Athletic Trainer Burnout: A Systematic Review of the Literature

Literature Search Strategy

The SPORTDiscus and OneSearch databases were accessed in February 2018 to locate valid research for this review. To obtain all available studies, we placed no limits on publication dates. Using the search terms athletic trainer AND burnout, we identified 55 results in SPORTDiscus and 503 results in OneSearch.

Included Studies

An initial search identified 558 results. For inclusion, articles had to be published in peer-reviewed journals and written in English. Articles that did not meet these criteria and those with titles that indicated the research did not pertain to athletic training were removed, which left 83 articles. Each of the remaining 83 articles underwent an abstract review and then a full-text review. Articles that did not address new research (ie, editorials, brief summaries) or did not investigate prevalence, causes, effects, or alleviation of burnout in ATs were then removed, which left 48 articles. After reviewing the bibliographies of all 48 remaining articles, we identified an additional 3 articles that did not appear in the original search, fully reviewed them, and determined they met all aforementioned criteria. This resulted in 51 articles for data collection (Figure).

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Data Collection

All articles included in the systematic review underwent an assessment of methodologic quality (Table 1). Different assessment tools were applied based on the type of research conducted. We used the Qualitative Checklist of the Critical Appraisal Skills Programme (CASP)⁷³ to assess all qualitative studies (n = 23). Although a numeric value did not suggest the overall worth of articles that were appraised using CASP,⁷³ it can help readers determine worth based on methodologic quality. Therefore, CASP scores were not used as a method of inclusion or exclusion for articles. Rather, they were simply reported in Tables 1–3 so that readers may be aware of the methodologic quality of each study. The maximum possible CASP score is 9/9.

Table 1 Overview of Reviewed Studies and Key Findings Extended on Next Page

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Table 1 Extended from Previous Page Continued on Next Page

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Table 2 Studies of Work-Life Conflict (WLC)

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Table 3 Studies of at Least 1 Component of Role Strain

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The remaining studies included in the systematic review were a case study (n = 1), cross-sectional studies in the form of a survey (n = 20), and mixed-methods studies that included qualitative and quantitative survey components (n = 7). These studies were all assessed using Study Quality Assessment Tools provided by the National Heart, Lung, and Blood Institute (NHLBI).⁷⁴ The case study was assessed using the NHLBI Quality Assessment Tool for Case Series Studies, which allows for a maximum score of 9/9. The cross-sectional studies were assessed using the NHLBI Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies, which allows for a maximum score of 14/14. Both tools allowed for lower maximum scores if certain aspects of the tool were not applicable to the study in question. Similar to the studies that were appraised using CASP, these scores were not used as a method of inclusion or exclusion but were reported in Tables 1–3.

Articles that met all inclusion criteria were categorized by the purpose of the study (ie, studying causes, effects, or prevalence of burnout). Based on the results of the search, articles were also categorized based on the subset of the AT population studied (ie, athletic training students, certified graduate assistants [GAs], high school or collegiate staff ATs, academic faculty). Meta-analyses were not performed for multiple reasons. Many of the studies (n = 23) were qualitative in nature. Also, studies of the same subsets of populations using the same instruments were limited. Specifically, only a handful of researchers^29,75 assessed burnout using the Maslach Burnout Inventory, and they investigated athletic training program directors (ATPDs), students, GAs, or staff.

Causes of Burnout in ATs

The causes of burnout in ATs have received much attention in the literature. Among the 51 articles we reviewed, 29 groups of authors investigated causes of burnout. Specifically, work-family conflict (WFC), role strain, and challenges with professional socialization were identified. The literature pertaining to each of the causes of AT burnout is discussed below.

Work-Family and Work-Life Conflict

Work-family conflict (WFC) is a disruption of responsibilities associated with family that is caused by one's work.⁷⁶ Twelve groups of authors^* investigated WFC in ATs (Table 2). Several suggested that ATs did suffer from WFC.^43,44,47 For example, in 1 study⁴³ (n = 587), more than 60% of respondents reported that their work interfered with home and family, sometimes resulting in missing family activities; other researchers^57,66 observed similar results. It is also important to note that 1 group⁴³ demonstrated no difference in the amount of WFC experienced by ATs based on marital status or number of children. The authors suggested that ATs who were single and had no children might still experience conflict between professional expectations and personal responsibilities outside of work. For this reason, the term work-life conflict (WLC) was introduced and will be used hereafter.

Multiple causes of WLC among ATs have been identified. The number of hours worked and travel requirements associated with athletic training were linked with increased WLC among ATs.^43,47,66 Staffing patterns can also contribute to WLC: fewer ATs resulted in more medical coverage per AT and may therefore be a source of WLC.⁴³ A lack of work flexibility also contributed to WLC. Rescheduled or delayed practices or games could interfere with family plans for ATs and thereby increase WLC.⁴³

Males and females both experienced WLC, although the causes of WLC and the experience itself varied by sex. Specifically, female ATs felt that motherhood presented an additional challenge to maintaining work-family balance because they must take greater responsibility in caring for their children than males.^26,59 Female ATs also expressed a belief that their gender played a role in whether they could maintain careers as ATs.⁵³ Mazerolle and Eason⁵³ posited that the increased strain could be attributed to the beliefs held by many participants regarding the traditional role of females in the family. Specifically, several participants in a qualitative study (N = 27) thought that the primary focus of females should be child rearing rather than pursuing a career, which made these participants fear that being ATs would interfere with their responsibilities as mothers.⁵³ Authors^55,58 examining male ATs found that the time of year and occupational demands of the job had a greater effect on WLC. Due to the seasonal nature of work for many ATs, certain times of the year could require that ATs spend more hours at work to provide medical care for their teams. During these times, WLC might reach a peak, only to lessen during the off-season.^55,58 The same participants also believed that personal time, separating work from life, and using a support network could prove beneficial in decreasing WLC.^55,58 Regardless of gender, ATs in these samples were concerned with work-family balance while having children, in that children made this balance harder to maintain.³² Due to this perception, ATs commented that childbearing decisions were strongly affected by their work setting, suggesting that some ATs might feel pressure to choose between career and children.³²

The effect of various work settings on WLC in ATs has also been addressed. High school and collegiate ATs reported greater levels of WLC than those working in the clinical, industrial, and professional settings.⁵⁴ Although Mazerolle et al⁵⁴ mentioned criterion scores for categorizing participants as experiencing low, moderate, or high WLC, no data indicated the percentage of participants in each category. Most research on WLC in collegiate settings occurred in National Collegiate Athletic Association (NCAA) Division I, yet 1 study⁵⁷ suggested that WLC was also prevalent in other collegiate settings (ie, Divisions II and III, National Association of Intercollegiate Athletics, National Junior College Athletic Association). In summary, WLC affected ATs employed in many work settings.

Although 12 groups of investigators examined WLC in ATs, only 2 of those 12 examined the relationship between WLC and burnout.^43,44 Both found a positive, moderate, and statistically significant relationship between these variables, indicating that as WLC increased in ATs, burnout also increased.^43,44

Role Strain

In 19 studies, researchers^† examined at least 1 component of role strain in ATs (Table 3). Role strain refers to an individual's inability to complete the requirements of the job role.⁷⁷ Pitney et al⁶⁵ highlighted several types of role strain, including role ambiguity, role conflict, role overload, role incongruity, and role incompetence. Role ambiguity was associated with a lack of specificity in a job description.⁶⁵ Role conflict occurred when there was no ambiguity, but multiple roles were unharmonious with each other.⁶⁵ Role overload referred to a situation in which job requirements exceeded the time and energy availability of the individual.⁶⁵ Role incongruity occurred when job expectations were not compatible with the employee's own values and beliefs.⁶⁵ Role incompetence resulted when an individual was not prepared for the role in terms of knowledge or skills.⁶⁵ Role strain has been investigated in high school ATs⁶⁵ and collegiate ATs serving as preceptors for athletic training students (ATSs).³⁸ Role strain was also identified as a reason some female ATs intended to leave their jobs or exit the profession.²⁴

As with other helping professionals (eg, educators¹⁵), an excessive workload has been connected to both role strain and burnout in ATs. One group of authors³¹ studying collegiate ATs identified hours worked per week as a significant predictor of role strain; post hoc testing revealed that ATs who worked 50 hours or more per week reported greater role strain than ATs who worked 40 hours or fewer. Excessive workload has also been cited by numerous investigators^22–24,51 as a reason for ATs' wanting to leave the profession altogether. A correlation was found between the perception of an excessive workload and burnout in ATs.^29,30,33 Insufficient staffing might contribute to the perception of excessive workload. In fact, 1 group of researchers²⁷ found that nearly 67% of participating NCAA Division I Football Bowl Subdivision institutions did not meet the recommended staff size for football. Insufficient staffing could lead to more hours worked per person or additional responsibilities. This additional workload might contribute to burnout^29,33 and specifically EE.³⁰

Professional Socialization

In 6 studies, authors^{48,63,64,69–71} examined the professional socialization of ATs. Professional socialization has been defined as one's growth and development as a professional in a chosen field.⁷⁸ Athletic trainers undergo professional socialization in 5 phases: envisioning the role, formal preparation, organizational entry, role revolution, and gaining stability.⁶³ These phases have been divided into the categories of anticipatory socialization (ie, envisioning the role and formal preparation) and organizational socialization.⁶³ Difficulty with any of these phases can be a potential cause of burnout. In fact, 1 investigator⁶⁴ determined that NCAA Division I ATs were often concerned about their assumed places in the hierarchy and the politics that surrounded many administrative decisions regarding athletics. The same author found that ATs were concerned about their quality of life because of large workloads and low levels of administrative support.⁶⁴

Another study⁴⁸ looked at the difficulties collegiate female ATs faced in professional socialization due to gender bias and learned that adequate communication, mentorship, and the support of supervisors all aided their navigation of the process. Another group of researchers⁶⁹ demonstrated similar results in the professional socialization of graduate assistant athletic trainers (GAATs) and added that a lack of adaptability by GAATs could create challenges. Difficulties such as these could create a fear of burnout in ATs and possibly lead to it.⁶⁴ Another group of investigators⁷⁰ observed that GAATs experienced initial stress during professional socialization because they were immediately immersed in their clinical responsibilities. Stressors induced by this immediate immersion included building relationships with coaches, patients, and physicians and learning to balance clinical responsibilities with graduate coursework. The GAATs in this qualitative study also noted that their graduate experience began without much formal orientation or preparation from their organization.⁷⁰ Although it was not named as an initial stressor, excessive workload was reported by an unknown number of participants as a hindrance to success.⁷⁰ Despite these initial stressors, maturation was a theme derived from this study as GAATs gained experience and developed confidence.⁷⁰ These same GAATs also stated that they relied on staff ATs who served in a supervisory role for socialization into the profession.⁷¹

Effects of Burnout

The effects of burnout in ATs have not been researched as extensively as the causes. In fact, our review of the literature identified only 6 studies^{18,22–24,34,35} of the effects of AT burnout. Two reports,^18,35 1 of which was a case study,³⁵ showed that ATs suffering from burnout were more likely to report headaches, high blood pressure, weight concerns, indigestion, fatigue, and sleeplessness. In addition, those experiencing burnout were more likely to experience emotional problems such as irritability and depression.¹⁸

Attrition of ATs from the profession has also been noted as an effect of burnout. One investigator²² found that ATs who left the profession listed several causes of burnout as reasons for leaving (eg, hours worked, salary, and overall lack of job satisfaction). Other authors^23,24 have supported this, finding that the nature of work-life balance challenges (eg, WFC) and role strain were reasons for ATs to leave the profession.

The authors^18,34 of 2 studies included in our review examined substance use and abuse in ATs, and 1 group addressed a possible relationship with burnout.¹⁸ Almost 69% of the sample consumed at least 1 alcoholic beverage each week,³⁴ and 5% of participants self-reported excessive drinking.¹⁸ The same authors¹⁸ also determined that those suffering from burnout in their sample were significantly more likely to report excessive drinking than those not suffering from burnout.

Demographics and Burnout

Burnout in ATs has been assessed in multiple settings and different types of employment. In the earlier study¹⁸ of burnout, the researchers were unable to correlate demographic variables with the risk for burnout; however, more recent investigators found links with age, gender, employment status, and career tenure in staff ATs (mostly at the NCAA Division I level), GAATs, ATSs, and ATPDs.

Differences in Age and Gender

Female ATs experienced greater burnout than male ATs.^34,62 This could partially explain why female ATs in any setting tended to leave the profession at approximately age 28,⁴⁰ as opposed to males, who tended to work longer and then shifted from collegiate settings to the high school settings in their mid to late 40s.²⁶ As previously mentioned, WFC arising from marriage and parenthood could be another major contributing factor to those gender-specific statistics, as well as the overall decline of ATs in the workforce that occurred after age 30.^24,26 Men and women working at the NCAA Division I level gave the primary reasons for leaving their jobs as life balance concerns and role strain, which are 2 major causes of burnout in this population.^24,51

Burnout in Full-Time Collegiate Staff ATs

Burnout research has typically been conducted on ATs who serve in staff roles, usually at NCAA institutions.^‡ In an early study, Capel²⁹ noted that ATs described lower amounts of burnout than those in other helping professions; the AT result was comparable with that of coaches. A later study by Giacobbi³⁴ supported Capel's conclusion but did not provide percentages. The prevalence of burnout in ATs has been speculated to be lower than in other profession because ATs have an off-season that allows an opportunity to work fewer hours for a time and recover.²⁹ However, Capel's study was published more than 30 years ago, and the work requirements of ATs have since changed. Recent NCAA rule changes have permitted more practice time in the summer, which requires ATs to supply medical care and thereby diminished the amount of off-season recovery time.⁶⁰

Burnout in GAATs

Three groups of authors^28,49,67 studied GAATs and their relationship with burnout. Six major stressors in the GAATs' lives contributed to burnout.⁶⁷ First was the workload associated with being a new AT.⁶⁷ Second was comparing one's workload with that of other GAATs; some GAATs might have worked more hours than their colleagues and believed it was unfair.⁶⁷ Third was attempting to balance newfound AT responsibilities with the academic requirements of being a graduate student.⁶⁷ Fourth was time management in balancing student, work, and life responsibilities.⁶⁷ This stressor coincided with that from another group of investigators⁴⁹ who found that GAATs who worked at NCAA Division I institutions were at greater risk of burnout than those working in Division III institutions or in high schools because of the increased hours worked. Fifth was social evaluation, which was described by GAATs' as feeling as though their coaches did not respect them because they were newly certified or not full-time staff members.⁶⁷ Sixth was concern about future plans such as graduation and obtaining full-time employment.⁶⁷

Failing to transition from graduate assistantships into full-time employment has also been evaluated. One group of researchers²⁸ studied individuals who had completed postprofessional athletic training programs but no longer worked primarily as ATs. All participants worked as GAATs during their graduate studies but left the profession for various reasons shortly after graduation. Most participants stated that they intended to stay in the profession after graduation, but low salaries, excessive workloads, and WLC contributed to their decisions to leave the profession.²⁸

Burnout in ATSs

Three groups of authors^42,46,68 assessed burnout in ATSs, whereas 3 other groups^36,42,52 explored either perceived frustration or coping strategies. Upper-level students have reported significantly higher burnout scores than lower-level students, and most students experienced some level of burnout.^46,68 The relationship status of students was also possibly correlated with burnout; Riter et al⁶⁸ reported that female ATSs in serious relationships had significantly higher levels of DP and EE than male ATSs in serious relationships.

The causes of and coping methods associated with burnout in ATSs have been briefly examined. Role strain and time commitments were 2 major factors contributing to burnout, and common methods of stress alleviation included social support and taking personal time.⁶⁸ Sources of frustration in ATSs included a lack of respect and the demands of the clinical experience.³⁶ Sources of stress were also evaluated in ATSs, and students at different levels in their programs had different sources of stress.⁴² Freshmen were stressed by the time demands of the major as well as a desire for more patient interaction at their clinical sites. Sophomores were stressed by the amount of information they were expected to retain as well as the performance of hands-on duties at their clinical sites. Juniors endured stress due to rigorous coursework, feelings of inadequacy during clinical experiences, and social conflicts among classmates. Seniors struggled with a fear of not achieving professional proficiency. Burnout was assessed qualitatively, and it is unclear if a definition of burnout was provided.⁴²

Coping strategies used by ATSs to manage their clinical and academic responsibilities were also addressed by authors⁵² of a single qualitative study. Students not only used support networks both inside and outside their athletic training programs but also relied on physical outlets (eg, sleep and exercise) and time-management skills (eg, making lists or keeping organized datebooks).⁵²

Burnout in ATPDs

Our review of the literature yielded 2 groups of researchers^39,72 who studied burnout in athletic training faculty members, specifically ATPDs. The ATPDs did experience some level of burnout, and weak negative relationships were present between EE and age (r = −0.263), years at current job (r = −0.162), and experience (r = −0.157).⁷² These findings suggested that faculty members who were younger, less experienced, and less established in their current positions experienced greater EE and explained why tenure-track faculty in this sample described greater EE than ATPDs who had already achieved tenure.⁷² Also, female ATPDs in their sample reported greater EE than male ATPDs. Although they examined EE, PA, and DP in faculty members, it is important to note that no statistically significant differences occurred for DP or PA based on any demographic variables.⁷²

Reasons for accepting and leaving ATPD positions have also been assessed. Reasons for accepting ATPD positions included wanting to move into an academic environment, considering the change a personal professional advancement, wishing to advance the profession, wanting to play a role in program development and administration, and desiring to interact more with students.³⁹ Reasons for leaving ATPD positions included accepting professional appointments, having personal challenges (including burnout), experiencing programmatic concerns (eg, bureaucratic problems, programs being eliminated), and seeking career advancement.³⁹

Alleviating Burnout in ATs

Of the 51 articles we analyzed, the authors^{35,46,47,50,56,61,67} of 7 either investigated or anecdotally suggested various management methods for burnout. Although burnout in ATs has no single remedy, it was important to identify factors causing burnout and modify them if possible. Some researchers⁴⁷ have recommended establishing boundaries, determining priorities, and learning to say “no” as ways to modify risk factors for burnout. Developing a social support system offered the potential for managing burnout in ATs.^46,47,67 A strong coworker support system was also suggested as important for job retention.⁵⁰ This social support system could include friends, family, coworkers, and others. One group of authors⁵⁶ also examined the role that head ATs played in promoting appropriate work-life balance for their assistants. They speculated that employee WLC could be decreased if head ATs modeled work-life balance, promoted appropriate disengagement from one's role, encouraged cooperation among staff members, and provided administrative support as needed. Athletic trainers also believed that organizational adherence to adequate staffing patterns and formalized work schedules could reduce WLC, which might lead to a decrease in burnout.⁶¹

The use of religious or spiritual coping mechanisms to combat burnout in ATs has received little attention in the literature. Specifically, authors of qualitative studies have described relying on a minister to help an AT manage his burnout³⁵ and the use of religion as a way for GAATs to manage their stress.⁶⁷ However, the precise role that religion played in the coping response to stress or burnout for the participants was not discussed. The relationship among spirituality, religion, and burnout in ATs remains unclear.

Future Directions for Research

Future researchers should continue to examine rates of burnout of ATs in a variety of workplace settings, especially understudied areas such as industry, clinics, and athletic training program faculty. Although reported rates of burnout in ATs were lower than those in other health care professions,⁴¹ the demands of the profession have changed greatly in the time since those data were published. These changes may increase burnout rates for ATs working in selected settings so they equal or exceed the rates of other health care professionals. As athletic training education moves to the graduate level, we also need to examine burnout in entry-level master's students and compare this rate with previous findings in undergraduate students.

Studies of the prevalence of substance abuse among ATs suffering from burnout should be conducted. Investigators should determine if ATs are abusing alcohol and other substances (either on or off the job) as an unhealthy way to cope with burnout and related factors. Although burnout rates seem to be lower in athletic training than in other health care professions, whether substance use and abuse rates would follow the same pattern is unknown.

The relationship between burnout and work quality, especially the quality of patient care, in ATs is also undetermined. Authors have found an inverse relationship between burnout and work quality in university faculty^15,16 and physicians,³ yet this relationship has not been examined in ATs. Because a decrease in work quality could lead to poorer patient outcomes, this relationship in ATs should be addressed.

Finally, the use of coping strategies to combat burnout in ATs should be explored more thoroughly. Because most research thus far has examined causes and effects, future investigators should focus more on methods of alleviation, including both positive and negative coping strategies. Although some healthy strategies (eg, spiritual or religious coping strategies) have received attention in the literature, these strategies should also be examined more thoroughly.