Burnout and Substance Use in Collegiate Athletic Trainers

Burnout has been defined as a mental state of emotional and physical exhaustion or a stress reaction to a person's inability to cope with the demands of his or her profession.¹ As a psychological syndrome, burnout consists of 3 components: emotional exhaustion, a decreased sense of personal accomplishment, and depersonalization of the patients under one's care.² The bulk of research on burnout has been conducted on allied health professionals, with researchers finding that many suffer from high rates of burnout.^3,4 In 1 study of physicians,⁵ 31% (n = 2181) reported a high level of emotional exhaustion; 25.3% (n = 1802), a high level of depersonalization; and 12.3% (n = 873), a low level of personal accomplishment. Thirty-six percent (n = 77) of nurses reported a high level of emotional exhaustion; 12% (n = 27), a high level of depersonalization; and 10% (n = 22), a low level of personal accomplishment.⁶

The association between burnout and substance use in health care professionals has been examined. Previous authors suggested that physicians³ (n = 7209) and psychiatrists⁴ (n = 936) suffering from burnout were more likely to engage in binge drinking. In another study⁷ (n = 80), nurses suffering from burnout were more likely to smoke tobacco.

Athletic trainers (ATs) also suffer from burnout⁸ but at lower rates than other health care professionals. Researchers⁹ in 1 study (n = 206) found that 20% of ATs reported a high level of emotional exhaustion; 23.3%, a high level of depersonalization; and 15.5%, a low level of personal accomplishment. Comparisons with other health care professions suggested that ATs suffered from emotional exhaustion at a lower rate but decreased personal accomplishment at a higher rate. Some investigators^8,10 have speculated the lower rates of emotional exhaustion reflect the ATs' off-season for recovery, especially in the collegiate setting. However, recent rule changes in the National Collegiate Athletic Association now allow many sports much more practice time in their traditional off-season.¹¹ Because these practices require the provision of medical care, it is possible that collegiate ATs are now working more than ever.

Although increased burnout has been associated with an increased risk of substance use in other health care professionals,^3,7 the examination of substance use and its relationship with burnout in ATs has produced mixed results. In 1 study,¹⁰ 5% of ATs self-reported “excessive drinking” and suffering from burnout increased an AT's risk of excessive drinking. However, the researchers failed to define the level at which drinking was considered “excessive,” and a time frame for alcohol consumption was not provided, which prevents comparison with other substance use investigations. In another study,⁸ approximately 67% of ATs consumed alcohol and 2.2% smoked cigarettes. These values were lower than those of other health care professions: more than 14% of nurses¹² and 14% of physicians¹³ had smoked cigarettes in the past year. Giacobbi⁸ measured alcohol consumption based on the average number of drinks per week but did not report a time frame. Similarly, he described percentages of smokers but did not give a time frame. More importantly, Giacobbi⁸ did not examine the relationship between substance use and burnout. To our knowledge, neither binge drinking (consuming 5 or more drinks in a row for males or 4 in a row for females¹⁴) nor its relationship with burnout has been examined in ATs.

Although alcohol consumption and tobacco use in ATs have been previously examined, the use of other substances, such as marijuana and energy drinks, has not been observed. With approximately 4.8% of physicians¹³ and 3.6% of nurses¹² reporting use of marijuana in the past year, comparing these rates with those of collegiate ATs would be beneficial. Although the use of energy drinks by the general population has received attention in the literature recently, consumption by health care professionals has not been examined. Those suffering from emotional exhaustion may use energy drinks to cope with fatigue, as more than 60% of energy drink consumers do so to gain energy.¹⁵ The current prevalence of binge drinking and other substance use in collegiate ATs remains unclear, as does the possible relationship between burnout and these behaviors.

The Smith Cognitive-Affective Model of Athletic Burnout (Figure 1)¹⁶ has been proposed as a possible theoretical model to explain the process of burnout in athletes and ATs. This model has found support within the athletic training literature and has been recommended for identifying ATs suffering from burnout.⁹ The model suggests that burnout follows a process similar to that for other stress reactions: situational concerns such as work-family conflict (WFC),¹⁷ high workload,⁹ and a low level of social support¹⁸ affect both cognitive appraisal (eg, the sense of personal accomplishment) and physiological responses (eg, emotional exhaustion). The cognitive appraisal and physiological response then lead to coping behaviors, such as depersonalization of patients and substance use. Although this model has been applied to investigate burnout in ATs, it has not been applied to determine if substance use is a coping behavior associated with burnout in this population. Also unknown is whether the model is still applicable to collegiate ATs due to the aforementioned changes in working patterns (ie, more practice time permitted in the off-season, which requires more AT coverage).

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The purpose of our study was to investigate the proportions of substance use (ie, cigarettes, marijuana, smokeless tobacco, and energy drinks) and substance abuse (binge drinking) in collegiate ATs as well as possible relationships between these behaviors and burnout. We hypothesized that there would be a significant positive relationship between burnout and substance use or abuse (or both) in our sample.

METHODS

Statistical Analysis

All statistical analyses were performed using SPSS (version 24; IBM Corp, Armonk, NY). All data were downloaded from Qualtrics into an SPSS worksheet. The analyzed variables were WFC, perceived social support, salary, average hours of work per week, burnout subscale scores, and use of various substances within the last 30 days.

Descriptive statistics (eg, mean, SD, and range) were used to examine the distribution and central tendency of responses. The assumptions of normality and homoscedasticity were checked using normal P-P plots and scatterplots. All hypotheses were tested using multiple regression models.

The variables were all mapped to the Smith Cognitive-Affective Model of Athletic Burnout (Figure 2).¹⁶ All situational variables (ie, WFC; perceived social support; salary; and fall, spring, and summer workload) were independent variables in 2 multiple regressions: 1 with emotional exhaustion and the other with personal accomplishment as the outcome variable. All situational variables were continuous. Salary was coded in $10 000 per year intervals from 1 = less than $20 000 per year to 10 = greater than $100 000 per year. Then, personal accomplishment was used as an independent variable, with emotional exhaustion as a dependent variable.

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Finally, emotional exhaustion and personal accomplishment were used as independent variables in several multiple regressions, 1 to predict depersonalization and then 5 to predict each substance use outcome (ie, binge drinking, cigarettes, marijuana, smokeless tobacco, and energy drinks). All 3 burnout subscales were considered continuous variables, and substance use was coded based on the number of times in the previous month (0 = never, 1 = 1–2, 2 = 3–5, 3 = 6–9, 4 = 10–19, 5 = 20–39, and 6 = 40+). Then, a multiple or simple regression (depending on the number of independent variables) was calculated to determine the extent to which variables altered the odds that a participant reported the symptoms or effects of burnout. Our treatment of ordinal data as continuous variables in multivariate regression is supported by previous literature.²⁷ While checking the assumption of normality, we found that several substance use variables (ie, cigarettes, marijuana, and energy drinks) followed a Poisson distribution. Therefore, we used Poisson regressions for models that included these substances as dependent variables. Because smokeless tobacco use followed neither of these distributions, we dichotomized this variable (0 = no use, 1 = use), and a binomial logistic regression was performed. For all multiple regression analyses, multicollinearity was checked using variance inflation factors.

RESULTS

Demographics

Of the 6867 e-mails that were sent to ATs, 1211 surveys were started and 857 were completed (29.2% dropout rate). Of those who completed the survey, 74 did not meet the inclusion criteria. This resulted in a sample size of 783 (11.4% response rate). Participants were 36.4 ± 11.1 years old (range = 22–79 years), with 12.6 ± 9.8 years (range = 0–45 years) of AT experience. They worked an average of 57 ± 11.6 (range = 30–100) hours per week during the fall semester (ie, August–December), 53.6 ± 11.2 (range = 30–100) hours per week during the spring semester (ie, January–May), and 23.3 ± 17.8 (range = 0–80) hours per week during June and July. The majority of participants identified as white, non-Hispanic (n = 713, 91.1%). Our sample was predominantly single (n = 409, 52.2%); most participants did not have children (n = 484, 61.8%), but those who did had an average of 2.05 ± 0.86 children (range = 1–6). Additional demographic information can be found in Table 1. By comparing our demographics with information collected by the NATA,²⁸ we found that our sample was representative of the overall collegiate AT population in terms of sex, ethnicity, and NATA district.

Table 1 Demographics of the Sample

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Means, standard deviations, and ranges of results for the MBI subscales, WFC scales, and Multidimensional Scale of Perceived Social Support are presented in Table 2. A total of 38.9% (n = 297) of participants scored ≥27 on the emotional exhaustion subscale, which indicates a high level of burnout.⁹ Similarly, 33.6% (n = 259) of participants had a high level of burnout according to the depersonalization subscale with a score of ≥10. Additionally, 17.7% (n = 135) had a high level of burnout based on a personal accomplishment score of ≤33.

Table 2 Participant Scores on Survey Scales

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Binge drinking at least once in the last 30 days was reported by 46.3% (n = 363). A total of 22.9% (n = 179) of participants stated they used energy drinks in the last 30 days. Other substance abuse behaviors were not as pronounced, with 3.5% (n = 28) admitting to marijuana use in the 30 days before survey completion. Additionally, few participants (n = 40, 5.2%) described smokeless tobacco use and 1.4% (n = 11) admitted to smoking at least 1 cigarette. A full report of substance use in our sample is shown in Tables 3 and 4.

Table 3 Substance Use Demographics for the Previous Month

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Table 4 Cigarette Use Demographics for the Previous Month

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Multiple Regression Analyses

After mapping all variables of interest (ie, WFC, perceived social support, salary, average hours of work per week, burnout subscales, and substance use) to the Smith Cognitive-Affective Model of Athletic Burnout¹⁶ (Figure 2), we conducted multiple regression analyses. Summaries for all analyses with significant results are provided in Tables 5 and 6. Situational factors correlated with emotional exhaustion were WFC with family being spouse or children or both (B = .475, P < .001; 95% confidence interval [CI] = 0.33, 0.62), WFC with family being other close relatives (B = 0.416, P < .001; 95% CI = 0.27, 0.56), social support (B = −0.172, P < .001; 95% CI = −0.23, −0.012), salary (B = −0.630, P = .002; 95% CI = −1.03, −0.24), and average hours worked in the spring semester (B = 0.084, P = .029; 95% CI = 0.01, 0.16). Similarly, WFC with family being spouse or children or both (B = −0.239, P < .001; 95% CI = −0.33, −0.15), social support (B = 0.113, P < .001; 95% CI = 0.08, 0.15), and salary (B = 0.468, P < .001; 95% CI = 0.22, 0.72) were all significantly associated with personal accomplishment. These 2 models explained 37.5% and 13.3% of the variance in emotional exhaustion and personal accomplishment, respectively, in our sample. A simple regression analysis also revealed that personal accomplishment was significantly negatively associated with emotional exhaustion (B = −0.796, P < .001; 95% CI = −0.92, −0.67; R² = .178).

Table 5 Summary of Regression Analyses

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Table 6 Summary of Substance Use Regression Analyses^a

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When using the cognitive appraisal and physiological response variables to predict coping and task behaviors, we found that emotional exhaustion (B = 0.288, P < .001; 95% CI = 0.26, 0.32) and personal accomplishment (B = −0.174, P < .001; 95% CI = −0.23, −0.12) were both significantly associated with depersonalization (R² = .460). Emotional exhaustion (B = 0.008, P = .023; 95% CI = 0.001, 0.015) and personal accomplishment (B = −0.016, P = .02; 95% CI = −0.029, −0.003) were significantly correlated with the number of binge-drinking episodes in the past 30 days (R² = .022). Emotional exhaustion was significantly positively correlated with energy drink use (Exp[B] = 1.017, P < .001, 95% CI = 1.009, 1.026). Neither emotional exhaustion nor personal accomplishment was significantly associated with cigarette, marijuana, or smokeless tobacco use.

DISCUSSION

The purpose of our study was 2-fold: to explore (1) substance use behaviors of ATs in the collegiate setting and (2) possible relationships between burnout and substance use. We found that approximately 46% of participants engaged in at least 1 reported episode of binge drinking in the last 30 days. This rate was much higher than the previous findings of 5% in ATs¹⁰ and 16% in nurses.¹² It is also double the national average of adults aged 26 and older, with 22.5% of respondents from the general population engaging in at least 1 binge-drinking episode during the past month.²⁹ In a study of AT drinking behaviors, Campbell et al¹⁰ did not define excessive drinking, which may have allowed participants to determine for themselves if their alcohol consumption was excessive. We explicitly defined the behavior (≥5 drinks for males, ≥4 drinks for females) without labeling it as a negative behavior (eg, excessive drinking or binge drinking). This could have resulted in self-reporting that was more honest. To our knowledge, we are the first to examine binge drinking with an appropriate definition in an AT sample.

Additionally, 1.4% of our participants smoked at least 1 cigarette in the last 30 days, which is similar to an earlier finding⁸ and lower than results in other health care professions: more than 14% of nurses¹² and 14% of physicians¹³ smoked cigarettes in the previous year. Although both sets of researchers examined past-year use instead of past-month use, the prevalence rates are remarkably different. However, comparing our results with those of studies that are 20 years old presents concerns, as current trends of cigarette use in physicians and nurses may differ. More recent research on these professions was not available in the literature. Regardless, the proportion of cigarette smoking among these professionals was lower than the 20.8% of the US population who reported smoking a cigarette in the previous 30 days.²⁹

To our knowledge, we are the first to examine the use of marijuana, smokeless tobacco, and energy drinks among collegiate ATs. Approximately 3.5% of our sample reported marijuana use in the previous month. This result was similar to the findings in other health care professions, with 4.75% of physicians¹³ and 3.6% of nurses¹² describing the use of marijuana. Thus, the proportion of marijuana use in health care professionals was less than half of the 8.4% reported in the general population.²⁹ We identified that 5.2% of our sample used smokeless tobacco in the previous 30 days. Because smokeless tobacco use has not been assessed in other health care professionals, a comparison is not possible. Yet this rate was approximately 1.5 times higher than the 3.3% rate in the general population.²⁹ Among our participants, 22.9% stated they consumed energy drinks in the previous month. Investigators rarely explore energy drink consumption in individuals other than adolescents or college students. As collegiate ATs spend many hours working and traveling with their teams, both physical and emotional exhaustion could cause them to resort to energy drinks to meet the demands of their days.

Approximately 38.9% of our sample reported a high level of emotional exhaustion; 33.6%, a high level of depersonalization; and 17.7%, a low level of personal accomplishment. High levels of emotional exhaustion were almost twice as common in our respondents compared with a 2009 study⁹ of collegiate ATs and high levels of depersonalization were 44% more common. Meanwhile, the low level of personal accomplishment was comparable with previous findings.⁹ Our findings are also similar to burnout statistics for physicians⁵ and nurses.⁶ This suggests that burnout symptoms in collegiate ATs are more prevalent today than previously. The constant decrease in the off-season time of recovery for collegiate ATs could be a contributor and should be examined further by future authors.

The Smith Cognitive-Affective Model of Athlete Burnout has been applied to ATs in the past and recommended for future use.⁹ We found that this model was appropriate for our sample. Using a multiple regression model, we determined that the situational factors of WFC, social support, and salary were all significantly associated with cognitive appraisal (personal accomplishment) and physiological response (emotional exhaustion). The relationships among WFC, social support, and burnout agree with the results of earlier studies.^17,18 However, our findings disagree with those of researchers²⁴ who identified no significant relationship between salary and symptoms of burnout. We recommend that salary remain a situational variable in the Smith model for future investigations due to these contradictory results.

The model showed that the average number of hours worked per week in the spring semester was significantly positively associated with emotional exhaustion but not personal accomplishment. A longitudinal study³⁰ of work-life balance in collegiate ATs showed that they suffered from increased conflict during their competitive season. It is possible that athletes in more sports are actively competing during the winter and spring months, which would lead to increased WFC. As increased WFC led to increased symptoms of burnout in our sample, this is a reasonable explanation for the association between hours worked in the spring semester and burnout. Examinations of ATs who work in specific college sports and how they experience burnout throughout the year should be conducted in the future.

After further evaluation of the model, we determined that emotional exhaustion and personal accomplishment were inversely correlated. These findings agree with those of previous researchers²⁵ who assessed relationships between the MBI subscales among helping professionals, such as physicians, psychologists, nurses, and social workers. We also learned that both emotional exhaustion and personal accomplishment were positively and negatively associated with depersonalization, respectively. This result is consistent with previous work²⁵ and further demonstrates that the Smith model is appropriate for the exploration of burnout in collegiate ATs. We recommend that future authors continue to use this model.

In the final portion of the model, we examined how emotional exhaustion and personal accomplishment were associated with substance use. Emotional exhaustion was significantly positively correlated with binge drinking. Also, the sense of personal accomplishment was significantly negatively correlated with binge drinking. These results agree with those of other health care professionals.^3,4 The use of binge drinking by collegiate ATs as a coping mechanism has not been addressed before by researchers. We acknowledge that other factors that significantly influence binge drinking in collegiate ATs must exist, as the explained variance in this model was small (R² = 0.022). Continuing efforts to characterize this relationship, as well as the potential effects of binge drinking on the overall performance of ATs, are warranted.

We did not find emotional exhaustion or personal accomplishment to be significantly correlated with cigarette use, although previous investigators⁷ indicated that nurses suffering from burnout were more likely to smoke cigarettes. This difference may be due to many college campuses now being tobacco-free zones, with cigarette use prohibited on campus. Even for ATs employed by colleges that allow tobacco use, the busy nature of their positions may not allow the time needed to smoke cigarettes. This inability to smoke cigarettes for a large portion of their day may also discourage use when away from work.

Another significant relationship was the positive association of emotional exhaustion with energy drink consumption. This is a unique finding that has not been previously observed. Because a desire for increased energy is a common motivation for the use of energy drinks,¹⁵ collegiate ATs may be using them as stimuli. To better understand this relationship, researchers should evaluate usage patterns for energy drinks as well as the motivations of collegiate ATs.

CONCLUSIONS

Binge-drinking behaviors and the use of smokeless tobacco were more common in our sample of collegiate ATs than in studies of other health care professionals¹² and the general population.²⁹ Although marijuana use in our sample was similar to that of other health care professionals,^12,13 it was less common than in the general population.²⁹ The proportion of cigarette use in our sample was less than in other health care professionals^12,13 and the general population.²⁹ By using the Smith Cognitive Affective Model of Athletic Burnout, we found that emotional exhaustion and diminished personal accomplishment were both significantly associated with increases in binge-drinking behaviors. We also demonstrated that emotional exhaustion was significantly positively associated with use of energy drinks. Our goal in this research was to illuminate substance use patterns of collegiate ATs and point to potential causes to try to improve the overall well-being of members of the profession.