Athletic Trainers’ Psychosocial Experiences During the COVID-19 Pandemic: A Qualitative Research Study

Given the generative, exploratory focus of this investigation, as well as our emphasis on the participants’ in-depth lived experiences, we selected an inductive conventional content analysis approach to identify emerging themes common to our participants’ narratives of their psychosocial experiences over the course of the pandemic.^15,16  Inductive conventional content analysis is used to explore questions for which structured theory or frameworks do not exist or are not well-developed,¹⁵  which aligned with the current state of knowledge regarding our purpose. Data were generated during the summer of 2021, which allowed participants to reflect on their experiences as they planned for, executed, and adjusted to the resumption of sports on their campuses in the previous months. The study was approved by the San Diego State University Institutional Review Board before the study began.

The total sample comprised 27 ATs; a summary of the participant demographics is presented in Table 1, whereas detailed individual participant characteristics are provided in Table 2. All participants were employed at the Division I, II, or III level with diverse sociodemographic and institutional characteristics. To be included, participants were required to self-affirm that they (1) were employed as an AT at an NCAA–affiliated institution during the COVID-19 pandemic and (2) were involved in the planning and execution of their university’s return-to-sport policies and procedures. Initial recruitment occurred via our professional networks and was supplemented by snowball sampling. We then applied purposive sampling to “round out” the group in terms of personal, institutional, and contextual characteristics.¹¹ 

A semi-structured interview design was used to elicit participant responses in alignment with the study’s purpose. Participants were interviewed regarding their perceived experiences throughout the implementation of their athletic department’s COVID-19 return protocols. The general flow of the interview guide prompted participant responses related to (1) the individual’s background, demographic, and work context; (2) planning for return to sport; (3) successful and unsuccessful outcomes; and (4) lived psychosocial experiences. Though only the final section explicitly probed participants to detail their mental, emotional, and social health, they often described components of their psychosocial experiences in addressing sections 1 through 3; thus, data generated from the full interview guide were included when deemed relevant to the participant’s psychosocial experience. This interview guide was previously validated by scholars and practitioners with expertise in the psychosocial health domain^10,11  and was used and published in research detailing the roles and responsibilities of ATs during the COVID-19 pandemic.¹¹  The full interview guide is included as Supplemental Material (see https://doi.org/10.4085/1062-0517.22.S1).

Each participant completed 1 interview session, which was scheduled for 60 minutes. Interviews were conducted via Zoom (Zoom Video Communications) and were recorded and transcribed automatically. All but 1 interview (participant 17 due to scheduling logistics) was conducted by 2 members of the research team, with the interviewers alternating questions while prompting follow-up and probing questions when they deemed appropriate. Purposive recruitment was used to create a contextually and demographically diverse sample across characteristics such as geographic regions, school size, and years of experience. Recruitment concluded when we deemed that data saturation had been reached on the basis of minimal information being yielded by ongoing interviews.¹⁵  Those who agreed to participate were emailed a form that gave an overview of the study’s purpose and requested their consent before the interview.

Several strategies aided in establishing credibility and confirmability.^15,16  Continuous echoing and comprehension probing were used for within-interview member checking to ensure clear, accurate communication of the participant’s intended messaging.¹⁷  In addition, field notes were taken by the interviewers during and after each interview session; multiple-researcher triangulation and peer review (as described in the Analysis section) were also used to establish trustworthiness of the results.^15,16 

To begin the inductive conventional content analysis process, a single member of the research team (J.S.D. or T.E.A.) completed an initial wave of independent coding to examine each transcript and determine a preliminary thematic structure. Next, a secondary coder on the research team (H.J.R.) conducted an independent internal review of the transcripts and met with the initial coder to hone the thematic guide and discuss, confirm, and challenge the generated themes. Transcripts were then peer reviewed by a third member of the research team (E.G.P.), who was not involved in the previous steps of the analysis; this coder integrated themes from review of the transcript into the existing thematic structure, at which point the other members of the research team discussed how these new themes aligned or challenged their more in-depth experience during their full review of the transcripts. We also discussed and came to a consensus on how best to label each theme and subtheme: when possible, we selected terminology that was explicitly used by the participants or was viewed as common language in health science domains.^15,16  Last, an external auditor with expertise in the psychosocial elements of health care conducted a peer review by independently analyzing a randomly selected transcript to ensure reliability of the results in relation to the transcript and codebook.^15,16  This auditor’s feedback was then distributed to the full group once more to obtain validation of the emerging themes, resulting in the final thematic structure (Figure).

The inductive analysis process generated 3 higher-order themes that characterized our participants’ psychosocial experiences: (1) internalized experience, (2) interpersonal interactions, and (3) AT identity. Through these themes and their associated subthemes (Figure 1), meaningful factors that enhanced and challenged the psychosocial well-being of these ATs during the pandemic were identified.

The first overarching theme of participants’ narratives pertained to the ATs’ internalized psychosocial experiences, such as their emotions, thoughts, and attitudes. Whereas these internal factors were likely affected by those around them and the environment in which they worked, this theme emphasized narrative elements that were isolated from the ATs’ larger social spheres, instead centering on constructs within the individual.

The first internalized experience subtheme that was commonly mentioned was a sense of burnout. Consistent with the qualitative nature of this study, we did not identify burnout using any objective measure but the term was used frequently and explicitly by the ATs (Table 3). Common causes of this perceived burnout included working long, inconsistent hours and the feeling that they were unable to take any time off to recharge. “You look back at it today and [think] ‘where did the year go?’ I am so ready, just like I believe a lot of ATs are, for a break. Because … it has been a long year” (Participant 3).

This accumulated pressure, as well as a self-imposed expectation to rise to this novel challenge, left many ATs feeling as if “their tank was empty”: “When things were bad and people were relying on me and I kept getting more and more added to my plate, that got very frustrating for me … because I couldn’t do it all and … I was just breaking down” (Participant 14).

Whereas this feeling of burnout was discussed in an internalized sense, our participants’ burnout was often affected by uncooperative or unsupportive stakeholders: “It’s bad enough already being burned out in a regular year … then you add COVID, and then a crazy coach is breathing down your neck—it makes the situation worse” (Participant 18).

The challenge of navigating the constantly shifting landscape related to the pandemic was commonly described. Respondents noted the counterintuitive nature of being asked to make decisions and recommendations that would affect the health of those in their setting without the requisite evidence to strongly support these plans. Given ATs’ emphasis on implementing evidence-based practice, the lack of empirical evidence and the questions that arose from identifying gaps in knowledge appeared to create a uniquely taxing situation: “What stood out to me was our lack of readiness with our written policies, our lack of readiness to answer questions that came up during the implementation process—there was just so much we didn’t know yet” (Participant 3).

The frustration caused by the lack of high-quality research evidence was compounded by pressure from other stakeholders to make immediate, precise, and effective decisions. When new information became available, plans needed to be adjusted and refined. Integrating novel and at times conflicting incoming information was a major source of stress across our sample, especially in the preparation phase: “I am reading daily updates and recommendations, procedural guidelines and things like that, and they’re changing daily—so I think the most frustrating [thing] for me has been the lack of consistency” (Participant 5). To best navigate this uncertainty, our respondents learned to practice acceptance of their evolving situation, even linking this approach to their role as an AT: “A lot of uncertainty, but I think we deal with uncertainty every day. Part of being an AT is being comfortable being uncomfortable” (Participant 3). One individual provided a mantra for overcoming this uncertainty: “Adapt, adjust, improvise” (Participant 8). Whereas participants appeared to perceive this attitude as helpful in mitigating the psychosocial distress they experienced, it was also clear that dealing with constant uncertainty without reprieve was a challenge: “[It] takes a toll over and over again, to keep waiting for something to get better—nope, things are worse … so there was no light at the end of the tunnel” (Participant 4).

Another key influence on our participants’ internalized experiences was their ability, or lack thereof, to maintain a positive, adaptive perspective during the challenging, and at times dire, circumstances. One respondent cited the mantra of “don’t sweat the small stuff” as a reminder of what was important and what was not (Participant 7). More broadly, the ATs benefited from recognizing that they could not control everything; despite their best efforts to plan and deliver health and safety protocols and create a controlled environment, a multitude of variables outside their control existed that threatened the effectiveness of these plans. Recognizing what could be addressed and then preparing for speed bumps along the way by “controlling what you can control” (Participant 6) appeared to be an optimal approach for maintaining the necessary perspective to benefit their psychosocial health.

An additional attitude that assisted in maintaining perspective was to look for any “silver linings” among the many difficulties of the pandemic. These included the enhanced trust that ATs built in themselves and received from others as they navigated the novel circumstances of COVID-19 and allowed athletes to participate in a safe manner: “Once you get to the top of the mountain, people saw what we were doing and how successful we were, and if you look at our numbers, we didn’t have a lot of positive cases” (Participant 26). In addition, it was common for respondents to show enthusiasm for the positive changes to their clinical practice that had taken place in response to COVID-19, such as more streamlined clinical procedures and structures (Participant 2), greater flexibility and effectiveness in working together virtually, and an enhanced knowledge of public health and infectious disease. Many ATs also expressed optimism that the changes and growth experienced during the pandemic would carry over into future endeavors:

However, 1 participant concisely summarized the simplest silver lining for several of the ATs in our sample: “I survived” (Participant 10).

As the final internalized experience subtheme, our sample emphasized their increased awareness about the importance of self-care and managing their mental health. Beyond this awareness, several participants mentioned that they sought resources or direct assistance in managing their mental health, something that was a new experience for them: “I think it’s been very difficult, I struggled with my mental health during this period … mentally it took a really heavy toll on me, I had to seek mental health assistance myself” (Participant 27).

One frequently cited method for mental health support was virtual counseling, which was generally well-received by ATs. However, this was not universally accepted by student-athletes, which led to more perceived stress on the ATs’ part:

Individuals did not clarify specific factors or characteristics that led to the virtual counseling being viewed as more effective by ATs than by their athletes.

The second overarching theme related to the social component of our participants’ experience was interpersonal interactions. These themes characterized how COVID-linked challenges and limitations affected the participants’ ability to engage with their surrounding social systems, as well as how these limitations affected the perceived quality of their social connections throughout the course of the pandemic.

The ATs in our study often detailed an implicit awareness of the heightened stress levels of those in their social circles. This sense of collective stress was multifaceted (ie, intrapersonal, interpersonal, emotional, cognitive) but ever-present, meaning that the vast challenges of the pandemic were palpable in interactions with others:

As the previous quote illustrates, sources of stress varied based on a person’s role and unique characteristics, but it was clear that this stress was widespread across campus and clinical settings, outside of work, and in society as a whole. A frustrating part of this experience for ATs was the inability to control how others were managing their stress; when managed poorly, it had a compounding effect: “[Our administrators] were facing pressures from the university as well … so I think there was kind of a trickle-down effect. I think everyone’s feeling that pressure” (Participant 7).

Another challenge to the psychosocial experiences of our participants was the inability to connect through social engagement. This included “not being able to see friends” (Participant 14), as well as a perceived lack of quality social interactions that occurred virtually. Also evident was hesitancy to engage in opportunities for in-person socializing due to a fear of spreading the virus, which was especially true for those who had family members or friends with elevated COVID-19 risk factors:

On a more positive interpersonal note, ATs commonly described an increased sense of cohesion among themselves and their staffs, institutional stakeholders, and professional networks. A key way in which this manifested was through frequent communication and collaboration with ATs at other institutions, partnerships that lessened our participants’ mental strain:

It is important to acknowledge that although these close partnerships had an overwhelmingly positive effect, having to rely so closely on these interpersonal relationships involved certain drawbacks. As one participant put it: “I’ve never been more salty with a lot of coworkers, but I’ve also never been more appreciative. I run the gamut of emotions throughout this thing; [it’s] been unprecedented” (Participant 17). Several respondents identified enhanced cohesion as a critical aspect of their experience that they hoped would carry on in their interpersonal interactions even as the pandemic subsides and clinical settings moved closer to their pre–COVID-19 state.

Last, our ATs indicated that their awareness of the importance of social support and how that support affected their well-being also increased throughout the pandemic: “That helped an awful lot in getting us through this … you never felt like you were alone, and you always had a big group of people supporting you to help you through this thing, so that was really cool” (Participant 4).

Similar to enhanced group cohesion, this heightened awareness of the influence of social support appeared to be in direct response to the challenges of the pandemic, which present another silver lining for future interpersonal interactions moving forward: “We’ve been through a lot and been able to … keep going to persevere and push through, and we’ve had support and got a lot of positive feedback from our coaches and administration in the job that we’ve done. So that should help [in the future]” (Participant 5).

The third higher-order emerging theme detailed the pandemic’s effect on how our participants viewed themselves and their role as an AT. Whereas these themes are related to and affected by the previously detailed internal and interpersonal factors, the AT identity theme differed in its emphasis on participants’ perceptions of their role, value, and tasks as an AT, as well as how their professional responsibilities influenced their experience as a holistic person outside of their clinical setting.

A typical element of our participants’ narratives related to their AT identity was the feeling that the novel demands of the pandemic had strained their ability to effectively fulfill all the tasks and responsibilities they associated with their role as an AT. Respondents discussed how they needed to “wear a lot of hats” (Participant 7), which included more public health–focused responsibilities as well as serving as a conduit for communication among various stakeholders and campus entities. This latter responsibility was especially difficult when translating policy and practical guidelines to campus stakeholders who were not supportive or were not accustomed to receiving instruction on how to manage their team from the AT: “Student-athletes, parents, coaches—who do they go to? I became the resource for all things COVID for athletics … so I’m taking the bullet on things I didn’t really have control of. I was just the messenger. So the messenger got beat up” (Participant 2).

In addition to communicating policy and recommendations, ATs often found themselves in the position of enforcing protective protocols, or as 1 individual termed it, being “the COVID cop” (Participant 1). This role was universally viewed as undesirable by our participants, and being forced into this responsibility was a key differentiator in their positive and negative psychosocial experiences:

Next, it was common for participants to describe the struggle of maintaining work-life balance, meaning that it was difficult to feel fulfilled and successful as both a professional and as a person outside of professional settings:

A main factor that contributed to these challenges was the inability to “clock out” of a professional mindset due to around-the-clock occupational demands and new information updates:

Previous researchers^10,11  explored the successes and challenges of policy and procedure development and implementation for ATs working in the collegiate setting during the COVID-19 pandemic. Our findings add to the literature by revealing the perceptions of psychosocial health and in-depth lived experiences of ATs during that period of time. The 3 emerging overarching themes were (1) internalized experience, or the emotions, thoughts, and attitudes of the clinicians; (2) interpersonal interactions, or the quality of participants’ engagement with their surrounding social systems; and (3) AT identity, or how the participants perceived their value and role as both an AT and as a person to be influenced by the pandemic.

Internalized-experience factors were the emotions and attitudes of clinicians that encompassed burnout, navigating uncertainty and changing conditions, and managing their health and self-care. Our ATs and many other health professionals had already identified professional burnout as a wide-reaching challenge before COVID-19.^18–21  Of note, we did not specifically measure burnout with an objective scale. However, participants often implicitly described elements of burnout during their interviews—such as experiencing emotional exhaustion and depersonalization of patients—and several individuals explicitly used this term to describe their psychosocial state. Earlier investigators²⁰  linked burnout with decreased sleep quality in clinicians and increased irritability, depression, anger, and frustration. Equally concerning, burnout can lead to decreased quality of patient care and more medical errors.^23,24  Concerns related to burnout are likely to be exacerbated by the pandemic, and it is critical to anticipate a rising rate of professional burnout in order to create effective interventions and systems to address the sources of burnout. These sources likely stem from the greater demands and pressures and new responsibilities in the workplace as a direct result of the pandemic but also from the added collective stress of daily living during the pandemic.^10,11,25  Whereas organizational factors have been shown to affect work-family conflict (a predictor of burnout) of collegiate ATs,²⁶  we are also continuing to learn how personal health, relationships, and financial stresses can contribute to workplace performance and burnout.²⁷  It is unrealistic for ATs to completely “leave their stress at the door” when they are at work or at home or to expect that those stressors would not affect their well-being and perceptions of burnout.

An apparent unintended benefit of the COVID-19 pandemic for ATs was an increased sense of their own capabilities, such that many participants felt they could get through anything after navigating the pandemic. This juxtaposition of respondents describing perceived clinical burnout while also feeling more capable of handling adversity in their settings is an interesting nuance that brings to light a potential silver lining of the pandemic: as ATs became more aware, educated, and effective in navigating their own psychosocial challenges, it stands to reason that they would also be more effective in addressing these components of their patients’ health. Although not measured explicitly in this qualitative study, this finding is conceptually linked to professional resiliency, a construct that has shown negative correlations with work-family conflict and positive correlations with work-family enrichment.²⁸  Those who are able to demonstrate resiliency in times of high stress are better equipped to “weather the storm” and navigate conflicts in their professional and personal lives.²⁹  Similarly, because patients needed more assistance in the area of mental health, clinicians may have developed increased awareness of resources and strategies for managing that area of health care.

The second emerging theme detailed interpersonal interactions and highlighted the participants’ quality of social engagement with their surrounding systems. A major subtheme was the role of collective stress: the clinicians themselves, coworkers and administrators, athletes, and other stakeholders were all experiencing stress, which compounded into an emotional weight larger than the sum of its parts. Our participants indicated that this prolonged intensive contact with patients and exposure to multidimensional stressors led to exhaustion and a decreased ability to empathize with patients, characteristics that align with the construct of compassion fatigue.³⁰  Participants also described a lack of social engagement opportunities as a barrier to stress relief because physical distancing restrictions and increased professional demands limited opportunities to see friends and colleagues outside of professional settings—often a vital component of personal self-care and wellness.¹⁰  At the time of the interviews, the ATs felt that as physical environment restrictions decreased and interactions increased, this would be less of a problem. However, many individuals also felt that socialization would likely feel strange or create anxiety while establishing a new normal, a social experience that has been previously identified in health care clinicians working during the pandemic.³¹  Alternatively, coworkers who were able to continue interacting regularly during the pandemic felt that they had strengthened bonds and created systems and communication strategies that would improve their work environment in the future. Earlier researchers³²  highlighted the role that social support plays in decreasing work-family conflict, and our results underscore the importance of collaborative relationships. Overall, participants emphasized the importance of social support and group cohesion moving forward: in other words, the need for system-level strategies to combat work- and life-related needs.

The third theme encompassed AT identity and how the pandemic influenced how participants viewed themselves and their role as both a professional and a person. Athletic trainers are often spread thin with normally assigned tasks, duties, and responsibilities.^19,22  During the pandemic, demands were higher and resources were lower, which further disrupted the ATs’ established identities. For example, whereas public health elements are woven throughout the athletic training accreditation standards, many clinicians did not anticipate serving in the role of an infectious disease expert; yet during this time, they were often the “point person” for multiple stakeholders in terms of translating information and best practices.

In addition, ATs frequently became the “COVID police” to enforce health and safety protocols that they had created because no designated system existed for enforcement. This required ATs to divert their time and attention from more typical operations to monitor and enforce protocols. In previous research,^10,11,25  ATs reported that they encountered stress at various stages of resuming sport, with people in their environment not following protocols and a lack of administrative support identified as stressors. At all levels, ATs experienced a compromise in their ability to be personally and professionally fulfilled as they navigated these challenges. Earlier work³³  not specifically related to the COVID-19 pandemic indicated that a higher professional self-concept was associated with lower levels of stress, which was supported by our results. The additions to daily job functions, outside of those typical of the profession, further heightened stress due to the increased hours needed for the new responsibilities and a lack of conventional home and work settings due to remote work and physical distancing. This made work-life balance even more difficult to achieve.³³  Also, because ATs served as leaders at their institutions for policy creation and implementation, the success and failure of these plans influenced how the participants valued themselves as ATs. Positively, respondents expressed pride in their role in reopening campuses and sport programming, which served to lessen feelings of burnout and psychosocial distress. Negatively, having low administrator or stakeholder buy-in and policing the implementation of policies exacerbated feelings of stress and led to devaluation of their own perceived value as health care providers.

Whereas the qualitative, inductive approach for this study yielded novel insights and depth of data, several important limitations must be considered. Participants were recruited on the basis of convenience and snowball sampling of individuals in our extended professional networks. Thus, the testimonies of these participants may not reflect those of ATs who were not approached or chose not to engage in the study. It is also possible that this recruitment procedure, though logistically practical, led to a degree of homogeneity in the sample. For example, most participants who completed interviews were men over the age of 50 years (Table 2). Moreover, to be included in this study, participants must have indicated that they were “involved in the planning and execution of their university’s return-to-sport policies and procedures.” However, included participants were not delineated by their specific job title (eg, head AT, assistant AT); given that their staff position may have influenced their psychosocial experience, this lack of role specificity in the analysis approach may be an important consideration when characterizing our sample and interpreting the emerging results.

Future researchers should evaluate psychosocial constructs (eg, burnout, self-efficacy, self-concept) in ATs using objective, quantifiable measures to inform associations and relationships between the characteristics of the participant, the setting, and these various psychosocial factors. Understanding the precursors to psychosocial distress can then inform the creation of testable psychosocial interventions and resources aimed at promoting clinician health and well-being. Furthermore, tracking the mental health trajectories of ATs and the athletes they treat—through direct, longitudinal tracking—is an important step in clarifying the degree to which the psychosocial experiences of our participants are isolated occurrences due to the pandemic or the new norm for the profession.

The role of collegiate ATs during the COVID-19 pandemic was associated with perceived strain on their psychosocial well-being, both professionally and personally. Psychosocial distress has been linked to job attrition and career departure; it would be prudent to consider the potential implications of clinician turnover on patient care and outcomes. For clinicians who stay in the field, psychosocial distress can lead to poorer patient outcomes and an increase in medical errors, so it is critical to characterize and understand these constructs in athletic training. Of note, clinicians were open to talking about these psychosocial stressors and the effects on their mental well-being, signifying a possible shift in the stigma that is often associated with mental health. This recognition of their own mental health and well-being may also help clinicians raise awareness among their patients. We identified key themes to outline these ATs’ experiences (eg, role strain, navigating uncertainty, burnout), emphasizing the need to create and test sustainable strategies and resources for enhancing stakeholder health as they rebound from the pandemic, as well as in navigating future challenges.

Found at DOI: https://doi.org/10.4085/1062-0517.22.S1