Participants

A geographic stratified random sample of institutions with Commission on Accreditation of Athletic Training Education-accredited entry-level athletic training education programs (ATEPs) were invited to participate in this study. (Accredited ATEPs at National Association of Intercollegiate Athletics schools were not included due to the small sample they represented.) All accredited ATEPs were grouped by National Athletic Trainers' Association (NATA) district and then categorized by their institution's National Collegiate Athletic Association (NCAA) division classification. An equal number of institutions from each NCAA division was selected randomly within each district. The NCAA division was used as a selection factor to account for ACIs working at institutions with various levels of staffing or resources. The number of institutions per district was based on the proportion of all accredited ATEPs in each district. For example, in 2005, District 4 contained approximately 24% (n  =  71) of all ATEPs. Therefore, 24 institutions were selected randomly from District 4. From this sample, a stratified sample of 8 ATEPs was then randomly selected from each NCAA division. Three ACIs (head athletic trainer [HAT], assistant athletic trainer [AAT], and graduate assistant athletic trainer [GAAT]) from each selected institution were invited to participate.

Instrumentation

The Athletic Training ACI Role Strain Inventory was adapted (with permission) from the Mobily Nurse Faculty Role Strain Inventory.6 The original instrument6 contained 44 items to measure the degree of role strain and 7 subscales to measure its contributing factors (Table 1). In addition, Mobily's6 instrument measured the effect of professional and employment demographics and job congruency on role strain; it was based on traditional faculty roles (ie, teaching, research, service). We adapted the items to fit the patient care (ie, injury prevention, evaluation, treatment, rehabilitation), athletic training clinical education (ie, instruction, student evaluation, student supervision, documentation of clinical proficiencies), and administration (ie, paperwork associated with patient care) responsibilities of collegiate ATs. Two versions of the Athletic Training ACI Role Strain Inventory were developed, with 1 version for HATs and AATs and the other for GAATs. Both versions of the instrument had 3 sections: role strain inventory, socialization experiences and professional and employment demographics, and job responsibilities. The instruments were pilot tested with a convenience sample of 15 collegiate ATs (2 HATs, 4 AATs, and 9 GAATs) who currently served as ACIs (years of experience ranged from less than 1 to more than 10 years). They reviewed the instruments for overall clarity, purpose, and relevance, and revisions were made accordingly.

Section 1 of both versions of the instrument examined role strain and contained 42 items that measured how often different aspects of the roles as a collegiate AT/ACI were perceived to contribute to role strain. Participants used a 5-point Likert scale to rate these items (1  =  never, 2  =  rarely, 3  =  sometimes, 4  =  frequently, 5  =  nearly all the time). Participants were asked to add items they felt contributed to their role strain. Alpha reliability coefficients were obtained using the 42 items constituting the total role strain inventory and for each of the 7 subscales. The α coefficient for the total inventory was .89. The α coefficients for the 7 subscales were as follows: Role Incompetence  =  .86, Role Overload  =  .85, Intra-Sender conflict  =  .80, Inter-Sender Conflict  =  .79, Role Ambiguity  =  .79, Role Incongruity  =  .75, Inter-Role Conflict  =  .67.

Section 2 of the instruments contained 7 items to examine socialization into the role of ACI. Anticipatory socialization was determined by the participants' highest degree earned and whether they perceived that the degree prepared them for the role as ACI (4 questions total), whether they had a teaching certificate, and whether they had a formal background in teaching and learning (eg, academic coursework regarding learning theories). For the purpose of this study, we considered the ACI training required at each institution to be a form of organizational socialization (because it is unique to each ATEP). One item was developed to determine participants' perceptions regarding the adequacy of this ACI training. Section 2 of the instruments also contained 6 items regarding professional and employment demographics: sex, NATA district, number of hours worked per week, number of athletic training students supervised per semester, number of years experience supervising athletic training students, and number of student-athletes for whom they are responsible each semester. The GAAT version also contained additional items to determine the average number of academic credit hours taken per semester and the number of semesters (rather than years) of experience supervising ATSs. At the time of this study, accreditation standards and guidelines permitted GAATs with less than 1 year of certification from the Board of Certification to serve as ACIs.

Section 3 of the instruments examined job responsibilities. On the HAT and AAT version of the instrument, participants were asked to indicate the job category that best described their current appointment (eg, full appointment in athletics department, dual appointment in athletics department and academic unit). Both versions of the instrument contained 3 items to measure congruency in job responsibilities. The purpose of these items was to compare participants' perceptions regarding their ideal job responsibilities with their actual and expected job responsibilities. Participants were asked to consider 3 areas of responsibility: patient care (included injury prevention, evaluation, treatment, rehabilitation), clinical education (included student instruction, evaluation, supervision, and documentation of clinical proficiencies), and administration (included completing any documentation associated with patient care and insurance). Participants were asked to indicate which combination of responsibilities represented how they would ideally like to spend their time at work, how they actually spend their time at work, and what expectations are encouraged or promoted by their immediate supervisors. Options for each question included primarily patient care; clinical education; administration; patient care and clinical education; patient care and administration; clinical education and administration; and patient care, clinical education, and administration.

Procedures

This study was approved by the Institutional Review Board at The University of North Carolina at Greensboro. The program director of each randomly selected institution was contacted via e-mail about participating in the study. Program directors were mailed a survey packet and were instructed to distribute the appropriate version of the Athletic Training ACI Role Strain Inventory to the HAT and AAT (1 each) and GAAT (1 only). Each participant returned the completed instrument directly to the principal investigator in a prepaid, self-addressed envelope. In an attempt to capture ACIs with various in-season sports and AATs and GAATs with various years of experience, we conducted 2 rounds of data collection. The first round was during the spring 2005 semester with 49 (51%) of the randomly selected institutions (37 ACIs responded). The second round was during the fall 2005 semester with 47 (49%) of the randomly selected institutions (81 ACIs responded). During the spring-semester round, program directors were instructed to administer the instrument to the AAT and GAAT with the most experience as ACIs. During the fall-semester round, program directors were instructed to administer the instrument to the AAT and GAAT with the least experience as ACIs.

Demographics

A total of 58 (60%) of the 96 randomly selected institutions participated in this study. We had an ACI response rate of 68% (n  =  118) from the participating institutions (potential of 174 ACIs with 3 ACIs from each institution). Participants represented all NCAA divisions, both sexes, and 9 of the 10 NATA districts. A total of 36% (n  =  42) of the HATs and AATs had full-time appointments with athletics while serving as ACIs; 38% (n  =  45) had dual appointments in the athletics department and in an academic unit with ACI and classroom teaching responsibilities. The Division III setting (77%, n  =  23) saw the highest percentage of these dual appointments, followed by the Division II setting (44%, n  =  14) and the Division I setting (26%, n  =  8). Only 31% (n  =  37) of the participants reported working more than 40 hours per week. Seventy-eight percent (n  =  92) of the participants supervised 3 or more athletic training students each semester, and 85% (n  =  100) were directly responsible for more than 30 student-athletes each semester. A total of 46% (n  =  12) of the GAATs were in their first 2 semesters serving as ACIs, and 88% (n  =  21) were enrolled in an average of 9 or more credit hours per semester. A complete description of participant demographics is presented in Table 2. We found no differences between total role strain and any of the demographic items.

Table 2 Participant Demographics

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Total Role Strain and Subscale Scores

Some degree of role strain appears to be inevitable in collegiate ATs who serve as ACIs. Figure 1 demonstrates a breakdown for levels of role strain within a normal, bell-shaped curve distribution. Forty-nine percent (n  =  58) of the participants experienced a moderate to high degree of role strain, whereas 51% (n  =  60) experienced a minimal to low degree of role strain. No differences were noted between total role strain and role occupant groups, NCAA division, or sex. Twenty-two items had a mean greater than 2.7, indicating that they contributed to a moderate-to-high degree of role strain (Table 3). The Role Overload subscale had the highest mean score (3.16), indicating that it contributed to a moderate amount of role strain (Table 4).

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Table 3 Items Contributing to a High or Moderate Degree of Role Strain

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Table 4 Results for 7 Subscales of Role Strain

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We found a difference between the subscale score for Role Incompetence and role occupant groups. The GAATs (mean  =  2.32 ± 0.76) experienced a greater degree of role incompetence than HATs (mean  =  1.75 ± 0.64) (F_2,115  =  5.421, P  =  .001) but no difference compared with AATs (mean  =  2.08 ± 0.80). We found no differences between role occupant groups in the following 6 subscales: Inter-Role Conflict, Intra-Sender Role Conflict, Role Incongruity, Role Ambiguity, Inter-Sender Role Conflict, or Role Overload.

A difference was demonstrated between the Inter-Role Conflict subscale score and NCAA division. Division II (mean  =  3.15 ± 0.82) ATs who serve as ACIs reported a greater degree of inter-role conflict than did Division I ACIs (mean  =  2.69 ± 0.82) (F_2,115  =  4.202, P  =  .02) and reported no difference compared with Division III ACIs (mean  =  3.06 ± 0.65). No differences among NCAA divisions were found for Intra-Sender Role Conflict, Inter-Sender Role Conflict, Role Incompetence, or Role Overload.

We noted a difference between the Role Incompetence subscale score and sex, with women (mean  =  2.19 ± 0.83) reporting a higher degree of role incompetence than men (mean  =  1.85 ± 0.66) (F_1,116  =  6.255, P  =  .01). We found no difference among male and female collegiate ATs who serve as ACIs in the following subscales: Inter-Role Conflict, Intra-Sender Role Conflict, Role Incongruity, Role Ambiguity, Inter-Sender Role Conflict, or Role Overload.

Role Strain and Socialization

Organizational socialization appears to affect total role strain. Sixty-five percent (n  =  77) of participants reported that their institution's ACI training prepared them for the ACI role, whereas 35% (n  =  41) reported that their institution's ACI training did not prepare them for the ACI role. An independent t test revealed a difference in total role strain in those ACIs who reported that the ACI training provided by their institution did not adequately prepare them for the ACI role (P < .001; Figure 2).

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Anticipatory socialization experiences did not appear to contribute to total role strain. No difference was seen in total role strain between participants with or without a formal background in principles of teaching and learning (P  =  .50). Also, no difference was shown between total role strain and participants who had a teaching certificate and those who did not (P  =  .38). In addition, the highest degree earned did not result in a difference in total role strain (P  =  .75).

Job Congruency

Job congruency did not appear to affect the total role strain score. No differences were apparent between role strain and ideal and actual job responsibilities promoted or encouraged by the ACI's immediate supervisor. Only 21% (n  =  24) had complete congruency (ie, participants' ideal and actual job responsibilities matched those of the supervisor), whereas 25% (n  =  29) had complete incongruency (ie, ideal job responsibilities were incongruent with actual and expected responsibilities).

Degree of Role Strain

Some degree of role strain in collegiate ATs who serve as ACIs appears to be inevitable. It is logical to assume that as an AT's role set increases to include clinical instruction, health care provision, and administration, the associated role obligations also would increase. Certainly, this can lead to increased likelihood of role strain.4 Although this finding is comparable to academic nurse faculty who report a moderate-to-high degree of role strain in balancing teaching, research, and service,6 it is opposite that of clinical nursing faculty. Clinical nursing faculty reported a lower (although still substantial) degree of role strain in balancing patient care and clinical teaching.11,13 A practical explanation for the discrepancy in role strain between collegiate ATs who serve as ACIs and clinical nursing faculty is the differences in the study designs. Although research on clinical nursing faculty11 focused on role strain related to patient care and clinical teaching, we also focused on role strain relative to administrative duties associated with patient care.

Similar to collegiate athletic training ACIs, academic and clinical nursing faculty report role overload as the highest subscale contributing to role strain.6,11 Nursing faculty (academic and clinical) role overload leads to an increased likelihood of burnout.18 We did not specifically examine burnout in our study, but our results regarding role overload in ACIs should be a cause for concern. Effective coping strategies will be necessary to avoid ACI burnout.

Also of concern is our finding that GAATs serving as ACIs experienced role incompetence. Due to a small sample size, we were unable to determine if the number of semesters of experience as a GAAT affected role incompetence. However, results of other studies seem to suggest that years of experience may be related to role incompetence. One such group19 examined the relationship between years of experience as an AT and clinical instructor behaviors. Novice ACIs (<1 year of experience) initiated active learning behaviors with their athletic training students less often than did more experienced ACIs.19 Researchers20 who examined sources of stress in GAATs found that even those with an average of 1.5 years of clinical experience reported time management challenges that came from balancing clinical education, patient care, and administrative responsibilities with academic responsibilities associated with being a graduate student. We surmise that role incompetence perceived by GAATs may be attributed to a lack of experience in all of these roles. Fortunately, the new Commission on Accreditation of Athletic Training Education accreditation standards require that ATs have a minimum of 1 year of clinical experience before serving as ACIs.2 However, as mentioned previously, 1 year of experience still may not be ideal for quality clinical instruction due to time constraints placed on GAATs.20 To this end, veteran nursing and medical educators21,22 recommended that clinical teaching be reserved for those clinicians who have had several years of clinical experience. In this way, the clinician could mature in the role of health care provider before also assuming the role of clinical teacher.21–23

The NCAA division classification of the institution also affected the degree of role strain experienced by ACIs. The ACIs at Division II schools reported a higher degree of inter-role conflict (eg, dual appointments in athletics and academics), suggesting that the expectations associated with these 2 roles are in conflict. The ACIs at Division I institutions more typically work solely in athletics departments, where the expectation for athletic excellence is high. This situation likely creates more of a sense of urgency in patient care to return high-caliber, scholarship athletes to competition. The priorities for these ACIs clearly are focused on returning these athletes to play. Although ACIs in Division III institutions reported the highest percentage of dual appointments, they likely encountered less pressure to return athletes to competition. Thus, they may report feeling less strain in balancing patient care and academic responsibilities. The ACIs with dual appointments at Division II institutions, however, may be caught in a conflict between the high expectations of the athletics department to return scholarship athletes to competition and responsibilities in the academic unit.

Lastly, sex did not appear to be a factor in total role strain, but female ACIs reported experiencing a greater degree of role incompetence. Literature in the nursing field11,24 offers some insight into this finding. One researcher11 studying female nurses concluded that they may experience additional role strain due to balancing career and family commitments. The nursing literature also discusses the fact that female nurses are socialized into multiple roles as wife, mother, teacher, and nurturer.24 These women may experience an attack on their self-concept as they realize that they cannot meet the demands of all their roles.24 Feelings of inadequacy or incompetence may follow. Some of these same dynamics are plausible in female ATs who serve as ACIs, and the issue warrants further investigation.

Organizational and Anticipatory Socialization

Organizational socialization influenced the degree of role strain for ACIs. This type of socialization often is equated with on-the-job training for skills specific to a particular working environment. Role strain can be reduced with adequate orientation to this environment.11 Conduct of the ACI is also specific to each working environment or clinical setting. Although all ATEPs must include the same topics in the initial training of ACIs, the implementation of this information is specific to each ATEP.2 For example, all initial ACI training must include information on student evaluation, but certainly the evaluation process is specific to each ATEP. The concept of ACI training was not originally designed with the goal of reducing role strain, but some ATEPs may need to reexamine how well their ATs are prepared for the role as an ACI. Clinical instructor educators should consider carefully how to improve on-the-job training of their ACIs. For instance, it may be helpful to conduct more frequent continuing training sessions for ACIs in order to reinforce concepts of effective clinical education and provide increased opportunities for ACIs to seek clarification and feedback on their performance.

Our results did not indicate differences in the degree of role strain between ACIs with different educational backgrounds (ie, anticipatory socialization), yet the nursing literature13 suggests that some level of formal preparation in clinical teaching may reduce role strain. It is not uncommon for nurses to specialize in clinical education at the graduate level.6 One investigator13 noted that approximately 90% (n  =  25) of the clinical nursing faculty who completed formal preparation for clinical teaching in their master's coursework experienced less role strain. In addition, 82% (n  =  23) of these clinical nursing faculty completed a practicum specifically focused on clinical supervision of students.13 Athletic training educators should consider incorporating principles of teaching and learning into their entry-level ATEPs or graduate-level postcertification programs to provide anticipatory socialization for future ACIs. Peer-assisted learning may be an appropriate method of introducing concepts of clinical teaching, feedback, and mentoring that are germane to becoming an effective ACI.25 For example, in a laboratory setting, ATEPs could easily require upper-level students to tutor their lower-level peers regarding psychomotor skills, such as manual muscle testing or assessing vital signs.

Demographics and Role Strain

Demographic factors did not seem to affect the degree of ACI role strain. The number of hours worked per week, patient load (ie, number of student-athletes for whom the ACI was responsible each semester), and the number of students supervised per semester did not affect ACIs' degree of role strain. We were surprised, however, that most of our participants reported working 40 hours per week or less. Some research in medical education contradicts these study results. For instance, physicians who supervise medical students typically had a longer workday,26 whereas other research demonstrated no effect on the length of the workday.15 Physicians working in high-volume patient care centers may have difficulty providing effective clinical teaching.26

The number and academic level of students being supervised may affect role strain in ACIs. Regarding the number of students being supervised, research in physical therapy education indicates that clinicians are actually more productive (eg, patient care load) when supervising 2 students versus 1 student.27 However, research15,26 in medical education revealed mixed results regarding physician productivity and the number of students being supervised. Furthermore, the effect of the student's academic level on ACI role strain warrants investigation. Evidence11 in the nursing literature suggests that nurses who supervise lower-level students (eg, sophomores) may encounter a higher degree of role strain. Certainly, then, the academic level of students assigned to particular ACIs should be considered in an attempt to reduce role strain, because some ACIs work better with upper-level students and others work better with lower-level students.

Job Congruency and Role Strain

Collegiate ATs serving as ACIs did not have congruency in their job responsibilities. Most ACIs were not in positions that allow them to perform their ideal job responsibilities. However, this lack of job congruency did not seem to affect total role strain in ACIs. Research28 in nursing suggested some connection between job congruency and job satisfaction. A meta-analysis28 of the nursing literature regarding job satisfaction revealed that role conflict and role ambiguity were moderate-to-strong predictors of job dissatisfaction in nurses. In addition, much has been written about job satisfaction in athletic training in recent years.29–33 Work-family conflict29,30 and salary33 were correlated negatively with job satisfaction in collegiate ATs. We may be able to presume from our results that when an AT's job responsibilities lack congruency (ie, ideal/actual responsibilities differ from those emphasized by a supervisor), job dissatisfaction increases. Because the majority of ACIs in our study had some level of job incongruency, further exploration of ACI job satisfaction is worthy of investigation.

Reducing Role Strain

Our study indicates that some degree of ACI role strain is inevitable. Therefore, ATEPs should consider strategies to assist their ACIs in reducing this role strain. Goode's4 role theory suggests that role strain may grow exponentially as ACI roles increase without corresponding increases in rewards for those roles. Therefore, ATEP administrators should consider various extrinsic means to reward their ACIs: for example, free textbooks or apparel, campus privileges, or public recognition at ATEP events. Perhaps ATEPs can even investigate opportunities to financially compensate ACIs for their service. Certainly, many ACIs are intrinsically motivated and receive ample satisfaction in helping to shape future professionals.22 Ideally, exceptional performance as an ACI should be recognized.11

Certainly one strategy to reduce role strain is to eliminate the number of role relationships, particularly those in which ACIs may have less interest or feeling of incompetence. For instance, GAATs accept positions to enhance their clinical experience, not necessarily to serve as ACIs. Further, GAATs will likely have difficulty managing the addition of the ACI role (about which they likely feel incompetent) due to their already-overwhelming role sets as clinicians and graduate students. Although many ATEPs rely on GAATs (who have a minimum of 1 year of clinical experience) to serve as ACIs, steps should be taken to ensure that they are receiving adequate organizational socialization to this role. Research9 examining role strain in novice clinical nurses who accept the role of clinical instructor illustrated that role ambiguity increases during the first 2 to 3 months, followed by role overload toward the end of the first year. Even though Commission on Accreditation of Athletic Training Education standards2 allow only ATs (and other qualified allied health care providers) with a minimum of 1 year's certification from the Board of Certification (or equivalent in other fields) to serve as ACIs, they may still experience role ambiguity and overload when they take on the additional role of an ACI during their second year as a GAAT. Therefore, it may benefit ATEPs to gradually introduce GAATs to the ACI role during the first year, progressively leading to service as ACIs during the second year.

Nursing clinical educators have offered several other suggestions for reducing role strain that are applicable to athletic training ACIs.22 For instance, as a reminder, program directors and clinical instructor educators could provide ACIs with a clinical education handbook that outlines the ATEP's curriculum, clinical education policies, and evaluation tools and expectations of the ACI.22 Also, ATEP administrators should be sensitive to time demands on ACIs and should be flexible in student clinical assignments. For example, an ACI may occasionally need a break from supervising students.22 Furthermore, ATEPs may consider assigning athletic training students with the same academic level (eg, junior students) to an ACI each rotation, so that the ACI can develop consistency in expectations.11,22 This will help to decrease ambiguity in student performance and evaluation.10 For instance, an ACI who is simultaneously supervising 3 levels of students is faced with juggling 3 sets of performance expectations and 3 different evaluation tools.

Last, role strain can be reduced by creating a positive climate within the ATEP. This could be fostered through ACI accessibility to the clinical instructor educator10 and open communication among program administrators, ACIs, and students.13 Nursing research10 indicated that several factors of role strain were reduced (eg, role overload, role conflict, role ambiguity) in staff nurses with the consistent presence of the coordinating clinical nurse faculty member in the clinical setting. In addition, this same research revealed that staff nurses experienced less role overload when they worked with clinical faculty who also were engaged in clinical practice than when they worked with nonclinical faculty members.10 Certainly, an ATEP clinical coordinator who is engaged in patient care in the clinical setting may have a heightened understanding of the multiple demands on the ACI10 and may be able to encourage open dialogue about student issues related to clinical education.10,34 When a coordinator is not able to engage in clinical practice, regular visits to clinical sites may provide these same benefits by offering a consistent presence in the clinical education setting.34