Athletic Trainers' Skills in Identifying and Managing Athletes Experiencing Psychological Distress

Participants and Recruitment

After receiving approval from the West Virginia University Institutional Review Board for the Protection of Human Subjects, we contacted potential participants via e-mail, informed them of the nature of the study, and invited them to complete the Web-based questionnaire posted on Qualtrics (Qualtrics, LLC, Provo, UT). Survey research collected via an Internet site is a viable method of collecting data for scientific purposes.^13,14 Dillman¹⁴ also noted many potential benefits of Web-based methods, such as easier access to participants, more flexibility for participants to retrieve the survey information, less intrusion from the researchers, and greater likelihood of participant anonymity.

As outlined by Dillman¹⁴ and Creswell,¹⁵ we used a step-by-step procedure to communicate with all potential participants. These steps consisted of (1) sending an e-mail to all randomly selected participants, including a description of the study, consent information, and a link to the Web-based questionnaire; (2) 1 week later, sending a reminder e-mail to all ATs who had not completed the questionnaire; and (3) after 1 additional week, sending a final e-mail notice to all who had not completed the survey. Each e-mail included a description of the study and goals and a link to the Web-based questionnaire. Participants gave their consent by choosing to complete the questionnaire.

Using this method of recruitment, participation was solicited from 2998 certified ATs randomly selected from the 2014 NATA membership database. Of the 2998 e-mails sent, 1496 (49.8%) were opened and viewed, and of those, 494 recipients (33.0%) accepted the invitation to participate. Of those who began the Web-based questionnaire, 326 respondents (21.8%) completed the entire survey and 168 (11.2%) completed part of the survey, for an adjusted response rate of 33.0% (see Figure).

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Validation

A panel of experts (n = 5) was assembled to determine the appropriate symptom identification, course of action, and psychosocial strategy for each case vignette. Experts were selected based on their experience and reputation in applied sport psychology, as well as their vast publication records in respected academic journals in the area of psychology of injury. All members of the expert panel held doctoral degrees in areas related to sport and exercise psychology; 4 were certified consultants with the Association for Applied Sport Psychology, 2 were fellows of the Association for Applied Sport Psychology, 2 were licensed psychologists, and 1 was an AT. Each expert was given a copy of the survey and asked to respond to all questions pertaining to the 3 case vignettes (ie, whether they believed a particular symptom was present and their intended course of action). In some cases, experts provided written feedback containing justification for the chosen response. After compiling all responses, we assigned a correct label when at least 4 experts (80%) agreed on a particular response. Any question that did not reach the criterion for agreement was subjected to a second round of expert review. Only 2 rounds were required to achieve agreement on all questions.

Instrumentation

Data Analyses

The quantitative analysis consisted of 2 steps. Regarding the first and second research questions of the study, we compiled descriptive statistics to summarize participants' ability to accurately identify psychological symptoms, match psychosocial strategies based on symptoms presented in the 3 case vignettes, and make referral decisions. These descriptions included a summary of their responses and an assessment of their relative accuracy compared with the responses of the expert panel.

The third research question asked how factors such as years of experience, perceived competency, and coursework in sport psychology related to an AT's accuracy in symptom identification, strategy matching, and intended course of action. Stepwise regression models were used to evaluate this research question.

Demographics

The average respondent to the Web-based questionnaire was 34.7 ± 10.8 years old and reported 11.3 ± 9.9 years of experience in the field. Of the 326 respondents, 191 (58.6%) were women, 132 (40.5%) were men, and 3 (0.9%) did not disclose their sex. Most ATs were employed in the high school (35.3%) or university setting (33.9%). A majority of the respondents (63.2%) reported having a master's degree, and 68% of the ATs had at least taken an undergraduate course in the psychology of injury. Additionally, as many as 41.3% of respondents reported taking a graduate course in sport psychology and 34.0% reported taking a graduate course in the psychology of injury (see Table 2).

Table 2.  Participants' Demographic Information^a

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Perceptions About Psychosocial Competencies

Participants perceived their responsibilities as ATs as varying in importance (Table 3). For instance, 97.3% of respondents believed that facilitating psychological referral was a major responsibility of all ATs when the athlete exhibited personal distress. In addition, more than 90% of respondents thought it was the AT's responsibility to recognize adaptive and maladaptive psychological responses during injury rehabilitation. However, only 43% of respondents thought it was their responsibility to implement psychosocial strategies of any kind with an athlete experiencing distress. This low number may be due to the overall lack of applied sport psychology training or the belief that ATs should focus mostly on the physical aspects of rehabilitation.

Table 3.  Athletic Trainers' Perceptions of Responsibilities and Sport Psychology Competencies^a

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Additionally, on a 4-point scale, ATs in the sample rated their overall ability to implement selected psychosocial strategies as competent (3.15 ± 0.74) and perceived themselves as most competent in facilitating the athlete's understanding of the injury (3.77 ± 0.47), goal setting (3.73 ± 0.56), encouraging effective communication (3.70 ± 0.54), and using active listening (3.65 ± 0.55). In contrast, ATs rated themselves as least competent in teaching and implementing performance imagery (2.49 ± 0.93) and healing imagery (2.51 ± 0.97), developing focus cues (2.59 ± 0.92), and teaching progressive muscle relaxation (2.72 ± 0.92).

Accuracy in Identifying Symptoms, Matching Psychosocial Strategies, and Making Referrals

Respondents correctly identified psychological symptoms as presented in the 3 case vignettes. When we compared their responses with those of the expert panel, ATs responded well in recognizing symptoms in the low (5.98 ± 1.00; maximum score = 7), moderate (6.03 ± 0.65), and high (6.75 ± 0.82) categories. Overall, ATs averaged 6.27 ± 0.49 on total symptom identification across all participants and all 3 case vignettes.

When asked to choose their intended course of action from among 4 choices, most ATs chose correctly (97.3% and 89.7%) for the patients with low-level and high-level symptoms, respectively. However, fewer than half of the ATs (38.3%) chose the appropriate course of action for the patient with moderate symptoms: 61% of respondents overreferred this athlete, choosing to consult with a supervisor/mental health professional (59%) or immediately refer the athlete to a mental health professional (2%).

Finally, ATs appeared to have some difficulty when choosing appropriate strategies for each athlete presented in the case vignettes. Specifically, compared with responses established from the expert panel (maximum score = 11), ATs responded moderately well to symptoms in the low (8.80 ± 1.43) and moderate (7.91 ± 1.38) categories yet averaged a score of 5.42 ± 1.62 in the high category. Closer examination of the data for the high category was revealing: the majority of ATs identified every strategy as helpful for this athlete, whereas the expert panel identified only 4 as helpful.

Predictors of Accuracy

We hypothesized that ATs' perceived competency, years of experience, and sport psychology coursework would positively predict their ability to (1) accurately identify symptoms, (2) match psychosocial strategies, and (3) make referral decisions. Three separate stepwise multiple regressions were conducted to test this hypothesis. In each analysis, we entered perceived competency, years of experience, and sport psychology coursework as predictors. In the first regression, with symptom accuracy as the outcome, the model was significant: F_1,297 = 9.03, P < .01. Closer examination of the β weights revealed that exposure to sport psychology courses was the only significant predictor of ATs' accuracy in diagnosing symptoms (β = 0.17, t = 3.01, P < .01), accounting for 3.0% of the variance in accuracy scores. Thus, ATs who reported specific coursework in sport psychology were able to more accurately identify symptoms in the 3 patients.

A second stepwise multiple regression included the ATs' recommended course of action as the outcome variable. The model was significant: F_1,308 = 8.39, P < .01. The β weights within the model revealed that years of experience as an AT was the only significant predictor of ATs' accuracy in recommending the best course of action (β = −0.16, t = −2.90, P < .01), accounting for 2.7% of the variance in accuracy scores. Contrary to our hypotheses, this small effect indicated lower accuracy scores as experience increased. Follow-up stepwise regression analyses on ATs' recommended course of action for Toby (moderate symptoms) demonstrated a significant model, F_1,308 = 5.08, P < .05. Closer examination of the findings indicated that years of experience was the only significant predictor (β = −0.13, t = −2.25, P < .05), accounting for 1.6% of the variance in accuracy scores. Those with more experience as an AT had slightly lower accuracy scores for their intended course of action.

A third stepwise multiple regression, with ATs' strategy recommendations entered as the outcome variable, resulted in a nonsignificant model. Because ATs did much worse in choosing recommended strategies for Oscar (high level of symptoms), follow-up stepwise regression analyses on ATs' recommended strategies for Oscar revealed a significant model: F_1,305 = 13.04, P < .001. Closer examination of the model showed that exposure to sport psychology coursework was the only significant predictor (β = −0.20, t = −3.61, P < .001), accounting for 4.1% of the variance in strategy scores. Overall, these results reflect a negative association between sport psychology coursework and the ATs' accuracy in identifying appropriate psychosocial strategies.

Identifying Psychological Symptoms

With nearly 500 ATs completing at least part of the Web-based survey, these findings represent the largest sample of ATs with advanced training in PS to date. The ATs in the current sample provided mixed responses regarding their perceived competencies relating to psychological aspects of sport injury. Overall, these findings are consistent with those of previous researchers^22,23 who found that ATs generally felt competent and frequently used goal setting, motivation, and self-talk, yet they reported feeling unprepared to implement many of the more advanced mental skills, such as imagery and relaxation training. A recent evaluation²¹ of psychological skill implementation may help us to interpret the observed variance in skill competency. Specifically, Zizzi et al²¹ used the perceptions of ATs, coaches, and psychologists to establish a hierarchy of psychological skills. Many of the same psychological skills that our respondents felt least competent in implementing were characterized as requiring high levels of specialized training. It is possible that mastering the implementation of certain psychological skills (eg, focus, imagery, self-talk) remains outside the scope of a single undergraduate- or graduate-level course in sport psychology, and therefore, these skills may not be appropriate for entry-level ATs to use. Thus, should the NATA and CAATE decide to revise the educational guidelines for PS, they might consider adjusting the psychological skills that ATs are expected to implement by excluding the more advanced skills. Additionally, established athletic training education programs could increase active learning techniques (eg, role playing, case studies, practical training) to supplement existing course content and improve the overall learning experience for ATSs or perhaps offer continuing education workshops in implementing more complex psychological skills.

The ATs demonstrated relatively high accuracy in identifying symptoms for all 3 case vignettes. Furthermore, symptom identification varied little, and respondents correctly identified at least 4 of 7 symptoms in all case vignettes. These patterns of high accuracy appear to result from the aforementioned training in sport psychology, especially because this variable was the only significant predictor in symptom identification. Our findings seem to contrast with those of earlier investigators^24,25 who concluded that ATs had difficulty identifying clinically meaningful emotional disturbances in injured athletes. However, those authors used correlations to compare athlete self-reports of psychological symptoms with ATs' observations of behavioral indicators of distress, making comparison with the current findings difficult. Also, all available research investigating this question was published before the NATA added the PS competency to the educational guidelines⁷ in 1999, which suggests that previously sampled ATs had significantly fewer opportunities to take courses in sport psychology. One might surmise that ATs will continue to improve in these areas, given the current availability of sport psychology coursework at the undergraduate and graduate levels at many institutions housing accredited AT programs.

Referral Decisions and Intervention Strategies

Despite their accuracy in identifying symptoms, these ATs appeared to struggle when choosing appropriate psychosocial strategies for each athlete. Of particular concern was the low level of accuracy in choosing strategies for the athlete with a high level of symptoms (Oscar). Many ATs believed all 11 strategies would be helpful for Oscar, even though the expert panel identified only 4 as correct. However, most ATs (90%) chose the correct course of action for him: immediate referral. Thus, it is possible that ATs recognized the severity of this athlete's symptoms and simply believed all strategies could be of some help to him. Although their accuracy in choosing strategies was low, it is encouraging that they would refer this athlete to a mental health professional rather than attempt to implement the strategies themselves. Furthermore, ATs were also mostly accurate in deciding how to proceed with Stanley (low-level symptoms), but more than half (61%) overreferred Toby (moderate-level symptoms), choosing to consult with a supervisor or immediately refer him to a mental health professional. It is possible that ATs were unsure of how to proceed with Toby and, therefore, chose to err on the side of caution by taking the more conservative approach to refer and ensure that no potentially serious problems were overlooked.

Regression analyses indicated interesting trends in the prediction of ATs' intended course of action. Less experienced ATs were slightly more accurate in deciding the best course of action for all patients, particularly the athlete with moderate symptoms. These results are contrary to results of studies on procedural decision making in health professions (eg, physiotherapy, nursing). Smith et al²⁶ reported that more experienced physiotherapists, when evaluated by a supervisor, adopted an approach to decision making that was more specific, refined, and ultimately, more accurate than did those with less clinical experience. Furthermore, Phillips et al²⁷ concluded that novice physical therapists often chose to follow protocol and guidelines derived from university-based teachings, whereas experts were more likely to view a situation broadly and critically apply rules and norms based on previous experience. Thus, more experienced ATs in this study may have felt limited because of the restricted options provided in the questionnaire and were unable to make more creative (yet still correct) procedural decisions. Additionally, the survey and written case vignettes may have favored the younger ATs who had been exposed to this type of evaluation in their courses more recently. Finally, it is possible that younger ATs were more likely to work in school settings rather than private clinics, where access to mental health professionals is more readily available. Future researchers should attempt to explore and understand this relationship more closely by asking ATs to explain the process they use to arrive at a procedural decision or by testing ATs' decision making in live or video scenarios to more closely mimic real-world conditions.

The absence of sport psychology coursework as a predictor in decision making was interesting but not entirely surprising. Stiller-Ostrowski and Ostrowski²³ reported that even formal sport psychology courses tend to be predominantly theory driven and lack practical emphasis and application of sport psychology concepts within the athletic training realm. Scherzer²⁸ recommended that courses should focus on educating students about referral procedures and protocols, yet few actually do. As a result, even highly trained ATs may struggle to make appropriate decisions.

Limitations

Our study had a number of limitations that should be noted when interpreting the findings. First, the questionnaire was disseminated using e-mail addresses that were provided by the NATA membership database. Thus, although distribution via e-mail may have reached more prospective participants, it may have also influenced the scope of the sample who took the survey. Specifically, ATs who do not use e-mail regularly or do not have an updated e-mail address in the NATA database were less likely to participate, perhaps leading to the low overall response rate. Additionally, many participants completed all survey questions relevant to the research questions but chose not to respond to basic demographic information (eg, the sport they work with). These ATs were placed in the partially completed portion of total participants. However, countering this limitation is the fact that the sample of respondents represents the largest pool of ATs with training and interest in PS to date. Also, none of the recruitment e-mails included any information about sport psychology in the subject heading, thus limiting the possible response bias. Second, the responses compiled by the panel of experts may not represent actual correct responses to the questions relating to symptom identification, intended course of action, and strategy choice. Rather, they represented the consensus of this particular group of professionals. However, given the experience level of each member of this panel, it is conceivable that many other experts would respond similarly. Third, respondents were asked to respond to questions relating to 3 male athletes with various psychological symptoms. Although this depiction was intentional, ATs might have responded differently if the case vignettes had described female athletes. Future authors should not only explore this possibility but also investigate the AT's sex as a variable. Finally, the questionnaire relied on ATs to self-report responses (eg, perceived competencies, referral behaviors, perceptions of sport psychology), which may have influenced the accuracy of the results and the conclusions drawn from them.

Future Directions

Although our study provided insight into ATs' accuracy in symptom identification, intended course of action, and matching of psychosocial strategies, a number of important questions have emerged that merit further research. Specifically, although ATs did well in deciding the best course of action for athletes, we did not explore how ATs came to their decisions. Thus, future investigators may use a qualitative approach to obtain valuable insight into the decision-making process and supplement our results. Also, given the highly trained nature of the current sample, future researchers could include a more diverse sample of participants. For instance, researchers may want to recruit ATs from conferences or conventions who may have less sport psychology coursework and training. Furthermore, due to our use of case vignettes, it is possible that some of the information was obvious (ie, “Toby is visibly frustrated”) and therefore led to high accuracy in the ATs' responses. Future authors may use other methods, such as videos, that require ATs to detect more subtle behavioral cues. Finally, an assessment of injured athletes' perceptions of ATs' use and knowledge of sport psychology could provide valuable insight and significantly increase our understanding of this important area of research.