Athletic Training Student Coping Strategies During the COVID-19 Pandemic

Research Design

A phenomenological research design¹³ was used to gain a better understanding of the experiences of professional master's ATSs during the COVID-19 pandemic. The fundamental goal of this type of research design is to describe the experiences of a particular group, and the commonality of that experience making it an appropriate choice based on our purpose. The authors used the COREQ checklist to ensure the study's design and analyses were rigorous and standardized as other published qualitative studies.¹⁴ An overview of the study's procedures is provided in Figure 1.

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Participants

Fourteen Professional Master of Athletic Training students (9 female, 5 male) from 14 colleges and universities completed interviews. Eight National Athletic Trainers' Association (NATA) districts were represented. Of the 14 programs represented; 13 different states were also represented (Pennsylvania = 2). On average, the participants were 26 ± 4 years old. All participants were in the final year of their program at the time of the interview except for 1; the remaining participant was already working clinically in the athletic training profession. Further individual demographic data for our participants can be found in the Table.

Table Individual Demographic Data

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Data Collection Procedures

Upon institutional review board approval, recruitment of students began via a gatekeeper (ie, program directors of athletic training programs). Program directors of Commission on Accreditation of Athletic Training Education (CAATE)-accredited programs were sent an e-mail outlining the study's inclusion criteria which included students who were enrolled full time in a Professional Master of Athletic Training program during the spring semester of 2020. Program directors were asked to communicate with any student meeting the criteria, and then interested students reached out to a member of the research team who set up a time to complete the study's procedures. All participants completed a semistructured interview with 1 interviewer lasting approximately 35 minutes. Using 1 interviewer allowed for consistency between interview sessions but also allowed 1 researcher the chance to become immersed in the data as well as develop a rapport during the interviews. The researcher took field notes during the interview sessions to help determine when saturation was met, which occurred at 12; however, 14 were included, as they were already scheduled at the time of the 12th interview. The field notes demonstrated consistency in findings throughout the interviews, and no new information was being collected, so saturation was determined to be satisfied.

The semistructured interview guide was developed with the research aims in mind. Questions were open ended (see the Appendix) to encourage conversation, reflection, and the chance for participants to share more about their personal experiences managing their academic requirements and life responsibilities during COVID-19. The questions were sent to 3 athletic trainers for a content review. All athletic trainers were versed in qualitative methodologies, 1 athletic trainer was a recent graduate of a professional master's program and practicing clinically, and 2 were experts in clinical education, socialization, and mentorship in athletic training. The review resulted in no content changes but some rewording and ordering changes. A pilot interview was completed before data collection with 1 participant, and no changes were suggested. Therefore, the data were included in analyses. All interviews were recorded via the Zoom platform and then transcribed by Otter (Los Altos, CA).

Data Analysis and Credibility

Data were analyzed using an inductive process, with the underpinnings of the phenomenological approach.¹³ The first 6 questions were not included in the analyses of this paper, as they pertained to learning and teaching strategies. Before coding could take place, basic member checks were completed with all participants. The participants were asked to read over the transcripts and make edits for clarity and content. No changes were made during the process. All transcripts were initially read multiple times for a better appreciation and understanding of the overall experiences of the participants; immersion of the data is a key step in phenomenological research. The field notes taken in the interviews also allowed for immersion to happen. The notes taken in the interview sessions were a summary of comments made by the participants that stood out to the researcher as it related to the experiences of the participants. In additional to adding in the process of immersion, it also helped determine saturation was occurring as similar notes were being recorded. Key findings were noted within the transcripts, and with subsequent reads of the data, more detailed notes were taken to illustrate commonalities between the participants. Once these common findings emerged, the data were labeled with a code, and the similar concepts were grouped and operationalized. Quotes were extracted from the transcripts to depict the findings and the themes as presented in the next section.

Upon completion of this coding process, the findings were shared with a peer for evaluation of the analysis process. The peer was provided the initial draft of the results, with 3 coded transcripts as well as the other transcripts uncoded. The peer was independent of the interview sessions and was used to evaluate the coding process as completed by the lead author. A trained qualitative researcher with a background in professional socialization, student development, and role balancing reviewed the codes and verified the authenticity of the presentation of the results. Credibility was also established by data saturation and the member check process, as already discussed.

Importance of Adaptability and Flexibility

Our participants discussed the importance of “going with the flow” and being “accepting of rapidly changing schedules” during the pandemic. Developing an adaptable and flexible mindset helped the students cope with the changing landscape of education and their learning. Taylor, during her interview, discussed ways she was managing her stress and the unknowns of her education. She shared about her takeaway from the last year of her education:

We need to be flexible and understanding and quickly accommodate and adapt to be successful students, successful athletic trainers, just successful people in general. So I think that was my major coronavirus takeaway.

Stephen, too, felt the biggest thing he learned and embraced during his experiences was “just, you know, be flexible. . . yeah, just because you have a plan today doesn't mean it's going to work tomorrow.” Stephen recognized that, when he was using a flexible mindset, his stress was reduced. He said, “I was focusing less on what I didn't have control over and more on just letting stuff go and trying to go with the flow. It helped me stay on track.”

James and Juliet both discussed the impact of uncertainty and the increase in stress with the unknown each day. The importance of being “adaptable” and “going with the flow” was the advice they shared for other students. Betty, related her experiences to becoming a better athletic trainer in the future “because you just learn how to be adaptable, which is already something that athletic trainers are kind of known for and how to really work with whatever the world is giving you really.” She used the mindset of being ready yet adaptable to her coping method. Taylor, who had talked about going with the flow, found value in having to learn to be okay with the unknown, as it would translate into clinical practice. She said, “In athletic training, you know, you have to go with the flow. . .” Taylor understood that “being okay with whatever happened” was hard at times but something that could help with the future because “athletic trainers don't usually have any control.”

Empathy for Oneself and Others

Taking a step back to appreciate that the pandemic was impacting others was shared as something that helped our participants cope with the stress of the pandemic. James said, when talking about his own personal stressors and trying to manage it, “I'm trying to understand and remember that it's not just us [as students] that got behind. It's not just athletic trainers. It's everyone.” Taylor summarized her overall experiences during COVID as “being a more understanding empathetic person. I think [that] was a huge takeaway for me from the pandemic.” She continued saying, “I think I became more empathetic towards other people and more willing to understand individual experiences.” Inez talked about taking a step back, looking at the bigger picture. She was reflective, “You can't control the global pandemic when everyone is going through it.” Inez recognized that her stress was her own but that everyone had something they were going through, and this helped her cope. She said, “There are a lot of bigger issues, not just the global pandemic.” Drew talked about his mindset and sometimes thinking about the big picture. He shared, “I think my overall mindset was that I knew I was going through something that was difficult, but I knew it was difficult for everyone.” Although the pandemic increased the stress for our participants due to changing expectations and delivery of education, many participants recognized that they were not alone, and this alleviated some of the stress they were feeling. Bill shared, “I am aware I am not alone. Taking a step back allowed me to be more empathetic as well as breathe easier.”

Stress Management

Our participants shared the need to manage their stress during the COVID-19 pandemic by creating downtime to rejuvenate. Many of those techniques were centered on making time for themselves, independent of schoolwork and studying. Karlie shared, “I just needed to feel relaxed. So I would do candles and set myself up in a comfy spot. I would have a cup of tea and listen to music.” Alone time to relax was also discussed by Abigail to reduce stress. She admitted “making sure that I am getting adequate alone/quiet time” was important to her stress regulation.

Time management was also discussed, as using it could help create more time away from schoolwork and feeling stress. Gigi and Karlie both talked about their use of “lists” to schedule time for different tasks and obligations. Gigi said about her stress management:

I like to make lists, just so I could check it off. I'm more of a visual type of person that just likes to have everything in front of her and be able to go down the list and not stress myself out about thinking over everything.

Karlie shared:

I think a big thing for me for stress was writing everything out, and I tried to do lists, so that was helpful. Quarantine was the same schedule [everyday], so creating some sort of schedule was helpful.

Time to exercise was also discussed as a stress relief technique and time to get away from the daily grind. Bill resorted to “working out as a stress reliever.” He also discussed cleansing his mind by using “meditation.” Other participants shared using “exercise or working out” as ways to cope with stress or to take time away from their studies. James said, “My number one thing and really the only thing I'll do to really relieve a lot of stress is just work out and run.” Betty said about her stress management, “I would try to work out every day like I normally would.”

Importance of Adaptability and Flexibility

Athletic trainers working within the athletic or sport model require some acceptance of changing schedules, being able to adapt quickly, and in some regard, accepting the unknowns often associated with athletics scheduling and culture.¹³ Our participants discussed they were not only able to become more flexible and adaptable due to COVID-19, but some also recognized the potential positive impact of developing these skills for their careers in the future. Neal,¹² in his editorial about managing stress as an athletic trainer, noted the positive impact of having to “weather a storm” to become better at stress management. Accepting the athletics way of life has been found to support career longevity for athletic trainers as well as facilitate improved work-life balance.¹⁵ Conflicts between work and home can be stressful, and in theory, learning to manage these demands can reduce stress. Thus, for our participants, learning how to be more adaptable and flexible with the work demands helped them not only reduce stress but hopefully have long careers that are balanced.

Empathy for Oneself and Others

Having support from friends, family, spouses, and colleagues who can sympathize as well as empathize with work and life stress is important. Although this recommendation regarding support systems seems commonplace, development of skills such as empathy may not be as natural. The COVID-19 pandemic appeared to foster the development of an empathetic mindset for our participants, which positively influenced their stress evaluation as well as management of their own stresses. The mindset can be a gateway to not only effective patient care but also to promote a positive workplace environment that can promote lower stress, improved work-life balance, and overall create a stronger morale among colleagues.^15–17 Past researchers^16,17 and testimonials¹⁸ have reported that having peers and colleagues who understand the demands of athletic trainers positively impacts work-life balance, as often shared life or work experiences translates to feeling understood, supported, and validated when stressed, all factors helpful in reducing stress and improving balance. Indeed, finding outside support networks of friends and family as well as programmatic (faculty, staff, preceptors) and peer support have been found as key coping mechanisms in ATSs previously.⁴

Stress Management

Stress management is often tantamount with coping, making our results demonstrating the use of stress management techniques to deal with COVID-19 unsurprising. Our participants discussed a variety of ways to manage stress, some of which were rooted in self-care such as exercise and disengagement. The importance of self-care practices as well as embracing moments of quiet and relaxation have been noted previously.¹² Several of our participants discussed taking the time to decompress and unwind through a variety of mediums. Using personal time to reduce stress has been found previously^4,10 when looking at perceived stress and burnout among ATSs. Most students stated they used exercise and physical activity to alleviate stressors related to coursework demands. Making time for personal rejuvenation is a common recommendation and finding within the literature for reducing stress as well as finding work-life balance.¹⁹ Staying active was also an important stress-relief technique discussed by our participants. Exercise beyond stress relief has positive impacts on one's physical health, as it reduces the negative effects of stress. However, we were surprised that no participants brought up unintended consequences of the pandemic due to mask wearing, social distancing, and quarantine, especially while discussing stress relief. We suspect their appreciation of adaptability, flexibility, and empathy for others may explain the avoidance of the topics. Using time management strategies such as to-do lists has been a longstanding recommendation for stress management and has been reported as a technique ATSs use to cope with their stress.^4,20,21,22 Prolonged stress is a precursor to burnout, and in some cases, burnout and stress can be viewed as similar. Therefore, consistent with the literature^3,9 examining burnout and prevention strategies, we found that to-do lists and other forms of time-management practices were used to reduce stress.

Future Directions and Limitations

Our study was purely qualitative, and thus, the findings only speak to a small group of ATSs. Although the findings help shed some light on how ATSs are managing the stress associated with the pandemic, continued research needs to be completed. We examined the coping strategies used in the current landscape of COVID-19 but not if and how their ability to cope with stress has been modified because of it. Authors of future studies should include a follow up to do a retrospective comparison of stress and coping before, during, and after the COVID-19 pandemic. Our sample included both sexes, and thus, in the future, a comparison of sexes and the impact sex can have on stress and coping could be of interest. Additionally, we had 2 participants who were outliers in age. Determining how life stage plays a role in coping is important. Finally, we did not measure any levels of perceived stress, and the focus of this study was purely exploratory due to the unique times. Future researchers should continue to quantitively and qualitatively assess the impact of COVID-19 on learning, stress, and coping.