Burnout Levels and Mood States Among Athletic Training Students in Professional Master's Programs

KEY POINTS

• Professional master's students reported high levels of burnout in both midterm and end of semester time points, mainly due to a lack of personal accomplishment.

• Participants reported meeting expectations contributed to their feelings of burnout, while personal time and social support assisted in reducing feelings of burnout.

• Identifying individuals at risk for burnout, or those who are currently experiencing burnout, may be an important step in preventing anxiety and depression in individuals.

INTRODUCTION

The rates of mental illness in individuals aged 18–25 has risen significantly in the last 10 years. Recent research suggests that 25% of individuals in this age range reported experiencing a mental illness in the last year.¹ Although many current studies do not include rates of burnout, they appear to be closely related to rates of mental illness, particularly depression.² Burnout is defined as a condition that results in emotional and physical exhaustion facilitated by prolonged stress.³ According to Kania et al,⁴ symptoms of burnout may affect performance and lead to decreased care provided to patients by health care professionals. In a previous study, it was reported that severe burnout was reported in nurses employed in the intensive care unit at teaching hospitals.⁵ Severe burnout was associated with increased depression levels, and many of the employees considered changing professions.⁵ Equally important, burnout can become a condition that influences the overall wellness and performance of professionals if they are not exposed to enough time off and positive professional relationships with coworkers and patients.⁵ If heightened levels of burnout exist in health care professionals such as athletic trainers (ATs), it may negatively affect their clinical work.^5,6

The occurrence of burnout has been more prevalent among ATs in comparison to other health care professionals (ie, physicians, nurses), teachers, and coaches.⁶ In a previous study of certified ATs at Division I-A universities, a significant amount of stress was exhibited in both the emotional exhaustion (EE) and personal accomplishment (PA) dimensions of burnout.⁶ These higher perceived stress scores were correlated with higher EE and depersonalization (DP) and lower scores of PA, as determined by the Maslach Burnout Inventory (MBI).⁶ In addition, a previous study focused on certified graduate assistant ATs concluded that newly certified ATs should be included in research efforts regarding burnout in order to more accurately represent both current and potential burnout in athletic training programs.⁷ Identifying warning signs of burnout in young professionals is especially important because they are learning to adapt and manage professional responsibilities along with personal obligations.⁷ It is indicative that ATs may encounter a considerable amount of burnout in their job choices because of the need to balance multiple sports at work and manage personal commitments. Coinciding, athletic training students specifically are upcoming professionals who are transitioning into the career stage of life. Stress levels are higher in undergraduate athletic training students who are seniors preparing and making plans following graduation compared to freshmen, who still have time before they need to be concerned with the next step in life.⁸

During an academic semester, stress may arise and mood states may vary. Mood state components include depression, anxiety, and anger⁹ in individuals and can result from academic workload, clinical experience, and clinical research, for example. Mood state levels can be determined by the Profile of Mood States (POMS) survey, which is composed of 40 questions, regarding how individuals feel about a specific mood during a particular time.⁹ Previous literature has suggested that students often begin academic semesters with low levels of depression, anger, and fatigue, later peaking in the midsemester and improving by the end of the year.¹⁰

Athletic training education has started to transition the professional degree to the master's level. The opportunity to obtain a bachelor's degree and enter the profession will be discontinued by the start of fall 2022, as required by the Commission on Accreditation of Athletic Training Education. With this in mind, we need to consider the altered mood states and burnout levels that exist in current athletic training master's level professional students. This area of interest is compelling because AT students currently in professional master's programs tend to exemplify a multitude of mood states and burnout levels throughout the first and second year of the program, and this may continue to be more applicable with upcoming professional master's students as well.⁸ Kania et al⁴ suggested that graduating from a professional master's program was an indicator of EE. There have been changes found based on time point during an academic semester among undergraduate students¹¹; however, this has yet to be studied in professional master's level students. Therefore, the purpose of our study was to determine mood states and burnout levels across all levels of professional master's students at distinct time points during an academic semester including midterm and end of the semester.

METHODS

Instrumentation

We collected data by asking the participants to complete the POMS⁹ and the MBI,¹² which were distributed online using Google Forms. In addition, 3 open-ended questions were included for the participants to explain their answers in greater detail (Table 1).

Table 1 Open-Ended Questions

View Fullscreen

We used the MBI to determine the risk of burnout through the constructs of EE, DP, and PA.¹³ The MBI is meant for use in health service professions to allow burnout measurement in those working in a wide range of health care occupations.¹³ Therefore, we slightly modified some questions to be appropriate for students rather than working professionals. Emotional exhaustion is defined as depletion of emotional resources which causes individuals to decrease in performance on a psychological level. Depersonalization can be described as having cynical feelings towards clients. Personal accomplishment is a measure of competence and successful achievement in one's work.¹³ By definition, and supported by Kania et al,⁴ a severe level of burnout is characterized by high EE (ranging from 0–54), high DP (ranging 0–30), and low PA (ranging 0–40). Average burnout is characterized by average EE, DP, and PA. Low burnout is characterized by low EE, low DP, and high PA.² The MBI consists of 22 questions and is reported to be highly reliable and valid.^12,14 The MBI is on a scale of 0–6, 0 representing never and 6 representing every day.¹³ In this inventory, participants were given statements such as: “I accomplish many worthwhile things in school.” The reliability coefficients were reported for each subset as the following: 0.90 for EE, 0.79 for DP, and 0.71 for PA.¹⁴

We used the POMS survey regarding how individuals feel about a specific mood during a particular time to measure mood states. The POMS consists of 40 questions and is reported to be moderately reliable and valid.⁹ The POMS is quantitative and is rated on a scale from 0–4, 0 being not at all and 4 being extremely, and participants were asked to rate words such as “tense,” “angry,” and “worn out.” The survey was divided into subscales consisting of tension, depression, fatigue, vigor, confusion, anger, and esteem-related affect. Reliability coefficients for the subscales of the POMS were reported to range from 0.66–0.95 with a mean of 0.80.⁹

Qualitative questions were determined by factors that demonstrated what was or was not contributing to feelings of burnout. Our initial question was: “Do you feel burnt out? Yes or no.” If the response was yes, the participant was directed to the question of: “What factors contributed to your feelings of burnout (ie, course load, clinical hours/experience, research)? Please explain your answer.” On the contrary, if the answer was no, participants were asked what some of the coping mechanisms were that they used to prevent burnout. We also asked all participants what they would change about the program in which they were currently enrolled. The use of these open-ended questions were to get further explanation for certain responses of quantitative questions.

RESULTS

A Friedman's 2 way analysis test demonstrated that, for burnout scores from the MBI, the PA subscale had statistical differences ({\rm{\chi }}_1^2 = 5.765, P = .016) among the 2 time points. There was no statistical difference in the DP ({\rm{\chi }}_1^2 = 0.027, P = .869) and EE ({\rm{\chi }}_1^2 = 1.256, P = .262) subscales over the 2 time points. For mood states based on the POMS scores, the composite total mood disturbance score was not statistically different between the 2 time points ({\rm{\chi }}_1^2 = 0.200, P = .655). The median scores for burnout subsets and mood state composite scores can be found in Table 2.

Table 2 Median Values (Range) for Burnout Subscales and Mood State Composite Scores for First (October) and Second (December) Time Points

View Fullscreen

We found 3 themes from our qualitative analysis. First, meeting expectations caused burnout most often. The second and third themes related to the use of personal time and social support as successful coping mechanism that assisted in the reduction of burnout. The majority of the responses to our qualitative questions for those who were experiencing burnout were associated a great deal with meeting expectations for course load and/or clinical hours. Adam mentioned, “The course load combined with the large amount of clinical hours and lack of sleep build up to feeling completely drained by the end of the semester.” Sarah agreed and had some outside factors that affected her as well. She acknowledged, “The class schedule is very heavy in terms of time commitment and material in addition to going to my clinical site every day. This leaves little time to study, work, socialize, and decompress.” Another important factor that some institutions have but others do not is the research component of their program. Jane said that this was one of the main causes of her burnout. She replied:

The number of clinical hours and number of classes we need to take is very challenging. Research is also demanding on top of this. Being able to segment this somehow would be a lot more helpful.

We also had reports of 3 participants who did not experience feelings of burnout by implementing coping mechanisms. Regardless of stressful endeavors from school work and clinical experiences, these 3 made sure they resorted to personal time and social support as a means to prevent burnout throughout the semester. Chad said, “Personal time, social support, and exercise” were what committed to benefiting him most. With a similar response, Shane added that he “practiced sports and would spend time with friends.” Finally, Shana said she copes with stress by using “personal time (relaxing, running, going out), social support (classmates, professors, preceptors, roommate), and sports (cross country).”

DISCUSSION

The motive for our study was inspired by the limited amount of research available on burnout and mood state levels in graduate students enrolled in professional athletic training programs. We found that students reported high levels of burnout in both midterm and end of semester time points. Two out of 41 participants did not report feelings of burnout during the midterm semester. By the end of the semester, only 1 participant reported no feelings of burnout. Personal accomplishment was reported to have an impact on burnout levels throughout the midterm and end of the semester. The EE component did not contribute to reasons behind heightened levels of burnout in students, and neither did DP over the 2 time points. In regard to mood states, we found a positive shift at the end of the semester based on median scores. However, mood state levels did not depict a change in how students felt at the 2 time points.

In Mazerolle and Pagnotta,¹⁵ students reported more burnout symptoms toward the end of the semester as well as high workload and lack of personal time as being the major factors of burnout and elevated stress levels, which supported our findings. A major attribute to the burnout and stress levels of the students was that they were experiencing prolonged stress that was directly correlated with demanding schedules of that particular semester. The 2 main variables that were found to be the cause of burnout for these students were time and role strain. It was reported that students felt they did not have enough time in a day to complete assignments and also have time to themselves to do other activities. Role strain was related to the time needed to be a committed athletic training student. The experience of burnout related to role strain consisted of being an athletic training student, a friend, family member, etc.¹⁵

Bellini et al¹⁰ suggested internal medicine students were less likely to sustain decreased mood upon the end of the semester, which was also similar to our findings. In second year students, this was due to nearing the end of the program upon graduation. These students were consistently identified as being less tense, depressed, and confused compared to first year students.¹⁰ However, it was found that the depression levels of students improved during the midterm period and peaked by the end of the semester. Bellini et al¹⁰ reported that, by there being a decrease in depression levels, confidence was improved, and students could remain calm in tough situations.

Our study was refuted in comparison to a study by Riter et al,⁸ who found that PA did not have a significant effect on students. When placing emphasis on stress level and mood states, Stilger et al¹¹ suggest that stress levels may vary with certain academic periods throughout the year. In the months of October and December, stress levels may heighten because of midterm and final exams having an effect on stress and anxiety.¹¹ Results may differ if the survey was distributed in other months, since there is usually a relief period for students.¹¹

Current research suggests that burnout has a complicated relationship with both anxiety and depression.¹⁶ A recent meta-analysis¹⁶ showed that, while there is some overlap between anxiety, depression, and burnout, they are different concepts. More longitudinal research needs to be conducted to determine whether burnout may result in an increase in depression and anxiety. Identifying individuals at risk for burnout, or those who are currently experiencing burnout, may be an important step in preventing anxiety and depression in individuals.

LIMITATIONS

It is important to note that there were some limitations to the study. We encountered an issue related to external validity which was having to depend on program directors to forward our original e-mail to the students in the programs they led. Having to depend on program directors could affect the number of students who received the survey at the first time point distribution. This would automatically exclude students from being able to complete the survey at the second time point and being included in data collection. We had to take into account the honesty and effort that participants put forth when completing the survey. Finally, we did not ask those who experienced burnout about coping mechanisms they used in an attempt to reduce stress. We believe this would be an important area for future research.

RECOMMENDATIONS

Further research should be conducted to determine whether similar results exist with other factors taken into account such as specific year, sex, and number of clinical hours averaged, for example, comparing burnout and mood state levels in first year graduate females against second year graduate females, as well as male counterparts. Also, for open-ended questions, researchers should speak with the participants over the phone or in person instead of having them answer online to obtain greater depth to responses. In addition, different time points should be used including the spring semester. Finally, a third time point could be added in as well for a beginning time point rather than just midterm and end of the semester throughout master's level programs.

CONCLUSIONS

Athletic training professional graduate students' burnout levels are high at both the midpoint and end of the semester, as determined by self-reported POMS and MBI subset scores. Our findings differ from previous research that found that students identified just in their last year of the athletic training program tend to experience high level stressors that resulted in increased burnout levels, which mostly contributed to EE. Our findings indicated that, as a whole, high level stressors were reported from lack of PA. Clinically, mood states were reported to improve from midsemester to end of the semester. Participants reported meeting expectations contributed to their feelings of burnout, while personal time and social support assisted in reducing feelings of burnout.