Secondary School Athletic Trainers' Experiences With Organizational Conflict: A Comparison Across Employment Models

Organizational conflict is a dynamic process involving many facets, including antecedent conditions, affective and cognitive states of the individuals involved, and the actions or behaviors that portray conflict.¹ Environments in which stakeholders interact and collaborate with each other are subject to such conflict. The risk of conflict is heightened when individuals working interdependently have diverging goals or opinions.¹ The structure and competitive nature of athletic programs can breed an environment susceptible to conflict, which may be counterproductive if not readily addressed. Conflict between medical and nonmedical personnel in athletic environments is not novel and often manifests as pressure to prematurely return an athlete to play.^2,3 Anecdotal^3–5 and empirical^2,6–9 evidence has highlighted this concern for years.

To date, the collegiate setting has held the spotlight for research regarding clinician-coach conflicts. Divided loyalties between coaches and medical personnel put athletic trainers (ATs) on the receiving end of pressures to return athletes to play based on coaches' timelines,^2,3 which are often not in the athletes' best interest from a long-term health care perspective. The bureaucracy in collegiate athletics has gone as far as coaches and athletic administrators firing ATs over medical decisions.³ In addition to return-to-play pressures, another form of conflict previously investigated at the collegiate level is workplace bullying.^6,7,10 Often spearheaded by coaches, these incidents led to higher levels of stress, feelings of inadequacy, and decreased trust in existing relationships.¹⁰ Organizational conflict is concerning, as negative workplace environments increase ATs' levels of job-related stress¹¹ and therefore may prohibit the provision of optimal medical care.

The extent of the conflicts ATs face outside of the collegiate setting is not well understood. According to the National Athletic Trainers' Association's 2019 year-end membership statistics,¹² secondary schools are the largest setting represented (23.7% of all members). With the vast number of ATs employed in secondary schools, it is important to understand their experiences providing care. Natural components of the secondary school setting present unique challenges conducive to conflict, including a lack of organizational or hierarchical structure, various employment models, parental input, and support networks that are largely nonmedical or the absent.

Characteristics of the secondary school setting may influence ATs' experiences with organizational conflict and thus warrant investigation. The purpose of our study was to measure the extents and sources of stress, pressure, and conflict faced by secondary school ATs. In addition, we examined whether organizational conflict and workplace dynamics differed across employment type (school district employee, school district teacher, medical or university facility, or independent contractor) and status (full time [FT] versus part time [PT]).

METHODS

RESULTS

Of 4745 secondary school ATs, 871 started the survey and 725 completed it, yielding a 15.28% (725/4745) response rate and 83.24% (725/871) completion rate. Our sample size was appropriate for the population based on sample-size estimations.²⁰ About half of the participants were male (n = 360, 49.7%). Average age was 39.8 ± 10.5 years, and responding ATs had been certified for 16.7 ± 9.7 years. Close to half of our sample was employed by a medical or university facility (n = 328, 45.2%), and most respondents, regardless of employer, worked in an FT capacity (n = 611, 84.3%). Additional demographic information is provided in Table 1.

Table 1 Respondent Demographics (N = 725)

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Likert-Scale Item Responses

Athletic trainers' responses varied for the agreeableness- and frequency-anchored Likert-scale items. Count responses, percentage responses, and median values are shown in Table 2 for agreeableness- and Table 3 for frequency-anchored items.

Table 2 Frequencies, Percentage of Responses, and Median Values for Agreeableness-Anchored Items

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Table 3 Frequencies, Percentage of Responses, and Median Values for Frequency-Anchored Items

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Sources of Job-Related Stress, Pressure, and Conflict

Participants were asked to indicate if various individuals they interacted with at work (coaches, athletic director, principal, athletes, parents, other ATs, or supervising physician) were a source of stress and if they had experienced pressure from or conflict with these individuals in their roles. For our sample of ATs, most job-related stress stemmed from parents (n = 478, 66%; Figure), followed by coaches (n = 404, 55.7%). Although coaches and parents were most frequently selected, 125 (17.2%) participants did not consider any of these individuals to be sources of job-related stress. The Figure also summarizes the number of ATs who received pressure from and experienced conflict with various stakeholders. Similar to job-related stress, parents and coaches were identified most frequently as sources of pressure. More than half of responding ATs (n = 425, 58.6%) received pressure from coaches, and 66.8% (n = 484) were pressured by parents. Secondary school ATs experienced the most conflict with parents (n = 428, 59.0%), followed by coaches (n = 391, 53.9%) and athletes (n = 236, 32.6%). Other sources of pressure and conflict included school board members, school nurses, visiting coaches, and physicians, but these only represented the experiences of a trivial percentage of our sample.

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Odds Ratios for Associations Between Sources of Stress, Pressure, and Conflict and Employment Type and Status

We calculated ORs to measure the association between sources of perceived stress, pressure, and conflict and employment type (employed by the school district versus not employed by the school district; Table 4) as well as employment status (FT, PT; Table 5). We observed a 43% reduction in the odds of an AT identifying an athletic director as a source of stress (OR = 0.574, 95% CI = 0.407, 0.809; P = .002) and a 72% reduction in the odds of an AT identifying the principal as a source of stress (OR = 0.280, 95% CI = 0.154, 0.507; P < .001) when the AT was employed by the school district compared with other employment types (medical or university facility and independent contractor). Similarly, we noted a 36% decrease in the odds of experiencing pressure from the athletic director (OR = 0.645, 95% CI = 0.435, 0.955; P = .030) and a 61% decrease in the odds of experiencing pressure from the principal (OR = 0.389, 95% CI = 0.191, 0.792; P = .009) when the AT was employed by the school district compared with other employment types. Regarding experiences of conflict by employment type, we found a 45% reduction in the odds of experiencing conflict with the athletic director (OR = 0.551, 95% CI = 0.374, 0.810; P = .003) and a 63% reduction in the odds of experiencing conflict with the principal (OR = 0.367, 95% CI = 0.175, 0.766; P = .007) when the AT was employed by the school district compared with other employment types.

Table 4 Odds Ratios Between Organizational Conflict Variables and Employment Type (School District Versus Other)

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Table 5 Odds Ratios Between Organizational Conflict Variables and Employment Status (Full Time Versus Part Time)

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For employment status, FT ATs were 1.6 times more likely to identify parents as a source of job-related stress than PT ATs (OR = 1.642, 95% CI = 1.093, 2.467; P = .018). We also observed a 53% decrease in the odds of experiencing pressure from the principal when employed FT versus PT (OR = 0.467, 95% CI = 0.226, 0.963; P = .044). Regarding experiences of conflict, FT ATs were 1.6 times more likely to report conflict with a coach than were PT ATs (OR = 1.550, 95% CI = 1.037, 2.317; P = .040), and the odds of conflict with the supervising physician were reduced by 81% when the AT was employed FT versus PT (OR = 0.187, 95% CI = 0.041, 0.852; P = .047).

DISCUSSION

The purpose of our study was 2-fold. First, we aimed to measure the extent and sources of stress, pressure, and conflict experienced by secondary school ATs. Our secondary purpose was to examine associations between organizational conflict measures and employment characteristics (type and status). More than half of the ATs reported pressure from and conflict with coaches and parents. Similarly, coaches and parents were also identified most frequently as sources of stress. The finding that coaches were a source of pressure for ATs aligns with previous research^2,3,6 conducted in the collegiate setting. Kroshus et al,² in their investigation of pressure placed on sports medicine clinicians to prematurely return athletes with concussions to play, found that 53.7% faced this pressure from coaches. Additionally, in a Chronicle of Higher Education survey,³ more than half of responding ATs employed at universities that sponsored competitive football described pressure from coaches to return athletes with concussions to play before they were comfortable. Although we did not collect injury-specific data, it appears that, independent of setting, the web of interrelationships required of the role puts strain on ATs.

Although it was discussed anecdotally, the role of parents in conflict is a novel finding in the athletic training literature. Much of the research has been done in the collegiate setting, where parents inherently have less influence because of the demographics of the college-aged athletic population. Our findings illustrate the growing concerns about parents' involvement in sport, as it pertains to being too involved, overstepping, being too zealous, or all of these.²¹ Some parents in today's society, independent of sport, have been stereotyped as having “helicopter” parenting styles, which implies that the parents take too much ownership in their children's experiences, particularly obsessing over their safety and success.²² Parenting of this nature can translate to the athletic field and may manifest as attempts to overpower, advocate, or push for their children to return to play despite injury.

In the secondary school setting, where most athletes are minors, parents or legal guardians are consulted on all medical decisions regarding athletes' plans of care.²³ Parental involvement produces social capital,²⁴ a valuable component of a school community, yet it also increases the chance for conflict if ATs' plans for the athletes do not align with those of the parents or guardians. Parental actions, including overstepping boundaries and upholding high expectations, are not only detrimental to young adolescents^25,26 but may also explain the increased frequency of reported incidents with ATs compared with other stakeholder groups. Parents can serve as allies when approached in the correct way, which includes providing an explanation of the AT's role and emphasizing the common goal of protecting and caring for their children.²⁷

It is important to consider the frequency with which the ATs in our sample experienced organizational conflict. Although participants described stress, pressure, and conflict in their roles, these incidents did not occur regularly. The distribution of scores on statements regarding organizational conflict and workplace culture demonstrated that most ATs answered always or often to positively framed statements, such as having a supportive coaching staff, and selected rarely or never for negatively framed statements, such as coaches criticizing ATs' decisions. Our data align with those of a dissertation project²⁸ investigating interpersonal conflict in high school athletic training settings.²⁸ Interactions with parents, coaches, athletes, peers, and others were identified by most participants as sources of conflict less than once a month or not at all.

Reduced frequencies of reported conflict in the secondary school setting may be attributed to an environment that emphasizes the enjoyment of sports participation over winning. Increased education on and exposure to ATs in this setting could also play a role in mitigating conflict, as ATs assert themselves as the authorities regarding student-athlete health and safety. Organizations such as the National Federation of State High School Associations have weighed in on return to play after injury and who ultimately makes the call.²⁹ According to an article²⁹ posted on the association website,

Administrators should develop a protocol that not only includes but encourages open communication among all individuals involved in the [return-to-play] process. If any individual involved in the return to play decision process does not believe the student is ready to return to activity, the athlete should be withheld until additional recovery has been accommodated.²⁹

Beyond the AT and patient, individuals involved in the return-to-play process may include coaches, parents, and other health care professionals. It is important that each stakeholder's role, as it relates to the return-to-play process, is clearly defined so that ATs are established as having complete authority and autonomy as medical decision makers. If this precedent is set, medical professionals should not be pressured to return an athlete to play before the health care team deems it appropriate. However, the multitude of factors at play and the inherent nature of human interaction will likely prohibit complete removal of conflict in athletics organizations. A select number of cases provide evidence for a lack of support and other challenges related to the AT's role. Still, when viewed collectively, our results demonstrated that secondary school workplace environments were largely positive and provided ATs with autonomy when making medical decisions.

A positive work environment is one with open communication and established interpersonal relationships among stakeholders.³⁰ We found that FT ATs agreed more strongly with relationship dynamic variables than PT ATs, though the effect size was small. The result is understandable because FT ATs spend more time at the school and therefore have more opportunities to build relationships with individuals. Compared with FT ATs, ATs employed in a PT capacity reported lower ratings of agreement with statements regarding strong relationships with and support from coaches and the principal. Given increased time in the role (from PT to FT), ATs interact with key stakeholders, such as coaches and administrators, more frequently and at greater length, which helps to further establish and strengthen the dynamics of the health care team. Despite differences in relationship dynamic variables based on employment type and status, we caution interpretation regarding the practical significance of these findings due to the small effect size.

Part-time ATs had lower odds of identifying parents as a source of stress and experiencing conflict with coaches than FT ATs. Although this could reflect less time spent in the role and subsequently limited encounters, it may also indicate the levels of relationships that develop between ATs and stakeholders. Because FT ATs interact with stakeholders to a greater degree than PT ATs, the stronger relationships that develop may make stakeholders, such as parents and coaches, more comfortable in pushing back on ATs' decisions with which they disagree. However, FT ATs were at lesser odds of experiencing pressure from the principal and conflict with the supervising physician than were PT ATs. Time spent in the role could work in favor of FT ATs in this regard as more time exists to build relationships with administrative staff at the school and other members of the health care team (eg, supervising physician). A more plausible explanation for the lower odds of experiencing pressure from the principal as a FT AT than a PT AT may be that some FT ATs have a teaching component of their role, which would likely require an established working relationship with the principal.

In addition to employment status, whether the AT was employed by the school district or an outside company influenced the odds of experiencing job-related stress, conflict, and pressure from various sources. Athletic trainers employed directly through school districts, in either teaching or nonteaching roles, were at reduced odds of reporting the athletic director, principal, or both as a source of job-related stress; experiencing pressure from the athletic director, principal, or both; and experiencing conflict with the athletic director, principal, or both than ATs employed by medical or university facilities or as an independent contractor. The 2 administrative personnel at the individual school level were consistently identified across stress, pressure, and conflict variables. A plausible explanation for this could be the way in which administrators view ATs employed by the school district versus ATs employed by another entity. The former may be seen more as part of the team or as members of the school community without any obligation to another facility, thereby enhancing rapport between ATs and administrative personnel. These results may provide further support for the importance of building rapport to mitigate conflict, but future research is warranted to directly assess this relationship.

Instances of pressure and conflict were relatively infrequent for our sample, yet this may not be a unanimous finding among all ATs. Within our sample and anecdotally, ATs are on the receiving end of pressures and conflict from individuals they interact with as part of their role. If ATs are put in situations where they feel pressure or experience conflict, prior knowledge, education, and training on how to diffuse the situation may lead to better outcomes. Professional or continuing education or both should address how ATs can recognize situations that may develop into conflict and use conflict-resolution strategies that promote compromise but not at the expense of athlete or patient safety.

CONCLUSIONS

Regarding our first aim, secondary school ATs reported experiencing stress, pressure, and conflict from various sources in their role, mainly coaches and parents. However, the frequency of these events demonstrated that, often, our participants were supported in their role. Our second aim was to determine whether employment characteristics affected the level of stress experienced or the level of pressure or conflict faced. Those ATs employed directly by the school district and those employed in an FT capacity agreed more strongly with statements regarding relationship dynamics with stakeholders and were at decreased odds of experiencing pressure or conflict from administrators and coaches. Because interpersonal relationships are a requirement of the athletic training profession and can create positive work environments, secondary school ATs, regardless of their employment characteristics, are encouraged to build rapport with coaches, parents, athletes, administration, and other health care professionals as a proactive strategy for mitigating conflict when disagreements arise.