'd let the team down.” In sum, participants shared multiple interpersonal and intrapersonal concerns related to sport injury rehabilitation.

Respondents discussed their perceptions of how ATs fostered their feelings of competence, which were largely tied to the feedback they received. The categories in this domain were (a) information about injury and recovery, (b) clear expectations and goals, and (c) encouragement and reassurance.

A number of participants commented that the depth and clarity of injury-related information given by the AT influenced their belief in being able to make a successful recovery. For instance, Tanya described the use of visual information in aiding her ability to understand her injury:

The AT not only explained the injury and recovery process to Tanya but held her accountable for understanding this information, which fostered feelings of competence. Furthermore, the quality of the information provided by ATs helped to “normalize” the recovery process for a number of participants. Brittany described how her AT was able to improve her perspective during the more difficult days of rehabilitation:

Reminding athletes that pain and other perceived setbacks were a normal part of recovery helped them maintain their feelings of competence.

Conversely, some respondents observed that they received limited feedback about their injury and rehabilitation exercises. For example, Mary stated,

Due to the lack of feedback on her rehabilitation exercises, Mary reported experiencing diminished feelings of competence. Moreover, it appeared that from Mary's perspective, her AT was not fully invested in her recovery. As a result, the relationship between Mary and her AT as well as Mary's motivation during rehabilitation appeared to be damaged.

In addition to providing helpful information, multiple participants discussed the value of working with ATs who set clear expectations and goals. Patrick mentioned how his AT's goals and motivations influenced his own motivations during rehabilitation:

Dawn liked that her AT set clear expectations through constructive criticism: “She definitely gives constructive criticism . . . ‘You can change this, but you're doing this [well],' so not just relying on the negatives. She balances it.”

However, not all participants reported receiving clear expectations and goals for rehabilitation. Mary noted, “There wasn't any structure in my recovery process at all.” Similarly, Caleb explained,

Caleb's poor perception of the AT's competency resulted in a negative influence on his own competence during rehabilitation.

Moreover, encouraging and reassuring comments (or the lack thereof) from ATs had a vital effect on athletes' perceptions of competence and overall motivation during rehabilitation. A number of participants credited their ability to psychologically manage rehabilitation demands to positive comments from their ATs. Interestingly, only female participants, such as Tanya, verbalized this experience:

Additionally, athletes including Dawn found value in ATs voicing their confidence “in me that I can do these things and that I can go 1 stroke further, I can go a certain amount farther of what I think I can accomplish.” Multiple participants perceived that this feedback positively affected their motivation during rehabilitation. Tiffany, a cross-country and track and field athlete, was grateful for her AT's encouragement, which “makes me feel like I really can do this—even when it's really hard. He makes me think that since I've gotten to this point I might as well keep going.” In contrast, Mary felt that her AT's lack of encouragement and reassurance had a negative influence on her recovery process:

Respondents addressed how their ATs used a person-centered approach (or lack thereof), which significantly affected their perceptions of autonomy. The categories in this domain were (a) input from the athlete, (b) availability and flexibility, and (c) a dual focus on health and performance.

Participants discussed connections between the input their AT solicited from them and their motivations during rehabilitation. This category emerged from all 10 transcripts. For example, Dawn believed that her input was valued with regard to rehabilitation exercises:

Similarly, Lydia, a swimmer, said, “Sometimes, if there's 2 different exercises that will work the same thing, she'll let you pick which one you want to do . . . like a bridge or a [bird-dog crunch].” In other words, some participants were provided choices within the confines of rehabilitation. In contrast, Mary commented:

Clearly, Mary's perceived lack of control had a severely negative effect on her motivation and overall experience during rehabilitation.

Multiple participants spoke about their AT's availability and flexibility. Lydia remarked, “Typically, she just looks at our schedule to see when our classes are and then tries to fit us around our classes.” Similarly, Dawn observed, “She knows if I had a big work week or I had a lot of school work . . . she's very accommodating with those things.” Tanya discussed how her AT was readily available:

Nonetheless, some participants expressed frustration that the AT was not always available in a timely manner. For example, Patrick said, “I guess when he's busy with other athletes . . . I mean he does have a lot of athletes to look into, but I feel like I should be a little bit more of a priority right now because I'm more injured.”

He noted that experiences such as these put a damper on his motivation during rehabilitation.

A few participants felt that ATs should balance health and performance during rehabilitation. Only a few participants referenced this category, but it was a dominant theme that emerged in their interviews. As Caleb explained,

In other words, Caleb expressed a strong desire for his AT to take risks so that he could resume running, particularly because it was his final year of collegiate competition.

In Mary's case, her AT told her that it was her fault she suffered an injury:

Mary and Caleb reported having unique encounters with their ATs regarding their health concerns; neither perceived that their ATs balanced health and performance concerns, which affected their rehabilitation experiences.

Respondents described the personal connection they had with their ATs (or lack thereof) and how it influenced their perceptions of relatedness. The categories in this domain were (a) personableness and rapport and (b) emphasis on the “whole person.”

Nearly all participants reflected on their AT's ability (or inability) to build rapport with them and how important it was for their motivation during rehabilitation. In fact, some mentioned that their relationship with the AT was similar to a friendship. Patrick recognized, “He's very comfortable with everyone; he's not a very strict individual. He's more of like a friend-type deal.” Brittany added, “It's not very rigid. We like to joke with each other. So, it's not awkward if I have to ask for anything. We're more like friends.” In contrast, Mary perceived that her AT did not invest in a strong relationship:

Overall, the athlete-AT relationship appeared to be a strong foundation for feeling (or not feeling) connected during sport injury rehabilitation.

Along with building rapport, many participants realized the importance of having ATs focus on their well-being beyond the sport domain. Tanya stated,

Tanya was able to talk to her AT about matters outside of the athletic context: “I had some family problems. My parents were going through a divorce . . . and any girls that I was dating at the time or anything like that. She was just super open and open-minded.” She continued to explain that

Consequently, being able to connect with her AT appeared to positively influence Tanya's motivation during rehabilitation. Though not describing his own relationship with his AT, Caleb made similar points when he discussed the ideal athlete-AT relationship:

Because this was not the kind of relationship he had with his AT, Caleb was not motivated to go to the athletic training room. He also believed that if his AT had inquired about other areas of his life, they could have developed a more personalized approach to his recovery.

The purpose of our study was to qualitatively explore NCAA DI student-athletes' perceptions during sport injury rehabilitation of (a) ATs' influence on their basic psychological needs of competence, autonomy, and relatedness and (b) the influence of need fulfillment and thwarting on their motivations. Several domains, categories, and core ideas were expressed by these participants. Throughout this section, we explore the connection between the study results and the relevant literature. Additionally, practical implications of the major findings are provided.

Participants identified a number of psychosocial concerns during rehabilitation that have been reported in the literature, including feelings of disconnectedness⁴  and anxiety due to lack of predictability and familiarity with the recovery process.²  Moreover, although apprehensions about letting one's teammates down have been described as salient at the onset of injury,³  we found that for some DI athletes, these concerns persisted throughout sport injury rehabilitation. As a result, it may be helpful for ATs to assist athletes in focusing on controllable aspects of their injuries (eg, completing rehabilitation exercises) instead of dwelling on the past. Similarly, educating coaches about providing appropriate social support rather than inadvertently conveying an “injured athletes are worthless” attitude would be beneficial. Additionally and consistent with previous research,^3,4  athletes expressed frustration with various physical concerns such as perceived loss of fitness, lengthy recovery times, and lack of progress during rehabilitation. We sought to understand how injured athletes perceived that ATs addressed concerns about injury and rehabilitation by fostering (or, in some cases, thwarting) athletes' basic psychological needs for competence, autonomy, and relatedness.

According to participant accounts, ATs enhanced their perceptions of competence by providing information about injury and recovery, clear expectations and goals, and encouragement and reassurance. Interestingly, each of these categories in domain II appeared to be aligned with the dimensions of informational support described by Hardy et al²⁸ : reality confirmation (ie, acknowledging that other injured athletes share similar experiences), task challenge (ie, challenging athletes' mindsets to enhance excitement and creativity toward rehabilitation), and task appreciation (ie, acknowledging athletes' efforts).

First, respondents observed that the detailed information supplied by ATs normalized their injury, which has been found to facilitate physical and psychosocial recovery.¹²  This form of reality confirmation allowed injured athletes to see the symptoms and challenges faced during rehabilitation as similar to what other injured athletes had experienced. Accordingly, this helped buffer any decrements in competence that are often experienced during the injury and recovery process. Consequently, ATs should provide clear and relatable information to athletes about injury and recovery.

Second, multiple participants noted that clear goals and expectations expressed by their AT positively influenced their feelings of competence. Also known as task challenge, this form of individualized support has been shown²⁸  to be effective because athletes can make adjustments during rehabilitation if necessary. Similarly, Podlog and Dionigi²  noted that coaches used goal setting to enhance athletes' feelings of competence as they returned to play. As a result, ATs should assist athletes in developing goals to initiate structure and deliver constructive criticism while maintaining high expectations.

Third, many athletes discussed the influence of ATs' reassurances (or lack thereof) on their perceptions of competence and overall motivation during rehabilitation. This finding is similar to the Hardy et al²⁸  conceptualization of esteem support, which involves strengthening an athlete's sense of competence or self-esteem by providing positive feedback on his or her abilities and skills and expressing confidence in the individual's ability to cope with injury. Interestingly, this category was prevalent in all 7 female participants and yet absent from the transcripts of the male participants. As in a previous study, women, in general, were more likely to be socialized to verbalize the need for emotional support than men.²⁹  However, it is possible that the sex or gender of the AT also affected the relationship with his or her athletes. Further research is warranted to investigate how the AT's gender may influence athletes' perceptions of basic psychological need fulfillment during sport injury rehabilitation. In any case, it is vital that ATs provide encouragement, especially during rehabilitation setbacks.

For a number of respondents, the injury they described was the first significant one they had sustained in their sport. Consistent with previous investigations,^3,30  athletes pointed to ATs as a vital source of informational support during rehabilitation. The fact that athletes' perceptions of competence seemed to be contingent on this informational support underlines the notion that a need-fulfilling interpersonal style—while providing individuals with a sense of choice—does not imply offering complete independence. With respect to the coach-athlete relationship, Mageau and Vallerand³¹  suggested that “without coaches' instruction and structure, athletes lack the necessary information and experience to progress in their discipline.” Although previous authors³⁰  have indicated that athletes need more informational support from sports medicine professionals during the return-to-play phase, our results highlight such guidance from the AT as necessary to foster an athlete's perceived competence during the entirety of sport injury rehabilitation. Overall, even though social support in the sport injury rehabilitation context has been researched and theorized,^28,30  our findings suggest that self-determination theory is another framework that can be used to understand and explain its effectiveness, particularly that of informational support.

Perceptions of ATs soliciting input from athletes, offering choices of rehabilitation exercises, and being available influenced participants' feelings of autonomy, which aligns with previous research.³²  This emphasizes the value of ATs using an autonomy-supportive interpersonal style that values “the other's [athlete's] perspective, acknowledges the other's feelings, and provides the other with pertinent information and opportunities for choice, while minimizing the use of pressures and demands.”³³  As discussed earlier, this is not meant to diminish the importance of ATs guiding athletes through the rehabilitation process but rather to encourage them to promote an autonomy-supportive climate in which athletes perform behaviors based on their own volition rather than a controlling environment that they feel pressures them to think, feel, and act in certain ways.³⁴  That is, ATs have the knowledge and expertise to develop a plan for athletes' rehabilitation, yet:

Thus, fostering athletes' need fulfillment will allow them to internalize the value of their behavior, and, in turn, increase their rehabilitation adherence. This appears to be an important consideration as ATs have reported low motivation to be a determinant of poor rehabilitation adherence.⁵ 

Finally, participants expressed dissatisfaction with their ATs for both not showing enough urgency in returning to play (ie, favoring the health of the athlete) and exerting too much pressure on the athlete (ie, favoring performance). Both situations are consistent with sport sociology research³⁵  suggesting that the hypermasculine nature of sport (eg, normalizing pain and injury) is often valued at the expense of long-term health. Although this notion was mentioned by a few respondents, it would be worthwhile to explore how ATs balance these health and performance concerns, particularly in the NCAA DI setting. In other words, a greater understanding of how ATs navigate these concerns at both the micro (eg, rehabilitation overadherence, pressure to return from coaches) and macro (eg, “win-at-all-costs” environments) levels is needed.

Injured athletes indicated that their AT's ability to build rapport was critical to laying a foundation for a positive attitude toward rehabilitation. Consistent with our athletes' perspectives, Tracey¹⁴  found that health professionals perceived rapport building as an important factor in their clients' psychosocial rehabilitation. Specifically, the ability to be personable and work with athletes who have different personalities appears to be instrumental in forming those personal connections. Rapport also facilitates effective communication between the AT and athlete.³⁶  That is, by fostering relatedness through rapport building, it may be easier for ATs to also indirectly promote competence (eg, communicating clear information about the injury) and autonomy (eg, seeking input on recovery). Therefore, these 3 basic psychological needs often do not operate independent of each other; rather, they synergistically directly influence and are influenced by each other.

Athletes who perceived that their ATs cared about them as a whole person (eg, athletic, academic, and social well-being) noted that this had a positive effect on their motivation. Investing in “whole-person” development has also been identified by coaches as instrumental to a caring relationship.³⁷  In turn, it has been theorized that when coaches demonstrate caring behaviors and athletes perceive that coaches care, athletes will increase their effort, which will lead to successful performance. This care-performance relationship is likely applicable to the AT-athlete relationship as well. Thus, ATs can demonstrate caring behavior (ie, whole-person investment) by asking personal questions outside of sport. Future research regarding the role of care in ATs' philosophies and behaviors is needed.

Our study offered an in-depth understanding of the relationship between a sample of athletes and ATs, but it also had a few limitations. First, for some participants, the time between the injury and the interview was lengthy (up to a year); therefore, the depth and breadth of the data may have been limited by memory decay and bias. Nonetheless, a retrospective design allowed these participants to make meaningful reflections about their injury. Similarly, the time from the injury to the interview varied among participants. As a result of these 2 limitations, we recommend longitudinal designs, which allow participants to be interviewed at multiple times, for future research.

Behaviors enhancing the basic psychological needs of competence, autonomy, and relatedness positively affected athletes' motivation during sport injury rehabilitation. Conversely, when competence, autonomy, and relatedness were thwarted, athletes perceived the relationship with their AT more negatively and reported that it decreased their motivation. These accounts from DI athletes suggest strategies for ATs to consider for promoting self-determined forms of motivation, and, in turn, facilitating positive physical and psychological recoveries.