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Mixed Methods Analysis of Occupational Burnout and Engagement Experienced by Certified Athletic Trainers in High School ...

Permanent Link: http://ufdc.ufl.edu/UFE0022279/00001

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Title: Mixed Methods Analysis of Occupational Burnout and Engagement Experienced by Certified Athletic Trainers in High School Settings
Physical Description: 1 online resource (112 p.)
Language: english
Publisher: University of Florida
Place of Publication: Gainesville, Fla.
Publication Date: 2008

Subjects

Subjects / Keywords: athletic, burnout, certified, engagement, high, methods, mixed, occupational, school, trainers
Applied Physiology and Kinesiology -- Dissertations, Academic -- UF
Genre: Applied Physiology and Kinesiology thesis, M.S.
bibliography   ( marcgt )
theses   ( marcgt )
government publication (state, provincial, terriorial, dependent)   ( marcgt )
born-digital   ( sobekcm )
Electronic Thesis or Dissertation

Notes

Abstract: Using mixed-methods and purposeful sampling procedures, four ATCs working in the high school setting were identified as being in phase V or VI of burnout and four were identified as being occupationally engaged. All eight individuals were then interviewed on three separate occasions using a semi-structured approach. A grounded theory analysis was then conducted to identify the sources of stress, challenges and coping responses of these individuals and how their unique stressors changed and evolved over time. Burned out individuals listed 33 distinct stressors, 29 challenges and 46 coping strategies. Occupationally engaged individuals listed 19 stressors, 21 challenges and 40 coping strategies. Overall the athletic trainers in this sample coped consistently with their stressors with few mismatches with the controllability of the stressor and the coping strategy.
General Note: In the series University of Florida Digital Collections.
General Note: Includes vita.
Bibliography: Includes bibliographical references.
Source of Description: Description based on online resource; title from PDF title page.
Source of Description: This bibliographic record is available under the Creative Commons CC0 public domain dedication. The University of Florida Libraries, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Thesis: Thesis (M.S.)--University of Florida, 2008.
Local: Adviser: Giacobbi, Peter B.
Electronic Access: RESTRICTED TO UF STUDENTS, STAFF, FACULTY, AND ON-CAMPUS USE UNTIL 2010-05-31

Record Information

Source Institution: UFRGP
Rights Management: Applicable rights reserved.
Classification: lcc - LD1780 2008
System ID: UFE0022279:00001

Permanent Link: http://ufdc.ufl.edu/UFE0022279/00001

Material Information

Title: Mixed Methods Analysis of Occupational Burnout and Engagement Experienced by Certified Athletic Trainers in High School Settings
Physical Description: 1 online resource (112 p.)
Language: english
Publisher: University of Florida
Place of Publication: Gainesville, Fla.
Publication Date: 2008

Subjects

Subjects / Keywords: athletic, burnout, certified, engagement, high, methods, mixed, occupational, school, trainers
Applied Physiology and Kinesiology -- Dissertations, Academic -- UF
Genre: Applied Physiology and Kinesiology thesis, M.S.
bibliography   ( marcgt )
theses   ( marcgt )
government publication (state, provincial, terriorial, dependent)   ( marcgt )
born-digital   ( sobekcm )
Electronic Thesis or Dissertation

Notes

Abstract: Using mixed-methods and purposeful sampling procedures, four ATCs working in the high school setting were identified as being in phase V or VI of burnout and four were identified as being occupationally engaged. All eight individuals were then interviewed on three separate occasions using a semi-structured approach. A grounded theory analysis was then conducted to identify the sources of stress, challenges and coping responses of these individuals and how their unique stressors changed and evolved over time. Burned out individuals listed 33 distinct stressors, 29 challenges and 46 coping strategies. Occupationally engaged individuals listed 19 stressors, 21 challenges and 40 coping strategies. Overall the athletic trainers in this sample coped consistently with their stressors with few mismatches with the controllability of the stressor and the coping strategy.
General Note: In the series University of Florida Digital Collections.
General Note: Includes vita.
Bibliography: Includes bibliographical references.
Source of Description: Description based on online resource; title from PDF title page.
Source of Description: This bibliographic record is available under the Creative Commons CC0 public domain dedication. The University of Florida Libraries, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Thesis: Thesis (M.S.)--University of Florida, 2008.
Local: Adviser: Giacobbi, Peter B.
Electronic Access: RESTRICTED TO UF STUDENTS, STAFF, FACULTY, AND ON-CAMPUS USE UNTIL 2010-05-31

Record Information

Source Institution: UFRGP
Rights Management: Applicable rights reserved.
Classification: lcc - LD1780 2008
System ID: UFE0022279:00001


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1 MIXED METHODS ANALYSIS OF OCCUPA TIONAL BURNOUT AND ENGAGEMENT EXPERIENCED BY CERTIFIED ATHLETIC TRAINERS IN HIGH SCHOOL SETTINGS By FREDERICK DAVID DIETRICH A THESIS PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLOR IDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE UNIVERSITY OF FLORIDA 2008

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2 2008 Frederick David Dietrich

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3 To my Mom and Dad, both educators.

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4 ACKNOWLEDGMENTS First I would like to th ank m y parents, Rick and Chris, and family for their support. I would also like to thank my committee, Dr. Paul Borsa, Dr Mark Tillman, and Dr. Peter Giacobbi for their guidance. I would especially like to also like to thank Dr. Pete Giacobbi for all his help with this thesis. I would also like to thank Matthew Buman and Justine Haroon for their help.

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5 TABLE OF CONTENTS page ACKNOWLEDGMENTS...............................................................................................................4 LIST OF TABLES................................................................................................................. ..........7 LIST OF FIGURES.........................................................................................................................8 ABSTRACT.....................................................................................................................................9 CHAP TER 1 INTRODUCTION..................................................................................................................10 Definitions of Terms Related to the Constr ucts of Occupational Burnout, Occupational Engagem ent and Stress and Coping.................................................................................... 10 Model of Burnout...................................................................................................................14 Model of Occupational Engagement...................................................................................... 18 Cognitive Motivational Rela tion al Theory of Stress, Emotion, and Coping.......................... 21 A Theoretical and Conceptual Inte gration of Three Perspectives .......................................... 24 Measurement of Occupational Burn out and Occupational Engagem ent................................28 Empirical Studies....................................................................................................................30 Empirical Studies on Burnout......................................................................................... 30 Empirical Studies on Occupational Engagement............................................................ 31 Empirical Studies with the Popul ation of Athletic Trainers ............................................34 Rationale.................................................................................................................................43 2 MATERIALS AND METHODS........................................................................................... 46 Research Design.....................................................................................................................46 Participants......................................................................................................................48 Measures..........................................................................................................................48 Qualitative Interview....................................................................................................... 49 Data Analysis..........................................................................................................................53 Issues of Reliability and Validity........................................................................................... 54 3 RESULTS...............................................................................................................................56 Descriptive and Comparative Findings.................................................................................. 56 Case Summaries.............................................................................................................. 61 Purpose One: Sources of Stress....................................................................................... 64 Challenges.......................................................................................................................71 Coping Strategies............................................................................................................. 77 Additional Analyses........................................................................................................ 88 Coping stability and consistency..................................................................................... 89 The Goodness of Fit Hypothesis..................................................................................... 93

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6 4 DISCUSSION.........................................................................................................................97 Theoretical Integration with Lazarus.................................................................................... 101 Limitations.................................................................................................................... ........102 Applied Implications........................................................................................................... .103 Future Directions..................................................................................................................103 LIST OF REFERENCES.............................................................................................................105 BIOGRAPHICAL SKETCH.......................................................................................................112

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7 LIST OF TABLES Table page 1-1 Progressive phases of burnout........................................................................................... 29 3-7 Stressors, challenges and coping strategies.......................................................................88 3-8 Analysis of the goodness of fit hypothesis........................................................................ 94

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8 LIST OF FIGURES Figure page 1-1 Adapted model of burnout................................................................................................. 17 1-3 Theoretical integration of Lazarus CM-R theo ry and occupational burnout and engagement........................................................................................................................27 2-1 Four step design of this study............................................................................................ 47 3-1 Burned out versus Occupationally engaged ATC MBI average scores. ............................57 3-2 Burned out versus Occupationally engaged ATC OES average scores. ............................ 58 3-3 MBI average scores fo r men and women ATCs................................................................ 59 3-4 OES average scores based on gender................................................................................. 60 3-5 Average MBI scores based on years experience.............................................................. 60 3-6 Average OES scores based on years experience................................................................ 61 3-7 Stressors Experienced by Hi gh School Athletic T rainers.................................................. 69 3-7 Continued.................................................................................................................. .........70 3-8 Continued.................................................................................................................. .........76 3-9 Coping strategies experienced by high school athletic trainers. ........................................ 84 3-9 Continued.................................................................................................................. .........85 3-9 Continued.................................................................................................................. .........86

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9 Abstract of Thesis Presen ted to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Master of Science MIXED METHODS ANALYSIS OF OCCUPA TIONAL BURNOUT AND ENGAGEMENT EXPERIENCED BY CERTIFIED ATHLETIC TRAINERS IN HIGH SCHOOL SETTINGS By Frederick David Dietrich May 2008 Chair: Peter Giacobbi Major: Applied Physiology and Kinesiology Using mixed-methods and purposeful sampling procedures, four ATCs working in the high school setting were identified as being in phase V or VI of burnout and four were identified as being occupationally engaged. All eight individuals were then interviewed on three separate occasions using a semi-structured approach. A grounded theory analysis was then conducted to identify the sources of stress, challenges and c oping responses of these individuals and how their unique stressors changed and evolved over time Burned out individuals listed 33 distinct stressors, 29 challenges and 46 coping strategi es. Occupationally engaged individuals listed 19 stressors, 21 challenges and 40 c oping strategies. Overall the athletic trainers in this sample coped consistently with their st ressors with few mismatches with the controllability of the stressor and the coping strategy.

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10 CHAPTER 1 INTRODUCTION Over 20% of North Am erican employees were in the most advanced phases of burnout according to Golembiewski, Boudreau, Munzenrider, & Lou (1996). Those in the helping professions who experience the burnout syndrome are more likely to demonstrate higher levels of absenteeism, lower job satisfaction, poor health, and perhaps diminished care to their clients. In all, a person experiencing burnou t symptomology might be said to have a lower quality of life than a person who is not burned out. In the upcom ing sections of this th esis I will elaborate on the burnout phenomena and also occ upational engagement with resp ect to those in the helping and athletic training professions. Definitions of Terms Related to the Constructs of Occupational Burnout, Occup ational Engagement and Stress and Coping To facilitate the re aders understanding of the theories a nd constructs in this thesis, I will define some of the key terms and components used in the literature. This review will begin with definitions related to the components of o ccupational burnout, occupational engagement, psychological stress, and coping. The term burnout originated from the popul ar lexicon and was us ed to describe a phenomenon that was happening to lawyers worki ng with those at the po verty level (Maslach, 1993). The experiences of poverty lawyers working in legal services were similar to those that Maslach studied with health care professionals Within the English language definitions of burnout are derived from the physical sciences and linked to the redu ction of a fuel or substance through combustion (Oxford University Press, 2007) Thus the word burnout, developed in rocketry, was adopted to describe a person who has come to a point in their work where they have spent all their energy and do not feel any desire to continue in that pursuit. Freudenberger

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11 (1974, 1975) similarly described burnout as exhaustion that is caused by excessive demands of energy and resources. Occupational burnout, according to Maslach an d Goldberg (1998), is comprised of three separate components: emoti onal exhaustion, depersonaliza tion, and lack of personal accomplishment. Emotional exhaustion is define d by being emotionally taxed and lacking the emotional resources for replenishment, with its sources being work overload and personal conflict with either fellow employ ees or clients. Similar to the definition of rocket burnout, a person feels like his/her fuel is depleted and l acks the energy to face another day at work or another patient/customer. This is the basic st ress component of occ upational burnout in the Maslach model and may be exemplified by an athl etic trainer (ATC) who feels chronically tired at work both emotionally and physically, and time off from work is not enough to restore the energy they need for their job. The second component of the burnout syndrom e, depersonalization, is defined as an adverse, unsympathetic or excessively detach ed response to other people. Depersonalization usually develops as a result of overloading emo tional exhaustion and may be a self-protective mechanism. For instance, a person may distance hi s/herself emotionally from work in order to feel a sense of protection from disappointment and exhaustion (Maslach & Leiter, 1997). This represents the interpersonal component of burnout in the Maslach Model and may be exemplified by limited dialogue with clients or co-workers. The third component of occupational burnout in the Maslach model (1993), is reduced personal accomplishment, and is characterized by a diminished sense of competency, selfefficacy, and productivity in the workplace. This self-evaluative portion of the Maslach model is represented by the reduced sense of personal accomplishment and may be demonstrated when an

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12 individual loses confidence in hi s/her abilities to treat injuries and feels helpless to have an impact in the field. The study of occupational engagement evolve d as an attempt to find the opposite of burnout in the workplace and has reflected a general shift in psychology focused on positive aspects of human behavior (Seligman & Csiksz entmihalyi, 2000). According to Schaufeli and Bakker (2004), the three major components of e ngagement are vigor, dedication, and absorption. High levels of energy and mental toughness in the workplace demonstrate vigor, personified by someone who perseveres in the face of difficult tasks and invests oneself personally in his/her work. An ATC might demonstrate vigor by meeti ng tasks head on with passion and enthusiasm while taking personal stake in accomplishing his/her job. Dedication, another key component in Schaufeli and Bakkers (2004) model of occupational engagement, is characterized by a pe rsons pride and enthusiasm in their work. A dedicated person believes that his/her work is significant and views it as a challenge. A severe injury sustained by an athlete w ould be viewed by a dedicated AT C as a challenge, and, a chance to show off his/her sk ills and abilities. The third dimension of occupational engageme nt is absorption. A person who is totally engrossed in their work, to the point where they b ecome absorbed in their tasks or lose track of time, would characterize absorption. An ATC experiencing absorption would be one who unknowingly works overtime because he/she gets a real sense of satisfaction when an injured athlete under his/her care retu rns to the playing field. Two other concepts that th e reader will encounter, repr esented as antecedents in Schaufeli and Bakkers (2004) model of occupa tional engagement, are job demands and job resources. Job demands are the physical and ps ychological elements of an occupation that require constant effort (Schaufeli & Bakker, 2004). For instance, a physical demand in the

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13 athletic training profession might involve taping an injured athlete or helping someone off the playing field. A psychological demand would be d ealing emotionally with being yelled at by an abusive coach when an injured athlete is not recovering per th e coachs wishes. Another important contextual element within Schaufeli and Bakers (2004) model of occupational engagement is job resources ch aracterized as the physical, organizational, psychological aspects of a job that reduce job de mands, allow one to achieve work goals, or stimulate learning and development (Schaufeli & Bakker, 2004). A physical job resource would be the medical supplies (e.g. athlet ic tape and ice packs) that an ATC might need to do his/her job, while a psychological resource might include soci al support from other athletic trainers or other personnel. Job demands and job resources are theorized here to play important roles within the stress, burnout, and engagement process within the help ing professions. As the preceding discussion suggested, careful attention to defining and clarifying the nature of the constructs under investigation here is needed. With this in mind I will now begin to review and offer conceptual clarity to the st ress and coping portion of my thesis. The reader should take in mind that the study of stress a nd coping dates back ove r 50 years and one is instructed to see Lazarus (1999) for a thorough re view. The most widely accepted conceptual framework for the study of ps ychological stress is based on Lazarus and colleagues (1999) Cognitive, Motivational, Relati onal (C-M-R) theory of emotion, psychological stress, and coping. Lazarus posited that when a person encount ers any given situation a cognitive process, called appraisal, occurs which is directly tied to stress emotions. According to Lazarus (1999), when a person makes an appraisal of a situation they are constructing a relational meaning about what that situation means to them in terms of their goals, ego involvement, and overall wellbeing. If a persons goals are threatened within go al-relevant situations, a series of primary and secondary appraisal processes are predicted to occur to define the nature of the threat followed

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14 by what can be done to reduce or ameliorate the situation. During secondary appraisal portion of the model, a person evaluates how they will deal with the stressor based on their own resources and capabilities. From this perspective, apprai sal and coping mediate the relationship between a stressful situation and the emotions elicited by that situation. In addi tion, Lazarus and Folkman (1984) believe that stress, apprai sal, coping and emotion are dyna mic in nature and change over time as a situation unfolds. This latter point w ill be expanded upon in subsequent sections along with the theoretical and practical relevance of studying the stress process in a longitudinal manner. Finally, coping as defined by Lazarus and Folk man (1984) is, The constantly changing cognitive and behavioral efforts to manage specif ic external and/or internal demands that are appraised as taxing or exceeding the resources of the person (p. 141). Several important issues can be discerned from this definition. First, the concept of cognitive appraisal is fundamental to Lazarus and Folkmans (1984) definition and this will be discussed in more detail below. Second, coping efforts constantly change over time and occur with in a specific context. From this perspective, individuals coping efforts subse quently impact the nature of the situation which then impacts the appraisal proces s. Finally, the C-M-R theory (Lazarus, 1999) is process oriented and coping strategies that work in one situati on may not work in anothe r so individuals might adopt different coping strate gies within the same or different situations or their coping responses might simply change as the nature of the stresso r changes. All of these issues will be discussed below. Model of Burnout Perhaps the most noted and knowledgeable sc holar on the study of occupational burnout is Christina Maslach who, over th e course of her career, has a developed a com prehensive model of occupational burnout, as well as multiple measures to assess this construct. I will now

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15 elaborate on Maslach, Jackson, and Leiters (1996) model to include the antecedents, components and outcomes of the burnout syndrome. Maslach and Goldberg (1998) postulate that the combination of imbalance and conflict within a job setting lead to a person experiencing burnout. Th e imbalance occurs when job demands are high and job resources are low (see Figure 1-1). Job demands, ever present over time, become chronic in nature, a nd job resources whether depleted or absent are insufficient to deal with the demands on a continual basis. Another key theme within this model includes conflict which could result from conflict with coworkers, clients, or managers. High job demands, low job resources, and conflict in th e workplace are precursors to the exhaustion component of the burnout syndrome. Adopting a stage model of the burnout syndrome, emotional exhaustion that results from the combination of conflict and an imbalance betw een job demands and job resources is the first component of burnout to manifest itself in an individual (Leiter & Maslach, 1988, Maslach & Jackson, 1981). Exhaustion is the most salient of the burnout components and the one most often described by those experiencing burnout (Mas lach, Schaufeli, & Le iter 2001). Although exhaustion is the most powerful dimension of burnout, its manifestation alone is not the sole requirement for explaining or diagnosing burnout. According to Maslach et al. (2001) emotional exhaustion prompts an individual to withdraw emotionally and psychologically from his/her work presumably as a coping mechanism. A human service professional would distance themselves emotionally from those that are under th eir care as the demands of constant attention become too great. The second component to develop in Masl achs model (1996), depersonalization, develops as an immediate reac tion to someone who is experi encing exhaustion. In order to manage the increased demands of those they ar e providing service for, exhausted individuals

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16 treat people as impersonal objects therefore distancing themselves from the cause of their exhaustion (Maslach et al., 2001). This detachment shifts over time negatively; practitioners begin to dislike their patients instead of showing concern for their welfare (Maslach, 1993). Burnout research across a va rying array of occupations a nd settings has shown a strong relationship between exhaustion and depersonaliza tion (Bernhard, 2007; Jenaro, Flores & Arias, 2007; Kanste, Miettunen, & Kyngs, 2006; Lindblom, Linton, Fedeli, & Bryngelsson, 2006; Peery, 2007; Templeton & Satcher, 2007). Some of these studies will be discussed later. The third component of burnout according to Ma slach et al. (1996) is a reduced sense of personal accomplishment or inefficacy in the wo rkplace (Leiter, 1993). This reduced sense of accomplishment or competence could also be ch aracterized by feelings of inadequacy and ineffectiveness. Maslach et al. (2001) surmise that inefficacy arises from a lack of job resources where exhaustion and cynicism are a re sult of job demands and conflict. As an individuals burnout experience pr ogresses and changes over time, exhaustion, depersonalization, a diminished sense of accompli shment and low self-efficacy are predicted to lead to specific cognitive, beha vioral, and health consequences. A burned out employee is likely to show reduced commitment to the organiza tion, high absenteeism, turnover, and physical illnesses as a result of this syndrome (Maslach & Goldberg, 1998). These costs, as outlined in Figure 1, affect both the organizatio n and the individual. A person f eeling ineffectual in their job and depleted might not want to come in to work leading to eventual job turnover (Maslach et al., 2001). Those who do work are not as effective in their jobs and may make the working environment stressful for others (Rowe & Sherlo ck, 2005). Job demands that lead to burnout in health care workers can include emotionally charged contact with those they care for (Dierendonck, Schaufeli, & Buunk, 2001), heavy workload, and lack of family time (Spickard, Gabbe, & Christensen, 2002). The le vel of care that patients rece ive from burned out health

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17 care workers is also affected and could lead to serious errors that lead to malpractice suits (Spickard et al., 2002). These consequences of burnout affect not only th e individual suffering from it but also the organization for which th ey work and the patients or customers. Figure 1-1. Adapted model of burnout. Dashed arro ws show paths surmised by Maslach et al. (2001) (Leiter, 1993; Maslach & Gol dberg, 1998; Maslach et al., 1996, 2001). With regard to the personal health of the burned out employee, these individuals are likely to suffer mental and physical health risks. Over whelming stressors that lead to burnout tax the individual to a point where they are unable to cope and as a resu lt their physical health suffers. Golembiewski et al. (1996) found that the more advanced the burnout phase the more physical symptoms were reported. This pa ttern was replicated not only in North America but in other sites as well; Belarus, Japan, and China for example. Th is also holds true of a persons mental health. Those individuals experiencing the more advanced phase of burnout reported more mental health problems. Burnout Exhaustion Depersonalization Low Personal Accomplishment High Job demands Low job resources Conflict in the workplace Outcomes Absenteeism Illness Job turnover

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18 Model of Occupational Engagement While theory and research was being adva nced on the study of occupational burnout during the 1980s and 90s, another group of scholar s were proposing a dim ensional structure of affective experience (Watson & Clark, 1992; Watson, Clark, & Te llegen, 1988). These scholars posited that affective expe rience were orthogonal states as either positive or negative. Within the occupational psychology literature, Maslach and Leiter (1997) propos ed that the three elements of burnoutexhaustion, depersonalization, and lack of personal accomplishment, had the opposites of energy, involvement, and efficac y, and that these comprised occupational engagement. Schaufeli and Bakker (2004) predicted that occupational engagement is made up of the two aspects of vigor and determination, whose opposites are the bur nout dimensions of exhaustion and depersonalization. A third aspe ct of engagement, absorption, is uniquely associated with engagement and does not have an opposite burnout dimension. Schaufeli and Bakker also believe that engageme nt, while being the positive antithesis of burnout is in fact an independent state and the two are moderately to highly related in a negative direction. In the Maslach Model (1996), bur nout is the result of an imbalance resulting from heavy job demands and limited job resources. In contra st, occupational engagement is proposed to be the result of physical, psychological, social or organizational res ources available to the employee (Bakker, Demerouti, & Schaufeli, 2003). These job resources provide support for achieving work goals, reducing job demands, and stimulating pers onal growth and development. Schaufeli and Bakker (2004), as depicted in Figure 2, predic t that burnout and engagement are mediators between job demands and health problems and j ob resources and turnover intention, respectively. This model was simultaneously developed and te sted with two samples of adults. The job resources tested were performance feedback, so cial support from colleagues, and supervisory coaching as predictors of occupational engage ment. Model testing usi ng structural equation

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19 modeling procedures showed support for the hy pothesis that occupational engagement was a mediator between job resources and turnover intention. Another study looked at the personal resource s of self-efficacy, organizational-based selfesteem, and optimism and their relationshi p with engagement (Xanthopoulou, Bakker, Demerouti, & Schaufeli, 2007). Dutch employees at six divisions of an elec trical engineering and electronics company were administered a que stionnaire via the companys intranet. The questionnaire assessed job demands, job res ources, personal resources and exhaustion and engagement and the data were analyzed using structural equation modeling. Job demands were assessed with questions about workload (Bakke r, Demerouti, & Verbeke, 2004), emotional demands (Bakker et al., 2003), emotional dissonance (Zapf, Vogt, Seifert, Mertini, & Isis, 1999), and organizational changes (Bakke r et al., 2003). Job resources were assessed with questions about autonomy (Bakker et al., 2004), social su pport (Bakker et al., 2004), supervisory coaching (Le Blanc, 1994), and opportunitie s for professional development (Bakker et al., 2003). Personal resources were assessed with questions about se lf-efficacy (Schwarzer & Jerusalem, 1995), and organizational self-esteem (Pierce, Gardne r, Cummings & Dunham, 1989). Exhaustion was measured with a Dutch version (Schaufeli & Van Dierendonck, 2000) of the MBI-GS (Maslach et al., 1996) and work engagement by a nine item version of the Utrecht Work Engagement scale (Schaufeli, Bakker, & Salanova, 2006). Results from a confirmatory factor analysis showed that personal resources mediated the relationship between job resour ces and engagement and were negatively related to exhaustion. So it might be said that certain j ob resources foster the development of personal resources that ultimatel y result in increased occupational engagement. Physical and psychological job resources are th e antecedents to occupational engagement while those who are engaged are likely to show greater resilience under a variety of different circumstances. A person highly involved and enthusiastic about their work will show

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20 Job demands Burnout Health p roblems Job resources Engagement Turnover intention determination and dedication, be totally immersed in various o ccupational tasks and derive a sense of pleasure and satisfaction from their wo rk (Maslach et al., 2001 ). Having the physical resources to meet job demands increases a person s perception that they can control their work environment (Xanthopoulou et al., 2007) that ultim ately leads to greater confidence to persevere and accomplish challenging tasks (Luthans, Avey, Avolio, Norman, & Combs, 2006). In addition to the three elements of occupational engagement, the burnout dimension of personal accomplishment, reverse scored in the MBI-G S, was found to correlate highly with the engagement factors (Schaufeli & Bakker 2004, Scha ufeli et al., 2002) and warrants inclusion as an additional factor when measuring engagement. Figure 1-2. Occupational engagement model (Schaufeli & Bakker, 2004) While the study of occupational engagement is important, other more long-term outcomes related to this construc t have not been studied. It is posited, however, that employees who are engaged will suffer less from deleteriou s outcomes that includes psychological stress, illness, and absenteeism (Schaufeli et al., 2002). As depicted in Figure 2, Schaufeli and Bakker (2004) did test the outcome of tu rnover intention, but not a direct path from engagement to health problems. Results showed that an engage d employee was less likely to consider leaving a job than a burned out employee. Indirectly, pers onal resources, antecedents to engagement, were

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21 shown to negatively correlate with the burnout dimension of exhaustion possibly leading to reductions in health proble ms (Xanthopoulou et al., 2007). Both models described above predict burnout or engagement based on the presence or absence of job demands and/or resources. However, they do not depict the cognitive process that lead an individual to these experiences. An i ndividuals behaviors are influenced by how they interpret and appraise a stressful situation and lead to their ultima te emotional experience of that event. Lazarus cognitive motiva tional relational (C-M-R ) theory of stress, emotion and coping addresses the cognitions that lead to a persons coping with a st ressor and emotion experienced. Widely cited in the stress and coping literatur e, the C-M-R theory is appropriate to offer interpretations on the cognitive processes that result in occupational burnout and/or engagement. I will now elaborate on this theory. Cognitive Motivational Relational Theo ry of Stress, E motion, and Coping Lazarus (1999) theory is a process oriented theory on how people appraise, cope with and emotionally experience situations they encounter in their life. These cognitions, based on the appraisals of any given situation, result in the emotions felt and coping behaviors of that individual. Lazarus (1999) identified two main antecedents to the appraisal process: environmental variables and person variables. W ithin the occupational context job demands can be included as environmental variables that in clude job specific expectations, hours worked, and the number of athletes an athletic trainer works with and job resources, a persons intelligence, social skills, education, and a social support netw ork of family and friends can be included as person variables. These resources will then impa ct a persons appraisa l of and coping with a stressful situation. In addition personality traits, such as the Big-Five or the five-factor model (Costa & McCrae, 1992) can also be considered a person variable and cont ribute to coping style

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22 or effectiveness (Campbell-Sills, Cohan, & St ein, 2006; Carver, Scheier, & Weintraub, 1989; George & Brief, 2004). The appraisal process, which occurs during a possible stressful encounter, is broken into two temporally based components, primary a nd secondary appraisal. These are cognitive processes that lead to copi ng strategies and emotions experienced. Although they work interdependently, the two types of appraisal, pr imary and secondary will be discussed separately. During primary appraisal, the individual determin es if the situation, first and foremost, affects his/her goals, values, or overa ll well-being. Lazarus (1999) de fined three types of primary appraisal: harm/loss, threat, and challenge. Threat and challenge are the two primary appraisals I will focus on. For instance, if the athletic training profession is highly valued and an individual appraises a particular event as threatening then he or she might experience a stress related emotion such as anger or anxiety. Challenge apprai sals occur when a situation occurs that allows for achievement of a goal or movement towa rd achievement of a goal. An example of a challenge might be a situation in which and athlete experiences a minor injury. The ATC has prior experience and the skills to handle such a situation and therefore views it as a challenge. Based upon these conceptually distinct cognitive appr aisals, it could be theorized that if an ATC perceives several situations over time as threaten ing, then high levels of stress emotions will be experienced. In contrast, if situations are c ognitively appraised as challenges then more positively toned emotions will be experienced and occupational engagement will occur. The secondary appraisal process is a person s analysis of their resources and coping strategies (Lazarus, 1999). The individual determ ines which strategies they are capable of undertaking as well as the likelihood for success using that strategy. If a person believes that they have the resources to cope effec tively with a given situation then that situation will be perceived as a challenge rather that a threat.

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23 Once a person has gone through the appraisal process, the indi vidual will then implement a coping strategy to alleviate a st ressor. Coping mediates the appraisal process and the emotions experienced in a process oriented manner that is predicted to change a nd evolve over time. Two issues related to coping are its consistency and stability over time. An individual coping the same way with different stressors demonstrates copi ng stability. An individu al coping the same way each time the same stressor is experienced demo nstrates coping consistency. Lazarus posited that a person utilizes different coping strategies with the same stressor until one is discovered to be the most effective at alleviat ing that stressor. Cl early, Lazarus and Folkmans (1984) process oriented views about coping respons es consider coping to be variab le across time and situations. However, there is evidence of temporal stability of coping with the coping process and others (Carver et al., 1989) view coping to be more consistent or stable over time. The issue of whether coping is stable over time versus variable and ch anging is important for th eoretical and practical reasons. From a theoretical standpoint the issue of coping stability might shed light on personal resources related to adaptation and help to explai n the deleterious impact of stress on health and well-being. With regard to practic al implications if coping is found to be variable then stress reduction programs would need to account for ma ny possible patterns of coping in response to stress. If however, coping is shown to be stable then it might be important for practitioners to help clients understand how and under what circumst ances their preferred coping styles work or do not work. Lazarus defined two types of coping, emo tion-focused coping and problem-focused coping. Emotion-focused coping deals solely with the emotions that a si tuation elicits while problem-focused coping takes a more active appro ach by attempting to resolve a stressor with either cognitive or behavioral efforts (Folkman & Lazarus, 1980). An article by Skinner, Edge, Altman and Sherwood (2003) on coping categories propos ed more than just the two coping

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24 styles posited by Lazarus. Their argument is that both problem focused coping and emotion focused coping are not mutually exclusive. For example a person plans ahead not only solves the problem but the act of doing so alleviates the emotions that stressor elicits as well. They analyzed over 100 assessments of coping resulting in a list of 400 distinct ways of coping and recommend a hierarchical system of 13 potential core families of coping. These include problem solving, support seeking, escape, distraction, cognitive restructuring, rumination, helplessness, social withdrawal, emotional regulation, information seeking, negotiation, opposition, and delegation. According to Lazarus (1999) there are 15 discrete emotions and these emotions are elicited as a result of the appr aisal process and how one copes w ith their threats, losses, or challenges. There are eight negative emotions, wh ich include anxiety, fear, anger, guilt, shame, sadness, envy and jealousy. These negative em otions might possibly lead to an employee experiencing burnout (see Figure 1-3) According to Lazarus (1999) there are seven positive emotions: hope, happiness, love, pride, relief gratitude, and compassion. These emotions I propose contribute to a person expe riencing occupational engagement. Therefore according to Lazarus C-M-R theory a person encounters a situation that they interpret as a threat or a challenge. The person then employs one or many coping strategies to effectively deal with the stressor itself or th e emotions elicited. Positive or negative emotions then result and in turn influence the appraisal pr ocess with respect to th e current situation and future situations. The next section attempts to explain how the C-M-R theory can be used to explain the constructs of occ upational burnout and engagement within the athletic training profession. A Theoretical and Conceptual Integration of Three Perspectives All three perspectives discussed above have stim ulated a tremendous amount of research over the past three decades. For instance, th e use and application of the MBI has been

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25 demonstrated by over 413 published studies while th e C-M-R theory is both widely accepted and has also stimulated a vast amount of comment ary and empirical scrutiny (Anderson, White, & McKay, 2004; Bunk, 2007; Dillard & Shen, 2007; Giacobbi, Tuccito, & Frye, 2007; Jackson, 2006; Jones, 2003; Kappas, 2006; Monat, Lazaru s, & Reevy, 2007; Nicholls & Pollman, 2007; Patton, Bartrum, & Creed, 2004; Pensgaard & Duda, 2003; Uphill & Jones, 2004; Zuk, 1994). The CMR theory is process-oriented meaning th at ones emotional and coping processes evolve and change over time through a process of c ognitive mediation. Similarly, Smith (1986) integrated tenets of Lazarus theory into a mode l that attempts to expl ain athletic burnout. In particular the cognitive processe s that lead to perceived stress and result in burnout. Therefore, the cognitive-mediational approach seems appropria te to use as a theoretical model to explore the constructs of occupational engagement and occupational burnout. I will now elaborate on how the basic tenets of Lazarus (1999) C-M-R theo ry will be integrated into the present focus on occupational burnout and engagement. In order to more clearly justify my theo retical integration of the work conducted by Maslach and colleagues, Schaufeli and Bakker (2004), and the C-M-R theory (Lazarus, 1999), an important question to ask is where does occupa tional burnout and engagement fit into Lazarus C-M-R theory. Figure 1-3 shows a possible location within the theo retical model. Columns A, D and E contain the elements of both burnout and engagement models whil e columns A, B and C contain the C-M-R theoretical el ements. Schaufeli and Bakkers model (2004) and Maslach et als model (1996) do not outright omit the cognitive processes that lead to either occupational burnout or engagement, but they are not elaborated in either model. Therefore I propose the appraisal and coping process as elaborated by La zarus (1999) theory as a mediator between the antecedents and experience of either burnout or engagement.

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26 Here in these antecedents to appraisal (colum n A in figure 1-3), para llels can be drawn to the antecedents in both burnout and engagement models. Job demands, whether they are job expectations, work overload, conf lict with others, are environmental variables in Lazarus C-MR theory (1999). Job resources like social suppor t networks, education, a nd past experiences are person variables. The interaction of person and environmental variables influence the way people appraise, cope with and experience a situation an d will lead to whether a person feels burned out or engaged. Lazarus environmental and person va riables can be thought of as synonymous with job demands and resources. An overloading of job demands/environmental variables with low job resources would lead to a thr eat appraisal (figure 13 column B) and if that person is unable to effectively cope with that situation the resu lting negative emotions of fear and anxiety could lead to burnout. In contrast to burnout, an i ndividual who possesses resour ces to match the job demands might appraise a given situation as a challenge rath er than in a threatenin g manner. An individual with the requisite resources to meet the demands will appraise the situation as a challenge, cope effectively and perhaps experien ce more benign emotions. This i ndividual may cope (figure 1-3, section C) with these appraised challenges in a variety of ways but most likely use more actionoriented coping responses. The resulting emoti ons of happiness and pride could lead to engagement. Another aspect to discuss is that a pers on who is experiencing burnout will appraise situations differently and cope w ith them differently as well. For example an athletic trainer who is experiencing burnout might appraise more s ituations as threats (figure 1-3 path a), subsequently feel that they are ineffectual and might employ a coping strategy (figure 1-3 path b) that is maladaptive and results in more anxiet y. Therefore, the experience of being burned out will affect the appraisal and coping processes..

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27 Figure 1-3. Theoretical integration of L azarus C-M-R theory (1999) and occupationa l burnout and engagement. Column A antecedents, Column B appraisal process, Column C copi ng and emotional outcomes, Column D burnout and engagement models Column E burnout and engagement specific outcomes.

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28 In contrast an engaged athletic trainer will ap praise more and more situations as challenges well within their control and matching their abi lities and cope effectively. Thus an engaged athletic trainer appraises more situations as challenges (path c) and has confidence in their coping abilities because they have been successful (path d). Therefore, the appraisal and coping processes are affected by the engagement experience Measurement of Occupational Burnout and Occupational Engagement It is im portant to now elaborate on how bur nout and occupational engagement have been measured. The Maslach Burnout inventory is a measure based on Maslachs Model (1996) of burnout. Specifically it measures the three com ponents associated with the model, emotional exhaustion, depersonalization and personal accomplishment. Persona l accomplishment is reverse scored to assess inefficacy. The Maslach Bur nout Inventory General survey (MBI-GS) was developed by Maslach et al. (1996) to assess burnout in individuals in occupations other than the health professions. It is a 16item measure assessing the thre e components of burnout, exhaustion (EX), cynicism (CY), and low self-efficacy (EF) Exhaustion is measured by 5 items, cynicism by 5 items and efficacy by 6 items which are revers e scored. Items are scored on a 7-point likert type scale on frequency (0 bei ng never and 6 being always) and a 7-point likert type scale on intensity (1 being very mild to 7 being very strong). Schaufeli, Salanova, Gonzalez-Roma, and Bakker (2002) observed Cronbachs levels of internal consistency of 0.85, 0.78, and 0.73 for EX, CY and EF for a sample using an unmodified version of the MBI-GS. An occupational engagement (OES) measure developed by Schaufeli et al. (2002) was developed to determine whether individuals score high or low on occupational engagement. The measure is a 17-item survey assessing three factors of engagement (vigor, dedication, and absorption). A three factor model tested by Scha ufeli et al. (2002) that consisted of vigor,

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29 dedication, and absorption subscale yielded alpha values great er than .70 for two separate samples. The three factor model fit the data reasonably well with a 2(6) = 284.81, p < 0.001 and correlations between the three latent f actors were r(VI.DE) = 0.77/0.84, r(DE.AB) = 0.75/.91 and r(VI.AB) = 0.98/0.93, (Sample 1/Sample 2). Each item is scored on a six point likert type scale and also has a seven-point intensity scale. For example the it em I can effectively solve the problems that arise in my work. Had respons es ranging from 1 A few times a year to 6 Every day. The intensity scale ranges from 1 Very mild, barely noticeable to 7 very strong, major. There is Never response option as well with each item. Utilizing the MBI and OES it is important to note how one would be identified as being either burned out or engaged or both. Golembie wski et al., (1996) establishes phases based on the scoring within the burnout sub-domains. He elaborates eight diffe rent phases of burnout. Phase one being the lowest and eight being th e highest level of burnout. Based on norms an individual, scores high or low in each sub-domain and then is assigned a phase. Golembiewski et al. (1996) identify scores 24 and over on the e xhaustion component, 19 and over on the cynicism component and 27 and above on the personal accom plishment (reversed) component of the MBI as being high in the dimension. Table 1 below breaks down each phase based on sub-domain scoring. Based on Golembiewski et als (1996) model a person who scored high on all three components of Maslach et al. ( 1996) model would be in the mo st advanced phase of burnout. Table 1-1. Progressive phases of burnout (Golembiewski et al., 1996) Phases of Burnout I II III IV V VI VII VIII Depersonalization Lo Hi Lo Hi Lo Hi Lo Hi Personal Accomplishment (reversed) Lo Lo Hi Hi Lo Lo Hi Hi Emotional Exhaustion Lo Lo Lo Lo Hi Hi Hi Hi Similarly, with occupational engagement, es tablished norms (Schaufeli et al., 2002) are used to determine whether an individual is c onsidered occupationally engaged. Scores greater

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30 than 3.82 on vigor, 3.74 on dedication and 3.53 on abso rption classify someone as occupationally engaged. It is also important to note that burnout and engagement as demonstrated by Schaufeli et al. (2004) do not lie on either ends of the sa me continuum but in fact are independent or orthogonal constructs. Schaufeli et al. posit that an individual can score both low on the MBI and the OES and that that person is not burned out but not engaged either. Su ch an individual could possibly have job demands that are so low and eas ily met that engagement is unlikely to occur: simply put their job is boring. Therefore, it is then theoretically possible to be burned out and engaged at the same time. Perhaps certain as pects of an ATCs job are demanding and that person does not have the resources to meet them but does have the resources to meet other job requirements. For example an ATC may not have the experience or knowledge to plan team meals but does have the skills and knowledge to d eal with severe injuries. In this case, one element of the occupational experience is difficu lt and may be associated with burnout while the other (injuries) is engaging. Both the MBI (Maslach et al., 1996) and OES (Schaufeli et al., 2002) have demonstrated reliability and validity in the measurement of burnout and engagement. However, neither measure assesses the overall impact of being burned out or engaged on the individual and how experiencing either affects that persons quality of life, job satisfaction or ability to cope with occupational demands. While both measures do an ex cellent job of metering the degree to which an individual is engaged or burned out neither ex plains how that person arrived at the point. Empirical Studies Empirical Studies on Burnout Burnout has been studied with respect to va rious occupations, orig inally exploring the phenom enon in the medical community resident physicians, nurses, health care workers

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31 (Dierendonck et al., 2001; Rowe & Sherlock, 2005; Thomas, 2004), as well as management (Schaufeli & Bakker, 2004), and air traffic c ontrollers (Demerouti, Bakker, Nachreimer, & Schaufeli, 2001). However, res earch examining burnout in the at hletic training profession is relatively sparse with respect to Burnout (Hendrix, Acevedo, & Hebert, 2000; Reed & Giacobbi, 2004). Empirical Studies on Occupational Engagement Research focusing on the study of Occupati onal Engagement has onl y existed since the turn of the century. A shift in focus toward positive psychology has proposed focusing not only on the weaknesses of human behavior but toward positive functioning and strength (Seligman & Csikszentmihalyi, 2000). I will now review some of the literature that ha s explored the study of occupational engagement. Schaufeli et al. (2002) deve loped and tested the Utrecht work engagement scale (OES) and tested higher-order factors with the (MBI-G S: Salanova & Schaufeli, 2000) with separate samples of 314 students (M=22.3) and 619 employees (M=32.8). Participants were administered the 24-item Spanish version of the MBI-GS (Salanova & Schaufeli, 2000) to assess burnout levels. As predicted the MBI-GS dimensions were positively interrelated as were all of the engagement dimensions and the burnout and enga gement dimensions were negatively correlated with one another. The authors then tested higher-order factors and suggested support for two latent factors one with cynicism and exhaustion and the other with all th ree engagement scales: vigor, dedication, absorption, and efficacy. This finding is questionable however because although there were significant differences betw een the models tested, the RMSEA of .11 which is outside of conventional cutoff standards (Byrne, 2005). The results of this study set preliminary ground work in distinguishing occupational and burnout as separate constructs and not opposite ends on the same continuum. Viewing these

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32 constructs as independent of one another yet moderately negatively related allows one to conclude that engagement is indeed an antipode of burnout (Schaufeli et al., 2002). Schaufeli and Bakker (2004) looked further at the relationship between burnout and engagement with respect to job demands and job resources in 2004, as well as the outcomes possibly resulting from the two phenomena (See Figure 1-2). Employees from various Dutch service organizations participat ed in the study, to include an insurance company, a pension fund company, an occupational health and safety service and a home-care institution. Sample 1 included 261 males and 120 females with a mean age of 40 years old and average of 12.5 years organizational tenure that worked at a Dutch insurance company. Sample 2 was comprised of employees at several branches of an occupational health and safety service including 76 males, 126 females with a mean age of 40 years and average time with that company or 7 years. 173 males and 334 females with a mean age of 35 years and average organizational tenure of 6.5 that worked at a pension fund company comprised Sample 3. Employees of a home-care company, 608 participants with 97 percen t being female, with a mean age of 42 years old and 9 years average experience at that company, were desi gnated as Sample 4. All participants were administered the Dutch version (Schaufeli & Dierendonck, 2000) of the MBI-GS (Schaufeli et al., 1996), the Utrecht Work Engage ment Scale (UWES; Schaufeli, et al., 2002), a Dutch version (De Jonge, Dollard, Dormann, Le Blanc, & Houtman, 2000) of Karaseks (1985) job content scale (to assess the job demand of workload and job resource of performance feedback), a five item scale to assess emotional demands in the wor kplace and a ten item scale to assess social support from colleagues both developed by Van Veldhoven and Meijman (1994), a Dutch version of Graen and Uhl-Biens (1991) 12 it em Leader-Member exchange Scale (Le Blanc,

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33 1994) to assess supervisory coach ing, a 13-item health compla int questionnaire (Dirken, 1969), and a turnover intention scal e consisting of three items (V an Veldhoven & Meijman, 1994). Similar to Schaufeli et al. (2002) the rela tionship between burnout and engagement were tested using SEM with three models. The thir d model, with the PE loading onto engagement instead of burnout fit the data be st. These results reinforce thos e reported in Schaufeli et al. (2002). Schaufeli and Bakker (2004) then tested the goodness of fit of the four samples using the model depicted in Figure 2 in order to test the hypotheses of whet her burnout mediates the relation between high job demands and experien ced health problems, whether engagement mediates the relationship between job resources and low turnover intention, as well as the various cross links depicted in Figure 2. The results showed support for burnout mediating the relationship between job demands and health problems as well as engagement mediating the relationship between job resources and turnover intention. Several models were run, the first (Moriginal) testing the paths as show n in Figure 2 and a second (Mre-specified) allowing the error terms of DE and AB, and VI and AB to correlate. Mre-specified improved the fit of the model significantly than Moriginal ( 2 (8) = 163.54, p < 0.001) and two constrained models that were also run with the data. The results of Schaufeli and Bakker (2004) s uggest that burnout a nd engagement mediate the relationship between job demands/job resour ces and health problems/turnover intentions, however, the effects of being burned out or engaged have further implications than just these two outcomes. They did not test for any positive outcomes that engagement might lead to, among them, job satisfaction, improved quality of life, etc.

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34 Empirical Studies with the Popul ation of Athletic Trainers Research focusing on occupational burnout, engagem ent, and coping experienced by athletic trainers is limited in comparison to othe r human service settings. While athletic training is similar to other human servic e occupations, it does possess its ow n specific set of stressors and challenges that warrant empirical scrutiny (Reed & Giacobbi, 2004). In this section I will provide a review of the literature focused on stress, coping, burnout, and at trition in the athletic training profession. Campbell, Miller, & Robinson (1985) were perh aps the first to assess the prevalence of burnout in the athletic training pr ofession. They distributed an au thor developed questionnaire at the 1984 National Association of Athletic Traine rs (NATA) Clinical Symposium. Two hundred and twenty one athletic trainers, out of a total of 1500 certified at hletic trainers in attendance, completed the survey packet (.15 response rate). The participants were 70.1% male and 29.9% female with an average age of 35 years old. For this sample, the length of time in their present positions were 40.8% with less than 4 years at th eir current job, 40.3% with 4 to 10 years, and 18.8% having more than 10 years. The questionna ire that was distribut ed at the convention consisted of the Athletic Trainer Burnout Scale (ATBS), developed by the authors for the purposes of this study, which focused on stress common medical conditi ons, and demographic questions. The ATBS included 43 questions and had a range of scores from 58 to 168. The authors did not report any reliability or validity statistics of the measure and those who scored over 117 on the ATBS were classified as bur ned out while individua ls who scored 117 or lower were classified as not burned out. Campbell et al. (1985) found that 60.3% of the sample was burned out and there were significant associations between burnout and frequent headaches (.22), high blood pressure (.20), nervousness (.23), depression (.43), indigestion (.27), fatigue (.28), and sleeplessness (.24).

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35 Fatigue was the most frequent medical condition reported in this study with 40.7%. No significant relationships were found between the susceptibility of being burned out based on background or other demogr aphic variables. There are some limitations to Campbell et al.s (1985) study related to the reliability and validity of the ATBS. The authors do not provide a ny validity or reliability statistics with respect to this measure nor did they provide a conceptual definition or theory from which the survey was based. Another limitation concerns their sampling scheme as the pa rticipants were comprised of attendees to a national conference, which ex cluded those not in attendance from being participants. With this approach it would be possi ble that those in attenda nce were systematically different from those not in at tendance, which limits the generalizability of Campbell et al.s (1985) findings. However, even though there ar e questions about the findings reported by Campbell et al. (1985), this study was important because it indicated attention being focused on issues of stress and burnout within the athletic tr aining profession. Capel (1986) studied the relationship of various psychological and organizational factors linked to burnout. She specifically looked at role conflic t, role ambiguity, locus of control, number of athletes the athletic trainer was responsible for, and hours of contact with those athletes each week. The participants were 332 fu lland part-time athletic trainers certified by NATA and included 209 males and 123 females. The researchers obtained a list of National Athletic Trainers Association ( NATA) certified athletic trainers living in the we stern portion of the United States and mailed a letter of consent and a questionnaire to a total of 900 ATCs. The sample was self-selected based on those who chose to return the surveys and part time athletic trainers who worked less than 20 hours per week were excluded from the data set. The mean age for the sample was 31.3 years with an average with only 4.6 years of experience. Fifty-two

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36 percent of the sample were married and 44% of the sample were employed in either the high school or Division I collegiate setting. The questionnaires included the Maslach Burnout Inventory (MBI), Rizzo, House and Lirtzmans (1970) role questionnaire, which assessed role ambiguity and role conflict, the Rotter Internal -External Locus of Cont rol Scale (Rotter, 1966), and demographic questions. Capel (1986) reported relatively low indivi dual subscale mean scores of 2.84 for emotional exhaustion, 1.95 on the, depersonali zation scale, and 5.20 for (M = 1.95), personal accomplishment. The range of scores for role ambiguity and role conflict ar e on a scale of 1 to 7 with a 1 representing high role ambiguity and a 7 representing high role co nflict. Role ambiguity and role conflict scores were al so generally low with mean sc ores of 5.2 and 3.0 respectively. According to Capel (1986) 78% of the ATCs ha d an internal locus of control and that the number of athletes and the hours of care were hi ghly variable. Results i ndicated that the higher the role conflict, number of cont act hours, having an external locus of control and having a higher level of role ambiguity correlated to higher levels of burnout. A regression analysis suggested that role conflict wa s the strongest predictor of burnout frequency and intensity, with beta weight coefficients of .356 and .672 respectively. Capel (1986) discussed several possible reasons that the burnout scores were low when compared to other helping professions. First, 45% of the athletic trainers in the sample reported being the sole athletic trainer in their work place and 76% repo rted being the head athletic trainer. Those working alone or as head ATC ar e highly autonomous which is reflected by lower burnout. Capel (1986) also surmised that it might be that burnout is low because trainers have an off season or time away from their professi on. Another possibility is that ATCs receive immediate feedback of their work (e.g., an injured athlete returns to competition). Time off and

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37 positive feedback, in the form of athletes progress, might buffer the athletic trainer against burnout. While Capels (1986) findings were im portant, several limitations preclude generalizations. The mean experience level of th e sample was only 4.6 years and it may be that many ATCs have left the profe ssion altogether due to early ca reer burnout are therefore not represented in the study. Likewise, a certain se gment of the population was not represented due to the self-selective nature of st udy participation, and the fact that individuals in other parts of the United States were not represented. Again, these limitations increase the difficulty of generalizability to the ATC population as a whole because it is po ssible that individuals in the profession for longer periods of time may exhibi t different responses. Finally, gender was not evaluated in either investigati on as neither Campbell et al. (1 985) nor Capel (1986) report any differences in burnout between males and females. The study does offer some strong evidence on some of the possible organizational predictors of burnout. Specificall y, role conflict might arise due to the additional duties that ATCs are required to do outside th eir expertise, such as travel and meal arrangements. Further study is needed to identify how the ATC appraise s these challenges and eventually cope with them. With a strong need previously demonstrated reason to systematic ally explore stress, burnout, and attrition in the at hletic training profession, Capel (1990) later attempted to determine why athletic trainers were no longer employed in the pr ofession. Eighty-two out of an initial sample of 219 former ATCs responded to a one-shot 22-question survey based study. The questionnaire included items to assess demogr aphic information, reasons for both entering and

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38 leaving the profession, and curre nt employment. Open-ended ques tions were also included to solicit more inductively developed information regarding the participants experiences. Over half of the sample (57%) reported that th e costs of being an athl etic trainer were too great such as having to do jobs not within their roles as athle tic trainers, work overload, and multiple people to please. However, ninety-one percent reported that the job was worth the time commitment. It can be inferred that certain aspe cts of the job are rewarding while others are taxing and, for some, ultimately lead to leaving the profession altogether The possibility then arises that certain aspects of th e job are engaging while others contribute to burnout and possibly can occur simultaneously. Again over half (58%) reported that they woul d take a job as an athletic trainer again but qualified their decision by describing speci fic criteria that would have to be met. Another study examined the relationships between a personality trait of hardiness, social support, and job-specific issues, and burnout wi th ATCs (Hendrix et al., 2000). The purpose of this study was to assess correlations between issues faced by athletic tr ainers, perceived stress scores, and the personality dimensions of hardin ess, and social support. Another purpose of the study was to provide evidence to support Smiths model of stress appraisal, and burnout (Smith, 1986). Smiths model of athletic burnout states that situation and person variables influence a persons appraisal of stress and that in turn influences burnout experienced. One-hundred and eighteen certified athletic traine rs from NCAA Divisi on I-A universities participated in the study. Of the athletic trainers in this sample, 57% listed footba ll as their primary sport with athletic trainers of other spor ts totaling 43%. The av erage age of the participants was 38.7 (SD not reported) years for football athletic trainers and 31.0 years for non-football athletic trainers.

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39 Forty-five percent% of the sample ranged in experience from 2 to 5 years with only 23% having over 11 years experience. The results of Pearson product-moment corr elations showed associations between perceived stress and all three elements of burnout: emotional exhaustion ( r = 0.59), depersonalization ( r = 0.43) and low levels of personal accomplishment ( r = -0.27). These results supported the hypothesis related to Smiths mode l (1986) that higher pe rceived stress would correlate to higher levels of burnout. Two step wise multiple regressions were run, the first analyzed how hardiness, athletic training issues, social s upport, and sport (football or nonfootball) predicted perceived st ress. The results of the first model showed that the personal variables of hardiness (.40), a nd social support (.05) uniquely c ontributed to the total variance with the situational variable of athletic tr aining issues accounting for an additional .07. The second stepwise multiple regression analyzed how the burnout dimensions (emotional exhaustion, depersonalization, and pe rsonal accomplishment) predicted perceived stress scores. Emotional exhaustion and persona l accomplishment each contributed significantly to the variance with 35% and 5% explai ned respectively. The burnout dimension of depersonalization did not significan tly contribute to the variance e xplained. These results suggest that athletic trainers wh o scored high on hardiness, had fewer athletic training related issues, and greater perceived social suppor t, were less likely to experi ence high levels of stress. Additionally, those with higher levels of emotional exhaus tion and lower levels of personal accomplishment also reported higher levels of perc eived stress. These findings also demonstrate that unique combinations of psycho-social and contextual variables are linked to the stress and burnout experience.

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40 The following two articles deal with a subset of athletic training: stude nt athletic trainers. Stilger, Etzel, and Lantz (2001) st udied the life-stress sources of collegiate athletic trainers over the course of an academic year. Eleven male and 9 female student ATs were administered the Quick Stress Questionnaire (QSQ: Otani, 1985) each month throughout an academic year. The participants were en rolled in a NCAA Division I undergra duate program ac credited by the Commission on Accreditation of Allied Health Education Programs (CAAHEP). The mean age of the participants was 22 years (SD = 4.6 years). Out of an original 43 student athletic trainers originally enrolled, onl y twenty participants completed th e study for various reasons discussed by Stilger et al. (2001). The study was intended to identify the sources of stress for student athletic trainers, explore gende r differences, and provide input to athletic training on how to assist the students. The QSQ (Otani, 1985) is a 25-item measur e that assesses stress and stress-related symptoms in college students. Each item is meas ured on a 9-point likert type scale (1 =little stress, 9 = extreme stress). Items assess the se verity of stress with respect to academics, social/personal stressors, family issues, financia l stressors, self-image issues, health issues, sexual issues, and day-to-day hass les. Stress symptoms are classi fied as cognitive, somatic and behavioral. Students completed the QSQ once a m onth during the academic year for a total of 8 administrations. An ANOVA was performed to de termine the severity of each stress source across gender and time. A sepa rate ANOVA was performed to de termine any changes over time in the expression of cognitive, somatic or behavioral stress. Stilger et al. (2001) found that academics and financial concerns were the primary sources of stress for the student athletic trainers. The authors no ted significant main effects for gender relative to cognitive (F1,18 = 5.99, P = .001) and behavioral expressions of stress (F1,18 =

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41 2.50, P = .019) with women reporting greater stress symptoms than men particularly. Women also reported greater overall stress during the academic year relative to men (F1,18 = 14.38, P < .001). Reed and Giacobbi (2004) explored the sour ces of stress and coping methods of certified graduate athletic training st udents in their study. Three men and three women enrolled in a graduate athletic training progr am at a NCAA Division I University volunteered to participate in the study (M = 23 years). All partic ipants worked in either a colle giate or high sc hool setting and all were in a supervisory position overseeing at least two undergraduate AT students. Utilizing qualitative and grounded theory methods (Charmaz, 2000) they interviewed student ATCs three times over a nine-month period to assess the majo r sources of stress and coping responses. A semi structured interview guide was develope d by reviewing the exis ting stress and coping literature and a series of probes we re devised to elicit rich details pertaining to the individuals experiences. The first interview was designed to establish trust and rapport between the participant and researcher allo wing for the participant to feel comfortable to relay personal information during interviews two and three. The interviews were tr anscribed verbatim and coded utilizing grounded theory anal ytic procedures (Charmaz, 2000). Reed and Giacobbi (2004) found a variety of stressors and coping strategies employed by certified graduate athlet ic training students. Six general dimensions of stress were determined from analyzing the interviews to include: At hletic training duties, comparing job duties, responsibilities as student, time management, soci al evaluation and futu re concerns. A multitude of coping strategies fell into 11 general dimens ions to include planni ng, instrumental social support (e.g. seeking advice), adjusting to job responsibilities, positive evaluations, emotional social support (e.g. venting), humor, wishful thinking, relig ion, mental and behavioral

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42 disengagement, activities outsi de of profession (e.g. exerci se, recreational activities), miscellaneous (e.g. try to understand others fee lings). These coping strategies were further categorized into emotion focused coping (e.g. humor, exercise, and venting) utilized to alleviate emotional distress and problem focused coping (e .g. planning, seeking advice) used to resolve the stressful situation directly. Tw o out of the six participants decided not to pursue a career in athletic training and though no specific reasons were elaborat ed upon, Reed and Giacobbi (2004) surmised that excessive stress and burnout could have been factors. Reed and Giacobbi (2004) identified stre ssors specific to graduate student ATCs, including student responsibilities, time management, future con cerns, and meeting expectations of peers, coaches and instructors. The authors note d that over the course of the academic year the student ATCs appeared to gain confidence in thei r abilities and cited social evaluative stressors less frequently in the final interview. Student ATCs used both proactive and emotional coping strategies to alleviate stress. There are a few limitations to this study. The sample consisted of graduate school ATCs and as a result cannot be generalized to the AT C population as a whole. Older more experienced ATCs might have learned to cope more effectivel y with the stressors that are AT specific. In addition the academic stressors will not be experi enced by ATCs established in their current job. Methodologically, only three inte rviews were conducted over a ni ne-month period and stressors when recalled over a great period of time are not as emotionally salient and therefore rich contextual detail can be ab sent from the interview. The extant literature is minimal with respec t to ATCs and the study of burnout with only six studies exploring this phenom enon. Of the six studies only one (Capel, 1986) used random sampling techniques to recruit participants and then only t hose who chose to return the

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43 questionnaires where included. Two of the studies explored stress and coping with respect to student ATs (Stilger et al., 2001; Reed & Giaco bbi, 2004) therefore making generalization of their findings to the ATC population as a whol e problematic. Only one study explored gender differences among ATCs reporting that females re ported more stress than males. No studies looked at occupational engagement with respect to ATCs. Therefore, it is important to build on this literature and explore the constructs of burnout, engagement, stress and coping with full time ATCs. Rationale As discussed in the previous sections, rese archers have only begun to study occupational burnout and engagem ent in the athletic training pr ofession. Much remains to be learned particularly with regard to how and why some i ndividuals in the profession are able to adapt to this relatively lower paying human service profession while others become burned out and leave the profession. Experiencing stressf ul situations with athletes, parents, coaches, physicians, as well as high athlete to trainer ratios, and dual role responsibilities are some of the stressors unique to the athletic training profession (Hendrix et al., 2000; Reed & Giacobbi, 2004). Hendrix et al. (2000) focused particular ly on hardiness, social suppo rt, perceived stress and their relationship to burnout. While so cial support is one coping mechanism, there are almost no studies that have focused on ot her coping strategies utilized by ATCs who have been in the profession for several years. Reed and Giac obbi (2004) examined the coping responses of student athletic trainers but it is possible that individuals who have more experience within the profession may exhibit more automated a nd perhaps adaptive coping over time. By understanding the stressors and coping strategies particular to a specific context important information can be used to develop interventions that can be designed and empirically tested. Whereas Reed and Giacobbi focused on student ATCs, this study will replicate and expand

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44 upon Reed and Giacobbi by interviewing ATCs in a secondary school setting. In addition to analyzing stress and coping responses this st udy will explore athletic trainers thoughts and feelings about the concepts of occupational burnout and engagement as well as coping consistency and stability over ti me. There are also indications of gender differences in other human service professions with regard to the burnout syndrome (Maslach &Jackson, 1985; Maslach, Jackson & Leiter, 1996). For instance, Bekker, Croon, and Bressers (2005) found that female nurses experiencing burnout had a significantly higher absent ee rate due to sickness than males. Lindblom et al, (2006) found women were more likely to be in a higher level group of individuals experiencing burnout. The issue of gender differences with regard to stress, coping, burnout, and engagement has not be en addressed with ATCs. Th e final shortcoming within the extant literature concerns the issue of coping st ability or consistency over time. The only study to examine ATCs coping responses over time was Reed and Giacobbi (2004) but they did not directly examine the stability or consistency of coping across the three interviews. The issue of whether ATCs cope with occupational stress cons istently over time, as would be suggested by a trait like perspective (e.g., Carv er et al., 1989), or wh ether coping is more variable and process oriented as posited by Lazarus (1999) and colleagues (Lazarus & Folkman, 1984), remains unclear and will be examined here. The purposes of this mixed-methods study were to examine the occupational constructs of stress, burnout, engagement, and coping with a sel ect group of ATCs previously identified to be in the most advanced stages of burnout or occupationally engaged. Efforts will be made to examine contextual elements of the particip ants occupational setting (e.g., resources and demands) along with characteristics of the indi vidual (e.g., cognitive appraisal, coping, overall occupational experiences), as well as the individu als coping stability and consistency over time.

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45 A secondary purpose was to make comparisons with regard to the construc ts depicted in Figure 1-3 between males and females and individuals w ith more (greater than 10 years) versus less (less than 5 years) years post certification.

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46 CHAPTER 2 MATERIALS AND METHODS Research Design This study used a m ixed-methods design based on the work of Giacobbi, Poczwardowski, and Hager (2005) who elaborated on different co mbinations of research methods that could involve qualitative and quantitative data sources Step one of my desi gn, depicted in Figure 4, involved quantitative data that was used to pre-sc reen individuals for recruitment into interviews. Individuals were selected as being an ATC in a secondary/high school setting and worked with the school football team. This involved identifying a sub-set ( N = 4) of ATCs who scored within the advanced stages of burnout (stage VI, VII or VIII) and a second sub-set identified as occupationally engaged ( N = 4) from recently collected data from a nationwide random sample of certified ATCs (Giacobbi, In Progress). For this por tion of the study, 6 individuals from a sample of 555 were identified as being in th e most advanced stages of burnout based upon accepted criteria (Golembiewski, Boudreau, Munzenrider, & Lou, 1996) and all were employed in secondary school/high school set tings. Specifically, individuals were considered burned out if they were in the fifth or sixt h stage of burnout according to Golembiewski et al (1996). No individuals met the criteria for being in stag e seven or eight however individuals with high emotional exhaustion subscale scores were selected. Of note, two of the participants were within 2 points of the personal accomplishment cutoff. Othe r factors that were c onsidered in selection were time certified (4 individuals with over 10 ye ars experience and 4 individuals with less than five years experience), and the number of clients in their facilities (ranging from 50 to 800). Likewise, those who had a mean score greater than 3 on all three subscales of the OES (Schaufeli et al., 2002) were classified as occupationally engaged. One hundred and thirty-seven individuals

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47 met these criteria. Four individua ls were selected based on gender, time certified, and number of clients. The remaining steps in my study design are described below Figure 2-1. Four step design of this study. Step 1: Identify ATCs who scored high on either the MBI and OES. Step 2: Contact a subset of these individuals for interviews. Step 3: Establish trust and rapport with pa rticipants and analyzed job context duringfirstinterview. Step 4: Conduct second interview. 2A: Verify their current occupational experiences as either being burned out or engaged. 4A: Transcribe interview two and analyze data. 3A: Transcribe interview one and analyze data. Step 5: Conduct third and final interview. 5A: Transcribe interview two and analyze data. Step 6: Analyze data using constant comparative method and sensitizingconcepts.

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48 Participants Approval was obtained from the University of Florida Institutional Review Board (IRB) in November 2007, UFIRB# 2006-U-0693. From an original sample of 934 ATCs sampled randomly, a sub-set of 555 individuals indicated their approval to contact them for follow-up interviews. Using the screening process described above, eight cer tified athletic trainers were recruited to participate in this study. Requirements for participati on were: 1) Must currently hold a position as an athletic trainer, 2) must be NATA certified, and 3) must be out of school. Additional efforts were made to counterbalance participants by year s of experience so that there were two individuals from each sub-set described above with greater than 10 years post certification and two individuals wi th less than 5 years experience. The final sample consisted of 8 individuals averaging 33.9 years old with a standard deviation of 8.69 years. Measures The Demographic Questionnaire. The following dem ographic data will be verified during the interviews : age, gender, racial/eth nic background, number of c lients at their facility, and the staff/client ratio. The Maslach Burnout Inventory (MBI). The original MBI (Maslach & Jackson, 1981) is a 22-item measure of occupational burnout that consists of three subscales: emotional exhaustion (e.g., I feel emotiona lly drained from my work), personal accomplishment (e.g., I have accomplished many worthwhile things in this job), and depersonalization (e.g., I worry that this job is hardening me emotionally). Participants answer each question based upon two dimensions: how often and how strong/intensely th ey experienced a given thought or feeling on a Likert type scale that ranges from 0 (never) to 7 (every day or very strongly). The MBI is the most widely used measure of o ccupational burnout and it has esta blished reliability and validity (Leiter & Schaufeli, 1996). I ndividuals who score 19 or grea ter on depersonalization, 24 or

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49 higher on emotional exhaustion and the reverse scored personal accomplishment subscale would be considered burned out. Occupational Engagement Occupational engagement was assessed with the Occupational Engagement Survey (OES) construc ted and validated by Schaufeli et al. (2002). This measure consists of 3 subscales and 24 items intended to measure vigor (i.e., When I get up in the morning I feel like going to work); Dedi cation (i.e., Im enthusiast ic about my job); and Absorption (i.e., When Im working I forget a bout everything around me). Items are scored on a 7-point frequency scale from 0 (never) to 6 (alwa ys). As stated above factorial validity for the OES was demonstrated in Schaufeli et al. (2002). Qualitative Interview Three interviews were conducted over the phone and efforts were m ade to establish rapport and trust between the interviewer and in terviewee (Johnson & Weller, 2002; Shuy, 2002). These interviews were semi-structured in na ture with the use of an interview guide and probing questions as discussed by Charmaz (2002) The first interview guide consisted of questions, which were used to confirm demographic data, build rapport, and to introduce the constructs of burnout, engagement, and coping. Participants were provided with the interview guide several days in advance of the actual inte rview. The interview guide for the first interview was as follows: 1. Please describe your typical day as an athletic trainer. Tell me more about the athletes you work with? Tell me more about your coworkers (if any)? 2. How long have you been at your current position? What other jobs have you held? How long were you there?

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50 4. Please describe how you came to the deci sion to become an athletic trainer. 5. Please describe some aspects of your job that you would like to change. Tell me more about ______? What is it about _____ that ma kes you want to change it? 6. Please describe some aspects of your job that you enjoy. Tell me more about ______? How does that make you feel? 7. A challenge is a situation, which allows you to achieve a goal or movement toward the achievement of a goal. Please describe so me of the challenges you face in your job. Tell me more about ______? How does that make you feel? 8. Stress is considered the negative emotions feelings, and thoughts w ith regards to your occupation. Please describe some of your current sources of stress? Tell me more about ______? What makes this situation stressful for you? 9. A coping strategy is anything you do to reduce or lessen the negative impact of a particular source of stre ss. Could you please describe a particular way that you coped with the situations, experiences, and incidents you described earlier? How did you feel after coping with it? Have you ever done something di fferent in that situation? 10. A lot of people talk about being burned out. Please describe what being burned out means to you. Have you ever experienced burnout ? If so what was it like?

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51 How did it affect you at work? At home? How did you get out of it? 11. Occupational engagement is hypothesized to be the opposite of burnout. Its characteristics are vigor, determination and absorption. Have you ever experienced this? If so what was it like? How did it affect you at work? At home? Interview two focused on specific experiences and the temporal stability of coping. 1. Could you please give me an update on how things are going within AT lately? 2. Since our last interview c ould you please describe some of the challenges you have faced? How did you cope with ______? How did you feel while it was happening? How did you feel after it was over? 3. Please describe some of the stressors you have experienced sin ce the last time we talked. How did you deal with _______? How did you feel while it was happening? How did you feel after it was over? Interview three explored similar issues as in terview two and in addition I asked questions pertaining to some of the t opics discussed previously. 1. Could you please give me an update on how things are going within AT lately? 2. Since our last interview, could you please describe some of the challenges you have faced?

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52 How did you cope with ______? How did you feel while it was happening? How did you feel after it was over? 3. Please describe some of the stressors you have experienced sin ce the last time we talked. How did you deal with _______? How did you feel while it was happening? How did you feel after it was over? 4. Last time we talked about ______. How do you feel about that now? Tell me more about ______. How will you deal with that in the future? 5. We also talked about ______. Ho w do you feel about that now? Tell me more about ______. How will you deal with that in the future? Throughout all three interviews elaborative pr obes were used in accord with suggestions by Charmaz (2000, 2002). For instance, the participants were asked to be a specific as possible in their descriptions of actual ev ents, experiences, and incidents that they have encountered between each interview. All inte rviews were digitally record ed and transcribed verbatim. Consistent with Reed and Giacobbi (2004), memb er check procedures were conducted where I gave the participants summaries of all three interv iews in the form of one to two pages of text. The participants were asked to review the summaries and provide additional information, clarification where necessary, and provide input about the ac curacy of my observations.

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53 Data Analysis The first s tep after acquiring the transcribed data was to conduct line-by-line or open coding (Strauss & Corbin, 1990). This consisted of a thorough review of all interview data until intimate familiarity was achieved with each par ticipants occupational experiences. Raw data themes that pertained to the participants sp ecific sources of stress and subsequent coping responses to those stressors were identified by specific quotes found within the interview transcriptions. The raw data themes were then compared and contrasted based on theoretically similar and dissimilar constructs (Charmaz, 2000) This analysis consists of comparing and contrasting a persons expe riences with other participants e xperiences as well as across similar situations within participants from one interview to the next. Similar raw data themes were grouped together to produce gene ral abstract themes and were named based upon the content of the information provided by the participants. A second coder analyzed the raw data themes and placed them into the broad categories provided by the primary coder independently from the primary investigator. Both coders then met to es tablish reliability with respect to the themes. Agreement was reached with respect to the appropriateness of each theme and categories. A separate independent auditor was given th e interview transcriptions and analyzed the data similar to the procedures outlined above. The purpose of this independent audit was to determine the validity of the raw data themes and broad categories. The raw data themes generated by this audit were compared to the initial analysis and inter-rater reliability was established through a series of meeting in whic h all themes were discussed, agreed upon or reanalyzed. The final step in the analysis was the axial coding or dimensionalizing of the data. This consisted of making connections and distincti ons between themes and sub-themes observed within and between the interviews (Charmaz, 20 00; Strauss & Corbin, 1 990). Each individuals

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54 stress and coping as well as burnout and engagement data themes were examined within the participants occupational context and the specific sources of stre ss relayed duri ng the interview process (Charmaz, 2000). Emerging themes from the interview text we re integrated into theoretical framework outlined in Figure 1-3. Sensitizing concepts were used to interp ret the data. Sensitizing concepts include background information, either a theory or empirical studies used as a st arting point to analyze and interpret the data. A combination of Lazar us (1999) and Reed and Giacobbi (2004) were used to evaluate and label the coping genera l dimensions and the goodness of fit hypothesis was used to evaluate consistency and stability of the participants coping responses over time. Lazarus and Folkman (1984) stated that the effectiveness of th e coping strategy is dependant on the context that the individual expe riences it in. Coping efforts should therefore match the controllability of the situation. Probl em focused coping strate gies, ones that direct address alleviation of the stressor, should be us ed when the individual can control the situation. Stressors outside of the controllability of the individual should be coped with using emotion focused strategies, ones that direct address the emotions elicited by the stressor. Issues of Reliability and Validity According to Lincoln and Guba (1985) trustworth iness of qualitative data needs to m eet the specific criteria of credibility (internal validity), transferability (external validity), dependability (reliability), and confirmabil ity (objectivity). This was achieved in my study by conducting multiple interviews that were analyzed by i ndependent auditors. Trust and rapport and the longitudinal nature of the present study allo wed for familiarity between researcher and participant. This trust is essentia l to ensure that the participants feel comfortable talking with the researcher on a variety of topics sometimes of a personal nature with respect to stress and coping in their occupation as an ATC. Trained qualitative researchers provided suppor t to the analysis as

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55 their input helped alleviate researcher biases or prior beliefs about the interview text. All of these strategies contribute d towards achieving credibility, de pendability, transferability, and confirmability. As cited by Sparkes (1998), techniques to achieve external va lidity include thick description and a database for reader judgmen t of potential transferability (p. 367). These techniques were utilized in the results secti on as each general dimension and higher order theme was explained in detail. In addition, specific quotes representing each general dimension were provided allowing readers to determine transferab ility. Steps to ensure reliability included verification of interviews by part icipants (member checks), and th e use of an independent audit by an unbiased researcher. These results were 93% agreement on stressor general dimensions, 80% agreement on challenge ge neral dimension and 91.3% agreement on coping strategy higher order themes (problem focused or emotion fo cused). These steps ensured the accuracy of transcribed interviews as well as agreement on the raw data themes observed.

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56 CHAPTER 3 RESULTS Descriptive and Comparative Findings The purposes of this study were to assess the sources of stress, challenges and coping strategies used over tim e by certi fied athletic trainers. An a dditional purpose was to explore issues of coping stability and c onsistency over time as well as make comparisons between males and females and year experience. Three semi-str uctured interviews were conducted with eight certified athletic traine rs employed in high school settings. The participants were asked about specific stressors, challenges and coping strategi es over the course of the three interviews. Prior to the interviews, the participants comp leted the MBI and OES at two specific times. The first was assessment occurred during the fall/winter of 2006/2007 as part of a larger study and the second occurred in N ovember 2007 prior to the interv iews. Initial scoring on these measures determined whether the participant wa s either burned out or occupationally engaged. Individuals who score above a 19 on depersona lization, 24 on emotional exhaustion, and less than a 21 on personal accomplishment are consider ed High in each factor respectively according to Golembiewski et al. (1996). An individual who is scores high in all thr ee factors is considered in phase VIII according to Golembiewski. An individual who scores high in emotional exhaustion is considered stage V and one w ho scores high in emotional exhaustion and depersonalization is considered st age VI. Out of the four particip ants selected for the burnout category, one was in stage VI and the other three were in stage V. All participants scored well above published norms for emotional exhaustion. An individual who scored above a 3.82 in vigor, 3.74 in dedication and 3.53 in absorption is considered high in occupational engagement according to the normative data (Schaufeli et al., 2002).

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57 Figures 3-1 and 3-2 depict the average sc ores on each factor of the MBI and OES respectively. Scores on each factor of the MB I for the burned out ATCs showed a decreasing trend with average scores for emotional exhaustion dropping around 6 points. Those ATCs identified as occupationally engaged showed rela tively stable scores on the MBI over time. On average, those individuals previously identified as being burned out remained in phase V across time. Also of note is that personal accomplishm ent scores (not reversed scored) were high regardless of whether participants were classified as either burned out or occupationally engaged. Figure 3-1 Burned out versus Occupati onally engaged ATC MBI average scores. Figure 3-2 depicts the average scores on th e OES. Interestingly, to note that those individuals identified as burned out also scored above normative data on all three factors of the OES. This in part could be due to the fact that certain aspects of thei r job are engaging while other aspects are not. Their scores remained the same over time for both those burned out and occupationally engaged. 13 35.75 38.5 2 5 44.75 9.25 29 37 1.5 6.25 43.25 0 5 10 15 20 25 30 35 40 45 50 DepersonalizationEmotional Exhaustion Personal Accomplishment DepersonalizationEmotional Exhaustion Personal Accomplishment Burned Out Occ. Engaged Time 1 Time 2

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58 4.46 3.88 4.6 5.88 4.79 5.75 4.96 3.88 4.75 5.46 5.04 5.35 0 1 2 3 4 5 6 7 Vigor AbsorptionDedication Vigor AbsorptionDedication Burned out Occ. Engaged Time 1 Time 2 Figure 3-2. Burned out versus Occupati onally engaged ATC OES average scores. Figure 3-3 depicts the average MBI scores ba sed on gender. Scores on each factor were similar for both the men and women ATCs. Across time, the only notable d ecrease found at time two was from 9.5 to 5 on the depersonalization f actor for men only. Women remained consistent on depersonalization. Personal accomplishment scores decreased for men across time and increased for women. Emotional Exhaustion scores decreased similarly for both genders. Table 3-4 depicts the average scores on the th ree factors of the OES with respect to the men and women participants. Ther e are no notable differences in OES scores based on gender. There were also no notable change s in factor scores from time 1 to time 2 suggesting that occupational engagement is stable over time.

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59 9.5 20 43.75 5.5 20.75 39.5 5 17.5 39.5 5.75 17.75 40.75 0 5 10 15 20 25 30 35 40 45 50 DepersonalizationEmotional Exhaustion Personal Accomplishment DepersonalizationEmotional Exhaustion Personal Accomplishment Men Women Time 1 Time 2 Figure 3-3. MBI average scores for men and women ATCs. Figure 3-5 depicts the average MBI scores based upon years post-cert ification. There are no noticeable differences between those with less that five years experi ence and those with over ten years experience. All factors decreased from time one to time 2 except personal accomplishment in those with less than 5 years e xperience, which stayed relatively the same. Table 3-6 depicts average OES scores based on years experience. There are no noticeable differences with the exception of the factor absorption with respect to those participants with less than five years experience. Absorption scores at both time frames were less for those with less that 5 years experience than those wi th greater than 10 years experience.

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60 Figure 3-4. OES average scores based on gender. Figure 3-5. Average MBI scores based on years experience. 5.17 4.38 5.2 5.17 4.29 5.15 5.2 4.75 5.05 5.21 4.17 5.05 0 1 2 3 4 5 6 Vigor AbsorptionDedication Vigor AbsorptionDedication Men Women Time 1 Time 2 6 19.5 40.25 9 21.25 43 3.5 17.25 41 7.25 18 39.25 0 5 10 15 20 25 30 35 40 45 50 DepersonalizationEmotional Exhaustion Personal Accomplishment DepersonalizationEmotional Exhaustion Personal Accomplishment < 5 yrs > 10 yrs Time 1 Time 2

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61 5.25 3.92 5.05 5.38 4.88 5.3 5.33 4.17 5.15 5.13 5.38 5.38 0 1 2 3 4 5 6 Vigor AbsorptionDedication Vigor AbsorptionDedication < 5 yrs > 10 yrs Time 1 Time 2 Figure 3-6. Average OES scores based on years experience. Case Summaries The f ollowing are brief case histories of the participants to familiarize the reader with the participants experiences and unique work cont exts. In all cases pseudonyms were used to maintain participant confidentiality. At the time of the study Dale was 39 years ol d with 17 years as an ATC. He was married and had two children. Dale worked in a high sch ool as both a teacher a nd an athletic trainer seeing approximately 150 to 200 athletes in a se ason with about 800 student athletes at the school in total. An assistant ATC also worked at the school for the fall and winter sport seasons. Dale taught health services and anatomy and physiology and made approximately $65,000 a year. At time one, he scored a 19 on depers onalization (CY), 43 on emotional exhaustion (EE), and a 40 on personal accomplishment (PA) on the MB I. This placed him in phase VI of burnout.

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62 At time two he scored a 12 on CY, 31 on EE, and 31 on PA. This placed him in phase V level of burnout. At time one he scored a 4 on vigor (V I), 3.3 on absorption (AB) and a 4 on dedication (DE) on the OES. At time two he scored 4.8 (VI), 4.2 (AB), and 4.2 (DE). Brian was a 28-year-old ATC with 8 year s experience. He was married and had one child at the time of the study. Initially he was se lected based on the belief he had less than five years experience but during the interviews it was re vealed that he actually had eight years. He worked in the high school setti ng but also does work in a spor ts medicine clinic. He was a teaching assistant at a local college and supervis ed one student AT each fall and spring semester. Brian had changed jobs between time 1 and time 2. At time 1 he worked at a school with over 1000 athletes and two ATCs. He also worked at a sports medicine clinic. At time 2 Brian was employed at a different school with only 400 athl etes. Brians MBI scores at time 1 were 12 (CY), 34 (EE), and 42 (PA). At time 2 his scor es were 4 (CY), 30 (EE) and 37 (PA). Brian stayed at phase V on the Golembiewski et al. (1 996) scale. At time one his scores on the OES were 4 (VI), 3.3 (AB) and 4 (DE). At time two they were 4.8 (VI), 3.8 (AB) and 4.6 (DE). Brian made approximately 50,000 dollars a year. Ann was a 28-year-old female ATC in her fi fth year of certificati on and at her current position. She worked as both a high school science teacher and athle tic trainer. She and another AT, who is licensed but not cer tified, are responsible for 650 athletes. The school schedule consisted of split days. One day she would teach and work as an ATC and the other day she would only work as an ATC. Her associate ATC had been at the school for 18 years. Their high school has split athletic facilities with the gym lo cated on school grounds and athletic fields at a separate location. She made 46,000 dollars a year and was married at the time of the study. Her scores on the MBI at time 1 we re 6 (CY), 35 (EE), and 33 (PA). At time 2 they were 10 (CY), 30

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63 (EE) and 43 (PA). She remained stable at phase V in her level of burnout. Her scores on the OES at time 1 were 4 (VI), 3.3 (AB), and 4.4 (DE) At time 2 they were 5 (VI), 4.33 (AB), and 5.4 (DE). Rachel was a 37-year-old female with 15 years experience as a certif ied athletic trainer. She was employed by a local hospital and, in additi on to her responsibilities as an ATC to a local high school; she was the ATC coordinator for that hospital. She made $39,000 a year at the time of the study and was responsible for 650 athletes at her high school. Sh e was single but in a relationship with a fellow ATC. Her MBI scores at time 1 were 15 (CY), 31 (EE), and 39 (PA). At time 2 they were 11 (CY), 25 (EE), and 37 (PA). She remained in phase V across time periods. Her scores on the OES were as follows at time 1, 5.2 (VI), 3.8 (AB), and 4.4 (DE), at time 2, 5.2 (VI), 3.2 (AB) and 4.8 (DE). Tom was a 36-year-old ATC with 11 years experience at his current high school. Tom was married and had 2 children. He was on staff at the high school but not required to teach. He taught some classes at a local college and has interns that he supervised from there as well. He made roughly $30,000 a year and worked part time as an ATC for local sporting events. Tom was responsible for 800 athletes at the high schoo l where he worked. His scores on the MBI at time 1 were 1 (CY), 1 (EE) and 45 (PA) and at time 2 were, 5 (CY), 4 (EE), and 43 (PA). His scores on the OES at times 1 were, 6 (VI), 6 (AB) and 5.2 (DE), and at time 2 were 5.2 (VI), 5.5 (AB), and 5.4 (DE). Chuck was a 25-year-old ATC with less th an five years experience and was in his current position for two and a half years at th e time of the study. He had a fiance and was responsible for the care of 250 to 300 athletes. He was contra cted to the high school from a hospital and not required to do any clinical work. There was no other ATC located at his school,

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64 however two other ATCs at the hospital are contracted similarl y to area high schools. Chucks scores on the MBI at time 1 were 6 (CY), 2 (EE), and 48 (PA). His scores at time 2 were 0 (CY), 4 (EE) and 47 (PA). His scores on the OES at time 1 were, 6 (VI), 3.2 (AB), and 6 (DE). His scores at time 2 were, 6 (VI), 5.5 (AB) and 6 (DE) Chuck did not specify his salary at the time. Crystal was a 27-year-old ATC with two and half years experience at her current position. She worked at a hospital and was cont racted out to three area high schools, which included 48 teams. There were three full time ATCs and one part time ATC that work out of the hospital. She was married to another ATC and made $31,000 at the time of the study. Crystals scores on the MBI at time 1 we re, 0 (CY), 7 (EE), and 38 (PA). Her scores at time 2 were, 0 (CY), 5 (EE), and 37 (PA). Her scores on the OES at time 1 were, 5.8 (VI), 5.3 (AB), and 5.8 (DE). Her scores at time 2 were 5.3 (VI), 4.12 (AB), and 5.2 (DE). Barbara was a 51-year-old ATC with 17 y ears experience at her current position. She taught math in addition to her duties as an athle tic trainer. She was responsible for approximately 500 athletes at her high school. A contracted ATC worked evenings for game coverage. Due to a past agreement with the school board and union, Barbara was rest ricted to a certain amount of hours a week both teaching and working as an AT C. Earlier in her career she was working excessively that resulted in her becoming exhausted and unaware of her condition. She has no spouse and lives alone. Her scores on the MBI at time 1 were, 1 (CY), 10 (EE), and 48 (PA). Her scores at time 2 were 2 (CY), 11 (EE), and 46 (PA). Her scores on the OES were 5.7 (VI), 4.7 (AB), and 6 (DE) at time 1. Her scores at time 2 were 5.3 (VI), 5 (AB), and 4.8 (DE). She was at the top of the pay scale but di d not mention an exact number. Purpose One: Sources of Stress Figure 3-7 depicts the 29 stressor raw data th em es representing 13 first-order, 5 secondorder, and 2 general dimensions that consisted of athletic tr aining/job duties and family and

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65 personal life. Athletic training/ job duties encompassed all the facets of the job that the ATCs experienced. These included both athletic training responsibili ties as well as teaching duties where applicable. Three second-order themes comprised this dimension: ATC and job duties, Administrative, and Communication with others. ATC and job duties consisted of the first-order themes of hours worked, job demands, athletes, and documentation. Five participants listed game and practice coverage of multiple sports as a stressor. These were particularly stressful for Ann and Tom, two athletic trainers th at had split athletic facilities at their schools. Ann, who was in phase V level of burnout, found it especially stre ssful when her associat e ATC was absent. Ann and Barbara found the requirement of teaching in addition to performing th eir athletic training duties as stressful. Ann stated, I dont hate teaching but if I had to teach every day and I didnt have athletics I would find another profession a long time ago. Barbara, an occupationally engaged ATC who was limited to the hours she worked as a whole, wished she could work full time as a trainer and not have to teach so she could dedicate more of her time to the athletes. Crystal, an occupationally enga ged ATC who was responsible for three separate schools, spent a lot of her time driving between the different cam puses to cover events. Job demands of being accessible to the athletes all day, covering multiple sports and events, and having to be in two places at once were listed by five ATCs as st ressful. Brian, a burnout phase V ATC with 8 years certified, described the pressure of having to be in two places at once: They want me to be in at like a junior va rsity game but at the same time Im treating the varsity players in the training room. So its lik e they want you to be at two places at once and The following quotation from Rachel, a phase V burnout level ATC with over 10 years experience, illustrates this point as well: Probably the other thing is with such a large school everybody thinks I work for just them. The cross-country team thinks Im their athletic trainer. Football thi nks Im their athletic trainer. And I cant be everywhere at once. And once in awhile that gets pretty stressful.

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66 Another first-order theme focused on working with the student athletes. In particular, ATCs mentioned malingering athletes, athl etes with different pain thres holds, overly dramatic athletes, athletes not following orders, ge tting a large group of athletes ready for practice in a short amount of time, and injuries beyond th eir capabilities as stressful. An example of this stressor is in the following quotation from Tom, an occupationally engaged ATC with over 10 years experience: I mean this year our coachs kid, senior, line backer, quarterback of the defense, by far the most football knowledgeable kid in the whol e program goes down on the third game of the year with an ACL. There is not a darn thing I can do about it so we are losing one of the best players of the team; he is the coachs son, senior captain. That is very stressful because there is nothing I can do about it. The final first-order theme under the second-or der theme of ATC/Job duties is documentation. Dale, a phase V level of burnout ATC with ove r 10 years experience, listed paperwork as stressful and Barbara, also with over 10 years ce rtified, mentioned state li censure inspections as stressful. Barbaras proximity to the state capital increased the frequency of inspections at her school. Another second-order theme under the ge neral dimension of ATC/job duties was administrative. The first-order themes of main taining certification and administrative duties emerged from the data. In order to recertify an ATC must take a required amount of continuing education units (CEUs) by a specified date. Dale and Rachel both listed getting their CEUs done in time as stressful. CEUs can be achieved by attending conferences, attending workshops and online. Due to the hectic work schedule Rachel noted that she cant al ways attend conferences and it becomes stressful to find en ough credits. A second first-order theme of administrative also emerged. Tom and Ann cited low pay as stressful, particularly as Tom noted that he had to pick up other jobs to compensate and provide for his family. Rachel listed her duties as the sports medicine coordinator as stressful. The hospital had told her she had to lay off a certain number of

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67 people, which she found extremely stressful. C huck, an occupationally engaged ATC with less than five years experience, found the demands for sport related referrals from him as stressful. Crystal, an occupationally engaged ATC with less than five years experience, experienced stress resulting from a difference of opinion with he r boss. She believed he was not as focused on quality customer service to the sc hools the program provides for. The final second-order theme that emerged from the data under the general dimension of ATC/Job duties was Communication with others. Fi rst-order themes of counterpart, parents, coaches and outside ATC comprised the elements of this second-order them e. Three participants listed their counterpart ATC being absent as a stressor. Barbara elaborates on when the contracted ATC is not on time with the followi ng quote, Butyou know I dont like my kids to be uncovered and it bugs the crap out of me. Another stress expe rienced by the participants was dealing with parents. Brian and Ann listed pare nts not taking their advi ce as stressful. Brian described this stressor: I know what I am doing and umm its a little frustrating that if I te ll em one thing and I talk to the parents and say their child, this goi ng on and then they stil l go to the doctor and they get disqualified for three weeks and the doctor said the same exact thing as me. And we both know I could have gotten the kid out in about a week. A nd so its a little stressful. In addition, parents who think thei r child is indestructible and don t need to sit out from games and parents who have high expectations of th eir children were also listed as stressors. Another source of stress under the general dimension of communication with others concerned coaches. New coaches who were not aw are of paperwork requirements were a source of stress for Ann. She elaborated on this point: Example would be a student who has not turned in physical packet information is not cleared to participate and I see him running out there on the field doing such and such. You know thats not ok with me. The first-order theme of outside ATC, particularly how they are viewed by othe rs in the medical community, was listed as

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68 stressful by two ATCs. Tom stated, But some of the physical therap ist that my athletes see are very anti athletic trainer, so the respect factor in the community is something I would love to change. Similarly, there was a perceived lack of respect in their capabilities from some doctors, usually those who do not work with ATCs on a regul ar basis. Rachel experienced an example of this at a wrestling meet where a physician in th e stands took over when an athlete was injured. Dealing with that was kind of frustrating, having this doctor who has no clue about the athlete and his history come in and try to take over th e situation. The athlet e in question had a low tolerance for pain and Rachel had made the corre ct diagnosis, a pulled hip flexor, however the doctor sent the child to the ER. The second general dimension shown in Figure 3-7 was Family and personal life. This dimension was comprised of the second-order them es of personal space and family and personal life. Ann explained a particularly stressful situation that was ongoi ng involving the privacy of the training room office. While the door can be locked to her room, all of the athletic staff have a key to the room and someone lets athletes in to the room and leaves them unsupervised. Ann elaborated: For example my athletic training room is apparently a public stomping ground and I can only lock up so many things but so many people have keys to so many things. So ummpeople borrowing things without aski ng and forgetting to return them. You know youre running around to set up for a basketba ll game and you only have one cooler. That is definitely a very negative stress. The second-order theme of family and personal life contained the fi rst-order themes of social life and personal life. Four participan ts labeled time away from either their spouse or family as stressful. Tom elaborates: Feeling the need to provide for your family, so I pick up a couple extra games, so I am making more for my family but yet I am sp ending another night away too. That stresses me out a little bit, because how do you ba lance that out? How do you keep providing for your family but spend time with your family at the same time?

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69 Raw Data Themes 1st Order 2nd Order General Dimension Game coverage (5) Teaching duties (2) Amount of driving Season length and intensity Game scheduling Unexpected scheduling of games Hours worked Accessibility all the time Being in two places at once Multiple sports demanding time Split facilities/multiple event coverage (2) Student drug overdose Job demands Athletes with differe nt pain thresholds Malingering athletes Overly dramatic athlete is injured Athlete not following orders Injuries beyond capabilities Getting athletes ready for practice in short time Athletes Paperwork State inspections Documentation ATC/Job Duties Continuing education credits (2) Maintaining certification Pay (2) Coordinator duties/having to fire people Demands of hospital Hospital boss not focused on customer service Administrative Administrative Student ATC absent Other ATC/boss going on vacation Contracted assistant late Counterpart Parents not listening to ATC (2) Parents think child is indestructible Parent high expectations of athlete Parents Communication with others ATC/Job Duties Figure 3-7. Stressors Experienced by High School Athletic Trainers.

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70 Certain coaches (2) New coaches Coach with no trust Coaches How ATC are perceived by medical community Physician taking over at sporting event Outside ATC Communication with others ATC/Job Duties Training room office easily unlocked (no privacy) Personal space Personal space Time away from family(2) Time away from husband (2) Social life Not getting to gym Personal life Family and personal life Family and personal life Figure 3-7. Continued.

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71 Rachel listed not being able to get to the gym as stressful. Thats usually stressful for me if I cant get there. If I cant get there 4 out of 7 days then I am stressed because Im thinking, I need to get to gymwhen am I gonna fit it in? Challenges In addition to the stressors experienced, partic ipants were asked what aspects of their job they felt were challenging. A challenge is a s ituation, which allows you to achieve a goal or movement toward the achievement of a goal. Ch allenges are distinct from stressors because goals are not appraised as being threatened in thes e situations. As can be seen in Figure 3-8 four general dimensions, with five s econd-order and 10 first-order them es emerged from the data. The four general dimensions were ATC duties, other than ATC duties, self-presentation and growth, and family and personal life. Three, second-order themes emerged from the general dimension of ATC duties. They were ATC duties, communication with others, an d job resources. ATC duties were comprised of two 1st order themes of athlete care and schedul ing and event coverage. Clearly the biggest challenges faced by ATCs are working with inju red athletes. Raw data themes included every facet of the process, initial assessments, rehabbing, and counseling on return to play. Five participants listed getting athletes back on to the field as a challenge and is best illustrated by a quote from Tom, who was occupationally engaged: Its funny because to me this is not that stressful of a job compared to a lot of people. Now some take it as a stressful job but I ki nd of thrive on stress (chuckle) If I have to have that star athlete back on the field on the next play I get all excited about that It is a challenge man! Its like all right lets go! Four ATCs said getting a star athlete on the field was a challenge and three listed dealing with malingering athletes as a challenge Other challenges faced by ATCs with respect to athletes were getting athletes with eating disorders hel p, athletes with fungus infections, and weaning

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72 athletes off of psychologi cal crutches. For example an athlet e who feels they need their ankle taped all the time. Another challenge el aborated on by Dale was the following: I would say that the challenge that I have is that people are so different, that everybody responds differently to a variet y of different things. So one of my challenges to achieving the goal of getting kids back in activity is reading people, reading how things are going with their body, their rehab, their treatmen t, and everything. And trying to customize things to allow them to return to play or activity or whatever it is. Two other raw data themes mentioned by one participant each were Dales challenge of evaluating the entire countys wrestlers body fa t and weight index and Chuck challenge of getting multiple sports athletes ready fo r practice in a short amount of time. The second 1st order theme falling under ATC duties was scheduling and event coverage. Multiple sport events and schedules and determini ng where the ATC needs to be was listed as a challenge. Ann states: Other challenges are just you know looking at the schedule and figuring out whats going on and being able to manage your time wisel y. So that you are present when you need to be and youre doing your job effectively. Crystal, who worked at a contracted sports medicine program, described figuring out her schedule, with not only multiple sports but also multiple schools, as a challenge. Ann and Tom listed covering multiple events at sp lit facilities as a challenge. Ev en more so when her assistant is absent Ann states, Yesterday my associate wa s out and with the split the training room, I was back and forth like a chicken but Chuck listed working an 8 team wrestling tournament and being able to provide quality coverage to all teams as a challenge. Cr ystal listed scheduling coverage of another ATCs schools when that ATC leaves for a pregnancy as a challenge. The second-order theme of communication was comprised of the first-order themes of coaches and parents. One participant listed gett ing the paperwork required from all the coaches as a challenge. Another challenge expressed by three ATCs was explaining to a coach why an athlete cannot return to play. Rachel states, Y ah know, especially the coach, Do you think hes

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73 going to be back by this time? Do you think hes going to be back by that time? Tom listed talking with a coach who also happens to be the injured athletes father as a challenge, That is kind of a challenge too, telling dad that his son is not faking it, a nd it is real. Two participants listed educating parents on what serv ices an athletic trainer provide s as a challenge. Brian talked about a situation where he explained to the parent s that their student athl ete had injured his head and should be taken to the hospital. The ATC found it challenging trying to find out if the parents had heeded his advice and finding out th at they had not, working with the Athletic Director to resolve the situation. On the other extreme Ann listed dealing with an overprotective parent who wanted to take her child to the ER for a minor inju ry as a challenge. Ann explains further: I said you know, theyre going to take an xray and then theyre going to refer him to a doctor and Im already pretty sure he doesnt need an x ray, so, you know, its the kind of thing, where, where parents who dont know us, or, or the public who dont know who we are and what we do dont understand the va lue of the specialized education that we have. So thats our opportunity to educate them. A final second-order theme of job resources fell under the general dimension of ATC duties. One first-order theme of equipment needs emerged from the data. Chuck listed getting the right equipment he needed to do rehab as a cha llenge. Chuck also listed getting a new training room built as a challenge. The following quotation illustrates this: You know one other goal that wethat I was kind of thrown into was getting and promoting and getting a new training room for our outdoor sports and having to convince administration that I need to have the say in it and the architect whos never seen an athletic training room and what goes in there and how its designed. Barbara listed the challenge of coordinating with other ATCs to provide the supplies needed for their athletes when they visit her school for ev ents. In the past Barbara would run out of basic supplies because she was using them up on other athletes who would visit for tournaments and away games.

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74 The second general dimension depicted in Fi gure 3-8 was other than ATC duties and was comprised of only the two first-order themes of teaching and hospital. Three challenges with respect to teaching were listed as raw data themes. Dale listed t eaching all the required material before winter break and taking students on a fi eld trip as challenging. Ann felt teaching required core curriculum material and getting the pare nts to care about their childs education as challenging. Ann states, and of course the parents only care whenyoure locking down the grades for a report card. And theyre going, Whys he failing? What can he do? Why couldnt he do extra credit? you know that ki nd of thing. Chuck listed dealing with his supervisor at the hospital, who is not an AT, which contracts him to the school as a challenge. Admittedly the supervisor is not sure what an ATC does and it is a challenge educating his supervisor to understand certain aspects of his job. A third general dimension that emerged fr om the challenges experienced by athletic trainers in a high school setti ng was self-presentation and growth. The dimension was comprised of two 1st order themes of self-presentation and fo cus. Ann and Chuck listed being a good role model for the students and athletes as a challenge. An example of this is the following quotation from Chuck: You know through the way that I present myself my demeanor the way that I represent my professionyou know that they can see that Everybody sees that I have fun and love my job and that you dont have to be a slave to the system all the time. Dale talked about the ch allenge of having to teac h all day and then trying to stay focused on his athletic training dut ies. Dale stated: But you know teaching for 7 to 7 hours and then going directly to athletic training for another 3 to who knows however many hours, th e day tends to just get eaten up all the time so the ability to kind of you know rea lly do a good job on one thing or to really focus on something and improve in this ce rtain area tends to just kind of go by the wayside and you do the best with what you can.

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75Raw Data Themes 1st Order 2nd Order General Dimension Returning and injured athlete to play (5) Reading people (athletes) Malingering athletes (3) Injuries Star athlete injury (4) Evaluating a lot of athletes in a short time Getting athletes ready for practice Athletes with eating disorders Weaning an athlete off of taping dependency Wrestler with fungus (MRSA) (2) Athlete care Managing time with sports schedule Managing time with multiple schools sport schedules Event coverage with assistant absent Event coverage with split facility (2) Multiple team tournament (8 teams) Losing ATC to pregnancy and school coverage Scheduling and event coverage ATC Duties Dealing with coaches (paperwork) Dealing with coaches about injured athlete Dealing with coach about star athlete (2) Dealing with coach who is also father of injured son Coaches Educating parents on what an AT does (2) Parents not taking athlete with head injury to hospital Overprotective parent Parents Communication Getting the right equipment to do job Getting a training room built Having supplies to match needs Equipment needs Job Resources ATC duties Teaching required material before winter break Teaching core curriculum material Taking students on a field trip Teaching Dealing with hospital supervisor who is not an ATC Hospital Other than ATC duties Other that ATC duties Figure 3-8. Challenges experience by high school athletic trainers.

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76Being a good role model for kids (2) Self presentation Staying focused after teaching all day Focus Self presentation and growth Spending time with children (2) Balancing home and work Spending time with husband Spending time with fiance Family time Family time Family and personal life Figure 3-8. Continued.

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77 So it is a challenge to be able to do a good job and focus when he is tired and has been teaching all day. The final general dimension that emerged from the data depicted in Figure 3-8 was Family and personal life that consisted of one 1st order theme of family time. Dale and Tom mentioned that it was a challenge to spend time with their children. Dale talks about this challenge, Ive kind of realistically evaluate th e amount of time that I spend away from my family and try to optimize the times when I can be with them. Cr ystal and Chuck said that it was a challenge to spend time with their husband or fiance, respectiv ely. Rachel listed balancing home and work as a challenge. Specifically trying to get a new home built while spending the amount of time that she does at work. Coping Strategies Coping behaviors were assessed across all three interviews and produced 45 raw data themes. Each raw data theme was coded and compared to produce 24 1st order themes and 13 general dimensions and are depicted in Figur e 3-9. The general dimensions included positive evaluations, emotional social s upport, activities outside of prof ession, social activity within profession, active problem-solving, in strumental social support, prev ent future stressors, humor, mental disengagement, wishful thinking, behavioral disengagement, time management, and miscellaneous. Positive evaluations. Two first-order them es emerged that represented the general dimension of positive evaluations. Figure 3-9 depi cts these first-order themes of acceptance and justify decisions. Coping raw data themes that emerged under the first-order theme of acceptance included, taking a deep breath when confronted with a particular in jury, telling oneself that they did the best they could today, and learning to just let a part icular stressor go and move on. Barbara stated that when dealing with frustratin g parents You just have to learn to let it go and

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78 say you did the best you could. Ann stated that with respect to th e sport schedule that she just realized that some things she couldnt control and accept it. Other raw themes were to try not to worry and try to relax. The other first-order theme of justifying decisions contained one raw data theme from Chuck. He stated that he put an at hlete in a walking boot for what he believed was just a sprained ankle and scheduled an appointme nt at a later date after a follow up assessment. Chuck stated: Yeah you probably could say the girl that sp rained her ankle on Friday should have gone to the ER and got and x-ray but you can al so say well youre in a walking boot theyre not going to do anything di fferent so why dont we wait and see how youre doing on Monday. Chuck further justified his decisi on that it would be much cheaper for the family to visit the family doctor than the emergenc y room. Chuck further states: And if youre still feeling bad on Monday then we can send you to your primary care, which is obviously, is a lot less cost to the patient and her family but just leaving onjust on the co pays alone. Emotional social support. The second gene ral dimension depicted in figure 3-9 is emotional social support and was comprised of th e single first-order theme of venting. Dale and Crystal listed venting to other AT Cs as a coping mechanism. Rachel listed venting to the coaches that the ATC was comfortable with and venting to the athletic director as coping mechanisms. Crystal and Rachel were in a re lationship with another ATC and remarked about venting to them because they were able to relate to the similar job stressors. Crystal stated that she vented to her husband about dealing with her boss at the hospital when he restri cted the number of miles they could drive. Two participants list ed venting to family members such as parents and siblings as a coping mechanism. Barbara listed crying as a co ping mechanism. She stated, And Im a typical girl I tend to cry and let it out, when dealing with a particular catastrophic injury to an athlete that had occurred in the past.

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79 Activities outside the profession. The genera l dimension of activit ies outside of the professions yielded two first-orde r themes. Ann, Dale, and Rachel mentioned they used exercise as a stress reducer. The following quotation illustrates the importance of ex ercise for Ann, My late day I can recover a little bit and get my workout in before I go to work so I have a much better outlook. I have a much bette r attitude. Barbara also stated that before she had her farm she too exercised as a stress reducer. The sec ond first-order theme was recreation and Barbara cited taking care of her farm and riding her horses as coping mechanisms. Barbara elaborates: I have a farm and I built that farm to be my serenity spot. So I go home and I go out in the barn and I pick up the poo and I say, You know there is a lot to shoveling the real stuff that relieves the other stuff. Social activities within the profession. C huck listed socializing with the coaches and faculty as a coping strategy. It allowed him to develop a better working relationship with his peers and allowed for his fiance to be accepted into the coaches wives social circle. This also allowed him to spend time with his fiance. Active problem solving. The general dimens ion of active problem solving yielded the most first-order themes that included event c overage, planning ahead, injury problem solving, career requirement planning ahea d, time management and admini strative problem solving all emerged as first-order themes. Seven out of 8 pa rticipants listed getting another ATC to help cover events as a coping mechanism. Tom utilized both the student ATCs on an internship at his school and a friend who was also an ATC to help cover multiple events at the same time. Dale and Ann who have counterparts at their school split duties for game and practice coverage. They also covered for each other when they needed a break. Dale stated: Having an assistant to be able to say I need to take this day off, Im just going to get out and not have to worry about this thing for a day gives you a huge reli ef from the stress and be able to recuperate from things.

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80 Similarly, three ATCs had either a contract assistant or utilized another ATC that worked at their sports medicine clinic to cove r events. Barbara had a contract assistant that would show up to cover events that she could not due to her hour restriction. Rach el and Crystal both utilized another ATC that was employed at their hospital program to cover events when they needed. Crystal talks about splitting up duties with anot her ATC she works with, in order to spend time with her husband: So hes pretty good about taking on a little bit more so, you know, we can go out of town, or ,um, whatever, but then, in return, I like to cover a lit tle bit more, because, you know, his children are off from school, a nd he doesnt see them that much. The second first-order theme in the active pr oblem solving general dimension was injury problem solving. This theme emerged with respec t to the challenges and stressors experienced when dealing with injured athletes. Dale stated that that he tried to focus solely on the athlete and the injury regardless of the severity: Im just kind of focused on them, on what s going on, I run through my sequences of you know questions I want to ask and figure thi ngs out and then from there I just start problem solving how I want to achieve my goal of successfully getti ng her back out there and the best way possible. When dealing with a large group of athletes that need to be asse ssed and treated Brian elaborated how he systematically triaged thos e athletes. Brian state d, I try to triage. I try to get the varsity kids out first and the JV kids out next. I do anybody who gets taped and who Ive taped before. Other raw data themes that emerged were treatin g every athlete the same and both Brian and Ann mentioned sitting down and counseling the athlete on the injury. Brian ex plains a situation: Ah I sit down with them and we have little discussion and I explai n to them, You know its great that you got cleared and its great that you are doing so well and you are getting stronger but in the same respect you have to s till take it a little eas y because if you get out there today and try to go cr azy like you did before you got hurt. Youre gonna re-injure yourself and we might have to talk about more surgery again.

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81 Another first-order theme was career requirement planning ahead. The subject of obtaining continuing education units was a source of stress and Da le and Rachel listed coping strategies of getting online cred its, trying to get credits well in advance of recertification and using down time to work on them as raw data themes. Rachel stated that she watched an online session during a teams practice, yeah I actu ally watched yesterday during practice. Time management was another first-orde r theme that emerged from the general dimension of active problem solving. Dale schedule d large groups whenever he could in order to finish body composition assessments for the entire counties wrestling teams by the deadline. Ann listed planning ahead as best she could for cove ring multiple events in order to know exactly where she had to be. Crystal planned the night before to meet her requirements of being at multiple schools for different events. The first-order theme of administrative probl em solving had one raw data theme. Chuck coped with the stressor generated in working fo r the hospitals medical program he worked for by actively developing a survey to help justify the amount of referrals based on the athletes primary care physicians. Instrumental social support. The general dimension of instrumental social support had two first-order themes that were communica tion and conversation. The theme communication dealt more with keeping coaches and physicians informed on athletes progress while the theme conversation entailed seeking out advice from the people the ATCs worked with. Open communication with the coaches was listed as a c oping strategy by 7 out of 8 participants. Both Tom and Rachel mentioned a coping strategy of ta lking to all of the coach es at the beginning of the school year and educating them on their capabilities and limitations to help prevent future stressors. Dale who was dealing with a malingeri ng athlete stated, Yea, defiantly I dont have

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82 any problems going to the coach and letting them know that I m having, you know, issues with a kid you know. Another raw data theme was to keep coaches informed of the injured athletes progress toward getting back to playing. To m and Barbara communicated with coaches and reached an agreement to leave practice ear ly by providing their cell phone numbers with instructions for the coaches to call should they need anythin g. This communication allowed Tom to spend more time with his family, which wa s especially important during the holidays. Ann kept the coaches informed via email of event coverage limitations when the other on site ATC was absent. ATCs also communicated with th e team physician and lo cal area doctors. Brian mentioned talking directly to a doctor about an athlete with an ea ting disorder. Barbara developed a good working relationshi p with the team physician in order to provide the best care to the athletes. The other first-order theme under the general dimension of instrumental social support was conversation. As stated earlier this theme re flected the participants actively seeking advice from colleagues. Ann stated that went to the prin cipal in charge of facilities to find out who had opened the training room without authorizat ion leaving several at hletes and student unsupervised. Five participants listed as going to th e athletic director at the school for advice or help with a particular situation. The follo wing quotation from Crys tal illustrates this: I dont confront anybody and shes a young coachbut you know that that kind of worked it self out through the athletic director, you know him sending out an email to everybody telling to you know respect the stuff that we do. Three participants listed seeki ng out advice from other ATCs as a coping strategy they employ. Crystal talks with her program coordinator and another has as ked a coach to back her up on dealing with an athletes parents. Chuck went to the administrati on at the school in order to get the training room he required built. Barbara in the past had the union file a grievance on her behalf due to the excessive hours she was worki ng that had resulted in serious health issues

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83 related to her exhaustion. This resulted in an agreement that limited the amount of hours she could work. Prevent future stressors. A general dime nsion of preventing future stressors also emerged from the interviews. These were coping strategies employed prior to experiencing any particular stressor. Two first-order themes comprised this general dimension: Education and future planning. Tom made a point to go to parent night at the beginning of the year in order to elaborate on his duties as an at hletic trainer and the services he provided for the athletes. Tom stated that, if I know that parents are going to ca use me stress I go to the parent meeting in the beginning of the season and try to explain who I am and what I do. Similarly Ann took as many opportunities to educate the parents on what an ATC does as possible in the hopes that that parent will listen to them on the care of their child. Tw o participants listed future planning with respect to their careers. Crystal was dealing with stress associated with the hospital that she worked with and mentioned getting a teaching degree in order to be more marketable and possibly get a job directly at a school in the futu re. Ann was working toward a graduate degree in administration. If I have a, another plan to go to. If I have a plan B then as long as I dont feel backed into a corner Im pretty much ok as long as I have an option and uh I guess last fall I went back to school to get an administration certificate so that I could potentially one day move forward toward athletic administration or principal administra tion and that helped me changed my attitude greatly because now I have another plan if I need it. Humor. Brian listed using humor as a coping mechanism. He would tell jokes with his student trainer and laughed a lot to deal with stress. He stated You got me thinking about that because I feel I handle stress very well and I don t know what I do. (participant laughs) I think I laugh a lot thats probably about it. Mental disengagement. The ninth general di mension depicted in Figure 3.3 was mental disengagement and contained the first-order theme of looking ahea d. Three participants listed

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84 Raw Data Themes 1st Order General Dimension Take a deep breath Try not to worry I did the best I could today Learn to let it go Some things you cant control Try to relax Acceptance They wouldnt have done any different at ER Justify decisions Positive evaluations Venting to other ATC (2) Venting to coaches Venting to AD Venting to wife Venting to significant other (also ATC) (2) Venting to family (2) Cries Venting Emotional social support Exercise Gym Pilates Exercise Goes home to farm and takes care of horses Rides horses Recreation Activities outside of profession Socialize with faculty Recreation Social activity within profession Split duties with assistant trainer on site (2) Get another ATC to cover duties (friend) Get another ATC from hospital to cover (2) Split duties with contract ATC Utilize Student ATC (2) Planning ahead Active problem solving Figure 3-9. Coping strategies experienced by high school at hletic trainers.

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85Focus on injury and problem Systematically triaging large groups Counsel athlete on injury (2) Treat every athlete the same Problem solving Get online continuing education credits Take CEUs well in advance of deadline Use down time to work on credits Planning ahead Schedule large groups of Body Fat assessments for wrestling Plan next days schedule the night before Plan ahead for multiple event coverage Time management Develop survey to learn of Primar y Care physicians Problem solving Active Problem solving Talk to coach about malingering athlete Talk to coaches at beginning of school year (2) Keep coaches informed on athletes progress Inform coach of limitations with event coverage Leave phone number with coach when off site (2) Communicate with doctors on athlete (eating disorder) Develop good relationship with team physician Communication Seek advice/help from principal Discuss problems with program coordinator Go to the Athletic director (5) Get coach to back you up Talk to other ATCs (3) Persistence with admini stration to get supplies Go to Union and have them file grievance Conversation Instrumental social support Talk to parents at parent night Educate parents on what ATC does Education Get a teaching degree Get an administrative degree Future planning Prevent future stressors Tell jokes with other trainer Laugh at certain situations Humor Humor Figure 3-9. Continued.

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86 Looking ahead to end of sport se ason (fall, winter, spring) Looking ahead to summer vacation Looking forward to family and friend activities Play hard on vacation Looking ahead Mental disengagement Cross my fingers Wishful thinking Wishful thinking Put off paperwork Procrastinate Avoid coach (2) Avoidance Behavioral disengagement Kids come to games Fiance comes to games Schedule family time Take a day off Make down time Schedule personal time Time management Doing my athletic training duties Helping athletes Have snacks in training room Miscellaneous Miscellaneous Figure 3-9. Continued.

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87 this as a coping strategy when asked how they d eal with some of the stressors of their work. Brian said that he looks forwar d to the next sport season (winte r, or spring sports) when he begins to get burned out on the current season. Brian states that, I think th e change of the sports helps ya. I think you get excited to watch anda di fferent form of sports. Chuck said when the hours get long he looks forward to the end of th e school year and summer break. Rachel listed planning and looking forward to activities with fa mily and friends as a coping strategy to deal with the stress of working long hours. Behavioral disenga gement. The two 1st order themes of procrastinate and avoidance comprised the general dimension of behavioral di sengagement. Dale listed procrastination as a coping strategy to the stress of having to do pape rwork. He allowed paperwork to pile up until he had a large stack and then would complete it. Rachel and Crystal liste d avoidance as a coping strategy. Rachel stated that sh e was avoiding a coach who was ups et about a district policy and she states, Im actually in my office with my doo r closed because my office is in the same hall where the (sport) office is. So, Im actually hi ding because I dont want to hear it. Time management. The general dimensi on of time management contained two 1st order themes: schedule family time and schedule personal time. In order to spend time with their kids, Dale and Tom would bring them to the sporting events they were working. Dale stated Its getting to the point now where my kids are the age where they co me by, spend a little time with me, they can get dropped off, we can watch games together. Chucks fiance does the same thing, attending games while he was working. Da le would take a day off when things were particularly stressful and have the other ATC cover for him. The following quote by Dale: I was too burnt out so having an assistant to be able to say, I need to take this day off, Im just going to get out and not have to worry about this thing for a day gives you a huge relief from the stress and be able to recuperate from things.

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88 Miscellaneous. Two first-order themes co mprised the miscellaneous general dimension. Chuck keeps snacks in the training room for the athletes and this allows him to build rapport with the athletes. Chuck states, F ood is the way to get them to ope n up to me then I buy a bag of pretzels every week. Ann had a unique mechanis m for coping with the stress associated with being in the classroom all day: doing her job as an ATC. Ann elaborates on this: Which goes back to the whole thing that I have athletics in the afternoon when I teach because if I went home feeling like that wa y everyday, I might not go back to work the next day. Umm so on the bright side the athlet ic part of my job kind of lifts me back up. And you know I did something good for this chil d today. I put him on a plan of action to get better and so I mean I guess its my way of balancing While all of the ATCs enjoy the athletic training aspect of their job she was the only one that saw it as a coping mechanism. Additional Analyses Each raw data them e from coding of the interv iews was counted and yielded the results as depicted in Table 3-7. The participants who were previously classified as being burned out listed 33 stressors while those occupati onally engaged listed 19 distinct stressors. Similarly, burned out participants named 29 challenges and while t hose who were occupationally engaged listed 21. Burned out ATCs listed 46 coping strategies a nd those occupationally en gaged listed 40. Those individuals with less than 5 years experience shared 23 sources of stress, 25 challenges, and 46 coping strategies. ATCs with over ten years expe rience discussed 29 stressors, 25 challenges and 40 coping strategies. Table 3-7. Stressors, challe nges and coping strategies Burned out Occ Enga < 5 yrs > 10 yrs Men Women Stressors 33 19 23 29 25 27 Challenges 29 21 25 25 29 21 Coping 46 40 46 40 40 46 Note. aOcc Eng = Occupationally Engaged.

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89 Coping stability and consistency The following section will addres s the seconda ry purpose of this study, which focused on assessing coping stabilit y and consistency over time both resp ect to the same stressors/challenges or different stressors. ATCs we re interviewed over the course of approximately three weeks and asked to discuss their current as well as past so urces of stress, challenges, and coping strategies. ATCs overall talked about the day-to-day stre ssors that they encountered and many of the stressors discussed were resolved between in terviews which made the opportunity to assess consistency with the same stressor difficult. The following are between interview results for each individual participant w ho experienced the same st ressor across interviews. Dale, a burned out ATC with over ten years ex perience, used multiple coping strategies across stressors under the genera l dimensions of active probl em solving, time management instrumental social support, emotional social support and behavior al disengagement. He consistently used active problem solving to cope with the chronic stressor of acquiring CEUs for his recertification. Dale stated: Getting all my CEUs done, thats a source of st ress. I dont necessarily have a lot of free time, and what free time I do have, I like to spend with my family, so trying to go to conferences, take courses, etc. is a hassle. Dale used active problem solving to find sources for credits that would count toward his CEUs. He stated, Ive had to call in to the board of certification about a specific class, a review class, about whether or not it meets th e requirements for CEUs. Dale also said with respect to acquiring credits that he was try ing to get a jump on that, because I tend to put that off. Its pretty low on my priority scale so I dont want to get caught, like I have in the past. Dales resulting emotions are demonstrated by the follo wing quote, in the past I havent done very good with that (laughs) but this year I think Im doing a little bit bette r job, so Im feeling better.

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90 Brian was an ATC in phase V of burnout with 8 years experience. Br ian utilized positive evaluation, mental disengagement, active problem solving, prevent future stressors, humor, and instrumental social support. Brian was cons istent in using active problem solving and instrumental social support for the situations he labeled as challenges, which predominantly were focused on athlete injuries. Brian stated that he us ed humor to deal with stress in general but did not list any specific instances. Ann was an ATC with 5 years experience a nd was in phase V level of burnout. Ann used coping strategies that fell unde r the general dimensions of act ivities outside the profession, positive evaluations, active problem solving, instru mental social support and miscellaneous. She used instrumental social support to cope with the recurring stre ssor of her training room being opened without her knowledge. Ann described how she coped: So umm and we went and tried to look at, we tried to figure out who left the door open. Uh, on the video system but the principal that was working is not the normal video principal so I have to go back later today and see if we can find out who it is. So we had one person get reprimanded last year. Ann showed consistency in that she used instrumental social support across several situations. She utilized her associate ATC to help cover ev ents and went to her athletic director, and assistant principal, as mentione d above, for help. This was someth ing she learned from the past year, where she would not follow up with her associ ate in helping with athletic responsibilities and as a result had a stressful year. Rachel was a burned out ATC in phase V a nd has over 10 years experience. Her coping strategies included activ ities outside of profession, instrume ntal social support, active problem solving, behavioral disengagement, positive evalua tion, and time management. In response to a coach she initially used instrumental social suppo rt and then behavioral disengagement when that

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91 proved ineffective. After she and the AD addre ssed the situation, she th en avoided the coach. Rachel explained, Im act ually in my office with my door closed because my office is in the same hall where the wrestling office is. So, Im actua lly hiding because I dont want to hear it. Tom, an occupationally engaged ATC with ove r ten years experience, utilized the general dimension coping strategies of active problem so lving, time management, instrumental social support, and prevent future stressors. Tom used time management and instrumental social support to deal with his biggest st ressor. He said, That is my bigge st stressor here. Is that family time right now. His coping responses were demonstrated by this quotation: They (his children) came to the basketball games Friday night for a while, but its not high quality time, but it is nice that they can co me hang out with you while you are at work. That is one thing nice ab out this job is that your kids can come to work. Tom consistently used active problem solving across several stressors and challenges. Tom recognized the need to meet with the parents at the beginning of the year to prevent future stressors and did so by attending parent night in the hopes of eliminating the stressor of dealing with parents. Chuck, an occupationally engaged ATC with less than five years experience, utilized active problem solving, instrumental social supp ort, positive evaluation, time management, and miscellaneous. Chuck mentioned few stressors overa ll with one that reo ccurred. Chuck described the strategy to deal with the stress imposed by the hospital he worked for: So anyway thats what were trying to come up with some discussions and questions and ways to set up an informal survey to look at the perceived quality of care they receive here in (local) county and also look at the referral issu e and primary care providers. Where theyre located at. Chuck mentioned only one emotion focused copi ng strategy. This coping strategy fell under the general dimension of positive evaluations and is demonstrated by the following quotation: You know I try not to worry about it. I think that if push comes to shove that Ive done enougha good enough job and impressed enough pe ople at here at the school that the

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92 school or the school district would find money and be able to hire me directly if the hospital dropped the program. Chuck used multiple strategies to address different aspects of the same stressor. Chuck consistently used problem focused coping strate gies, specifically activ e problem solving and instrumental social support. Crystal, an occupationally engaged ATC with less than five years of experience, utilized the coping general dimensions of time manageme nt, emotional social support, prevent future stressors, positive evaluation, instrumental soci al support, active problem solving, and wishful thinking. Crystal used multiple strategies to deal with a stressor imposed on her from her boss. Crystal used instrumental as well as emotiona l social support, demonstr ated by the quotation: But, you know, I talk to everybody, and, you know, theyll sit there and let me vent, and well go from there. Ive kind of tho ught about it over the weekend, you know, thinking about our meeting, and, you know, Im going to make it clear, which, you know, my boss knows where I stand, but, you know, Ive told him before Crystal consistently used emotional and instrumental social support in coping with her stressors. Barbara, an occupationally engaged ATC with over ten years experience, utilized activities outside of profession, positive evaluation, instru mental social support and active problem solving as her coping strategies. Barbar a used activities outsid e the profession and positive evaluation to cope with a chronic sta ffing stressor. The following quote from Barbara states how she coped with this stressor: I just have to make sure to cover my base s and I have to make sure that the parents understand you know that its not my decision. So ummits like I said before my farm is my serenity spot and I just ha ve to learn that once I turn in that driveway I just have to not worry about it and it you know that didnt come in the first year I was a trainer. Barbara talked a lot about her farm and taking ca re of her horses. She relieved a lot of stress when she was in the barn taking care of the animals. This coping strategy fell under the general dimension of activities outside of the profe ssion and was coupled with a coping strategy of

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93 acceptance (I did the best I could), which fell under the dimension of positive evaluation. Both of these general dimensions are emotion focused coping strategies. The Goodness of Fit Hypothesis Another way to exam ine coping stability and co nsistency is to look at the fit between the nature of the stressors (e.g. controllable vers us uncontrollable) and the participants coping responses. For this portion of the analysis the goodness-of-fit hypothesis was used as a sensitizing concept to look at th e participants stressors and how they coped over time. Lazarus and Folkman (1984) emphasized that one way to evaluate coping effectiv eness is by the match, or mismatch, of ones coping strategies and th e appraised controllabil ity of the stressor. Basically, an emotion focused coping strategy for situations beyond the cont rol of the individual would be deemed adaptive: problem focused copi ng in situations within the control of the individual would be considered adaptive. Only stressors paired with a specific coping strategy for this level of analysis were utilized. Coping mechanisms that fell under the general dimensions of active problem solving, instrumental social support, prevent future stressors, and time management were considered problem focu sed coping strategies. Coping mechanisms that fell under the general dimensions of positive eval uations, emotional social support, activities outside of profession, social activity within profession, humor, mental disengagement, wishful thinking, and behavioral disengage ment were classified as emo tion focused coping strategies. As shown in Table 3-8, columns 1 (match controllable stressor paired with problem solving coping) and 4 (match uncontrollable stre ssor paired with emotion focused coping) were considered adaptive while columns 2 (mismatch controllable stressor paired with emotion focused coping) and 3 (mismatch uncontrollable stressor paired with problem focused coping) were labeled maladaptive. According to Lazarus when a mismatch occurs the stressor is not effectively dealt with and leaves the individual susceptible to furthe r psychological distress.

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94 Participants matched problem focused coping strategies with controllable stressors on 15 occasions while emotion focused coping strategies were used in response to uncontrollable stressors in response to 20 stressful situations. Overall 6 mismatches occurred when participants used a problem focused coping strategy and an uncontrollable stressor or an emotion focused coping with a controllable stressor. Table 3-8. Analysis of th e goodness of fit hypothesis. 1 2 3 4 Controllable stressor Problem focused strategy match Controllable stressor Emotion focused Strategy mismatch Uncontrollable stressor Problem focused strategy mismatch Uncontrollable stressor Emotion focused strategy match Burned out 9 1 4 14 Engaged 6 0 2 6 < 5 yrs 4 0 5 9 > 10 yrs 11 1 1 11 Men 10 1 2 4 Women 5 0 4 16 Total 15 1 6 20 Burnout levels. Participants classified as burned out matched 9 controlla ble stressors with problem focused coping strategies and mismatched one controllable stressor with an emotionfocused strategy. Burned out ATCs matched 14 unc ontrollable stressors with an emotion focused coping strategy and mismatched 4 uncontrollabl e stressors with a problem focused coping strategy. Occupationally engaged individuals ma tched on the goodness of fit for 6 controllable stressors and 6 uncontrollable stressors. There was a mismatch only with 2 uncontrollable stressors. One of the mismatches that illustrated th e goodness of fit hypothesis pertained to the stressor experienced by Ann, a burned out ATC. Ann had no control over the individual(s) who

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95 repeatedly opened her training room without her knowledge and repeatedly tried to cope by going to the administration for help. Over time Ann perhaps had become quite frustrated and angry at the situation, as nothi ng she did resolved the issue. While her emotional exhaustion score decreased her depersonaliza tion score increased from time one to time two. It might be inferred that Ann had a growing disdain for her coworker(s) reflected in this cynicism. As frustrating and unfair the situati on is, a better coping strategy, one that focuses on her emotions, in addition to the problem would be considered more adaptive. Years experience. ATCs with over 10 years experience listed 12 controllable stressors and 12 uncontrollable stressors matc hing on 11 controllable stressors and 11 uncontrollable stressors, as can be seen in table 3-8. ATCs with less than 5 years experience matched 4 controllable stressors and 14 uncontrollable stressors and mismatched on 5 uncontrollable stressors. It might be inferred that with regard to years experien ce the 5 mismatches with uncontrollable stressors can be attributed to youth and that better learned coping strategies might develop over time as Barbara with over 15 years experience stated: I mean I dont how to tell you how I cope with it. Because the first couple years I was a trainer Id have been stressed. Id have gone home. Id have worried, been worried. Id have been trying to go about do what I need ed to do but Id be worried and constantly wanting them to call me and check on things and blah, bla h, blah, blah, blah. This was in response to the stressor discusse d earlier about having a new assistant every day that was late. ATCs with over ten years experience might have learned to recognize situations they can and cant control and have developed appr opriate coping strategies. This would imply that coping stability over many y ears could be changed to more appropriate responses. Gender differences. Male ATCs talked about coping w ith 11 controllable stressors that matched on 10 of them. They also matched 4 uncontrollable stressors and mismatched on 2.

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96 Female ATCs talked about coping with 5 contro llable stressors and matched coping style on all 5. Females talked about 20 uncontrollable stre ssors and matched on 16. While men used both emotion focused and problem solving strategies they predominantly mentioned the stressors in which they used problem solving coping strategies Women also utilized both coping strategies but predominantly talked about those stressors in which they used emotion focused coping strategies. Over the short term (approximately three weeks) ATC remained consistent with their coping strategies on the same stressor over time in the instances where the occurred repeatedly. Controllable stressors and challenges were coped with utilizing problem solving strategies and uncontrollable stressors and chal lenges were coped with using emotion-focused strategies.

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97 CHAPTER 4 DISCUSSION The participants in the study were a diverse gr oup that shared the c ontext of being in the high school setting. They were fr om different regions in the c ountry and em ployed by either a hospital based sports medicine program or by th e school district itself. Both men and women were selected based on years experience and scor es on the MBI and OES to obtain a sample that was either burned out or occupationally engaged. F our of the participants were required to teach as well as perform their duties as an ATC and fo ur were not required to teach at all. Some participants were the sole athlet ic trainer at their hi gh school while others had an associate or student interns. This study attempted to find the differences if any in the stressors, challenges, and coping strategies that th ese individuals experienced. Overall there were no differences in the type s of stressors experi enced based on burnout level, years experience, or gender. In general stressors fell into two main dimensions, either they pertained to aspects of the ATCs job or stress experienced in their family or personal life. All of the participants listed similar job stressors for example ones pertaining to sporting event coverage, coaches, parents, athl etes and paperwork. Both burned out and occupationally engaged participants listed not being able to spend time with their family as a stressor. So it can be inferred that ATCs in the high school setti ng overall experience the same stressors. There was a difference in the amount of stre ssors reported. The burne d out ATCs listed 33 distinct stressors while the occ upationally engaged ATCs listed 19. It would be unrealistic to say that the burned out ATCs experienced more stre ssors than the occupati onally engaged ATCs, but it is very possible that individua ls who are burned out have an eas ier time recalling stressors. In addition the burned out ATCs also recalled more challenges (29) than the occupationally engaged ATCs (21). This would leave one to believe that burned out individuals perhaps spend

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98 more time thinking about their work than occupationally engaged ATCs and ruminate on both the good and bad aspects of their job. Conversel y when things are going well the occupationally engaged person has an easier time detaching th emselves from both stressors and challenges associated with their work. Generally there were no differences in the type of coping strategies employed by the participants based on burnout leve l. For the most part all participants used forms of both emotion-focused and problem-focused coping. Em otion focused general dimensions included positive evaluations, emotional social support, ac tivities outside the profession, humor, mental disengagement, wishful thinking and behavioral disengagement. Problem focused coping general dimensions included time management, instrument al social support, activ e problem solving, and prevent future stressors. Again there was a difference in the amount of coping strategies repor ted. Burned out ATCs employed more coping strategies (46) than oc cupationally engaged ATCs (40). The reason for this could be simply that if stressors are easily recalled then coping strate gies would be as well. There was also a difference in the amount of copi ng strategies based on years experience. ATCs with less than five years experience reported more coping strategies (46) a nd fewer stressors (23) than did ATCs with greater than ten years, w ho listed 40 coping strategi es to 29 stressors. The secondary purpose of this study was to a ssess coping stability and consistency and note any differences based on burnout level, year s experience, and gender. Participants used problem focused and emotion focused coping strate gies consistently acro ss day to day stressors and challenges and with resp ect to the goodness of fit hypothesis matched on the majority of situations. Participants matc hed on 15 controllable stressors and 20 uncontrollable stressors. Seven mismatches occurred, where the particip ant applied either an emotion focused coping

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99 strategy with a controllable stre ssor or a problem focused coping strategy with an uncontrollable stressor. Out of the 7 mismatches within the goodness of fit test 5 were participants who were burned out and 5 were by participants with less than 5 years experience. As stated earlier less experienced ATCs employ more coping stra tegies and it appears they might do so inappropriately by attempting to apply a problem solving strategy to an uncontrollable stressor. These mismatches might not lead directly burnout but if experienced repeatedly over time might contribute to it. However, in four of the mismatch es, secondary coping strategies were utilized as well. For example, Chuck used both a problem fo cused coping strategy and an emotion focused strategy to deal with the demands on him from the hospital. This highlights the complexity of some stressors and possible requirement of appl ying multiple strategies to address different aspects of the situation. There was no way to truly assess stability or consistency with respect to chronic stressors experienced, as there were very few mentioned by the participants. Dale and Rachel mentioned obtaining CEUs as a chronic stressor and both used active problem solving to address the stressor. Barbara talked about the chronic stresso r of having a different contract assistant who was late every day. She coped with the uncontroll able stressor with an emotion-focused strategy. All three of these individuals had over ten years experience and in these three instances the ATCs showed stability in coping style and approp riateness. No chronic stressors were mentioned by participants with less than 5 years experience. When asked if they had ever experienced burnou t, three of the individuals classified as being burned out said that they had experienced it. Dale, Brian and Ann each mentioned that they felt symptoms similar to burnout. Dale said he ha d been burned out in the past but now that he

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100 had an assistant he dealt with the stress a lot bett er. This is possibly reflected in his MBI scores and the fact that at time one he was in phase VI and at the time of this study was in phase V. Brian mentioned he was burned out at his prio r job the year before. Factors that possibly contributed to this were long hours split between the clinic and the high school and the number of athletes he was responsible for. After changing jobs Brians scores on the MBI with respect to exhaustion and cynicism decreased. Ann, also in phase V, mentioned that the year before she had felt a little burned out but made an attitude adjustment over the summer. Part of her attitude adjustment included the following, So part of it s realizing what you can or cant change and part of its trying to work within the system to make those positive changes. Another part included her going to her associate for help more in event coverage. A result of this can be seen in the decrease in her emoti onal exhaustion scores. Her cynici sm score did increase and, as discussed earlier, could be due to the unc ontrollable stressor she was experiencing. All of the participants mentioned that they had experienced occupa tional engagement and this was especially with respect to working with the student athletes. The nature of athletic training allows them to see the rewards of their ef forts. Tom stated, That is my goal, thats my job, and I absolutely love to be a part of these ki ds athletic career and help them enjoy it to the fullest. The following quote from Dale elaborates: So when you see an athlete that has been you know out for 2 weeks with a sprained ankle, youre getting them back in a playing activ ity and theyre successful and they do great, hey contribute to the team. Then you feel like you have done something to contribute something to that team and to that kid a nd whats been going on in their life. You get great feeling of accomplishment that you play ed a role in whatevers been going on in that situation. As a reflection of this all the participants ha d above published norms on the OES. So one aspect of their job allows them to be engaged ev en when they might be experiencing burnout.

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101 Theoretical Integration with Lazarus Another secondary purpose of the study was to interpret burnout and engagem ent using Lazarus C-M-R theory (1999). There is mild support for paths a and c in figure 1-3. Burned out individuals did talk about more stressors overall than those indivi duals who were classified as occupationally engaged. Therefore it might be inferred that thos e who were burned out are more likely to label situations as threats (path a) and experience them as stress ors. However, the data does not suggest that these individuals coped any differently than those who were occupationally engaged as burned out individuals overall coped with controllable and uncontrollable stressors appropriately. The bulk of education Athletic trainers undergo specializes in athlete injuries and treatment so ATCs are well suited to deal with any situatio ns that arise within this context. According to Lazarus (1999) ATCs will appraise the situation as a challenge because they have the requisite skill set to cope with the situation effectively and are relatively sure about a positive outcome. This was the case in this study as the bulk of ch allenges mentioned by the pa rticipants dealt with injury treatment. Occupationally burned out individuals did not list fewer challenges than occupationally engaged ATCs as hypothesized. The data revealed that both occupationally engaged as well as burned out participants talked about an equal am ount of challenges during the interviews. This is not surprising when looking at the OES sc ores for both groups. While the burned out participants scores were lower than the occupationally engaged participants scores, they were still above published norms. When asked about wh at are the aspects of the job that you enjoy, every single participant listed working with the athl etes as one of them. This is also reflected in the number of job challenges repor ted. Out of 50 separate challenge s 24 were related directly to the care of athletes and an additional 19 were considered ATC duties (managing sport schedules,

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102 dealing with coaches about injured athletes, get ting the right rehab equipment, etc.). So it is possible to say that the duties of an ATC directly related to at hletics is occupationally engaging. Other extraneous situations, for example having to teach, or deal with hospital bureaucracy that are viewed predominantly as stressors could be the factors that lead to burnout. Out of 52 stressors reported only 6 had to deal directly with athletes. Limitations The generalizability to the entire ATC population is obviously not appropriate as only high school athletic trainers w ere in terviewed. Additionally, out of the participan ts that were burned out only one was classified as be ing in the VI stage of burnout w ith the remaining three in stage V. Initial participant recruiting targeted four ATCs whose resultant scores on MBI classified them as stage VI on Golembiewski et al. (1996) scale. However, only one individual replied from round one and one individual replied from round two. In fact two of the individuals email addresses were no longer active. This could be due to the individuals no longer being at that current job. Perhaps because they had reached a level of burnout where they felt they need to leave that current position or the occ upation altogether. Another limitation was the use of telephone in terviews. While rapport was established with most of the participants, there were a few wher e full trust was not established until the final interview. Therefore, the ATC might have been more apt to discuss more stressors with the interviewer during the final interview and stressors experienced earlier might ha ve been lost or at the very least not fresh in the mind. The feas ibility to conduct actua l physical face-to-face interviews was not financially possi ble. In the future online video chat interviews might prove to be more beneficial to establishing ra pport much like face-to-face interviews. Ideally more than three interviews are necessa ry to truly evaluate the participants coping stability and consistency. One way to facilitate this is by conducting multi ple interviews over an

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103 entire sport season. The fall high sc hool season being the most stre ssful would be appropriate as many high contact sports are ongoing. In addition the measures could be administered at the beginning and at the en d of the season. Applied Implications Athletic trainers with over ten y ears experience where less li kely mismatch coping strategy with controllability and those mi smatches were experienced by burned out individuals with less than five years experience. ATCs with greater experience seem to be better at recognizing the stressors that they can control and those they ca nnot control and cope w ith them appropriately. Instructing younger ATCs on these situations w ould seem to be an appropriate target for intervention. Future research s hould be conducted to determine what stressors are misinterpreted by younger ATCs and what coping stra tegies they use. Younger traine rs then might be instructed how to recognize stressors as uncon trollable and which strategies ar e best used to alleviate those stressors. These would be emoti on focused coping strategies. Ba rbara talked about having other interests outside of the profession: But you have to have other interests. Every si ngle one of us that I can think of has other interests or other activities that we do away from athletic traini ng. Theres one of us thats a mountain biker. I have my hors es. Uh one of the other guys does a lot of volunteer work forI forget who he likefo r dog rescue or something. You know we all have to have something else that we do. And um and thats how you get away from it. From this research interventions can then be developed and tested. Future Directions As supported by the results athletic trainers view their job dem ands pertaining to the care of athletes as a challenge and therefore the tr aining and education that ATCs receive in this context prepares them to cope appropriately. The job demands they view as threats or stressors are predominantly those outside what they were educated on. Possible future applied implications might focus on educat ion pertaining to specific job contexts, in this case the high

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104 school setting, and include topics on time management for when an ATC is required to teach as well as practice sport medicine and appropriate coping methods for dealing with stressors outside their control. Future studies should focus on ATCs beyond the high school setting, for example collegiate, professional sports and clin ical work. Stressors a nd challenges are possibly different as well as coping strategies empl oyed by individuals in other job settings.

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105 LIST OF REFERENCES Anderson, A. G., W hite, A., & McKay, J., (2004). At hletes emotional responses to sport injury. In: D. Lavallee, J. Thatcher, & M. V. Jones Eds. Coping and Emotion in Sport. Hauppauge, NY: Nova Science Publishers, 285. Bakker, A. B., Demerouti, E. & Schaufeli, W. B. (2003). Dual processes at work in a all centre: An application of the job demands-resources model. European Journal of Work and Orgainzational Psychology, 12, 393-417. Bakker, A. B., Demerouti, E., & Verbeke, W. (2004). Using the job demands-resources model to predict burnout and performance. Human Resource Management, 43 83-104 Bekker, M. H. J., Croon, M. A., & Bresse rs, B. (2005). Childcare involvement, job characteristics, gender and work attitudes as predictors of em otional exhaustion and sickness absence. Work & Stress, 19 (3), 221-237.maslac Bernhard, H. C. (2007). A survey of burnout among college music majors. College Student Journal, 41(2), 392-401 Bunk, J. A. (2007). The role of appraisals, emo tions, and coping in unders tanding experiences of workplace incivility. Dissertation Abstracts International : Section B: The Sciences and Engineering, 68 (1-B), 657 Byrne, B. M. (2005). Factor analytic models: Vi ewing the structure of an assessment instrument from three perspectives. Journal of Personality Assessment, 85 (1), 17-32. Campbell, D., Miller, M. H., & Robinson, W. W. (1985). The prevalence of burnout among athletic trainers. Athletic Training, 20 (2), 110-113, 148. Campbell-Sills, L., Cohan, S. L., & Stein, M. B. (2006). Relationship of re silience to personality, coping, and psychiatric sy mptoms in young adults. Behavior Research and Therapy, 44(4), 585-599. Capel, S. A. (1986). Psychological and organizati onal factors related to burnout in athletic trainers. Research Quarterly, 57 (4), 321-328. Capel, S. A. (1990). Attrition of athletic trainers. Athletic Training, 25 (1), 34-39 Carver, C. S., Scheier, M. F., & Wientra ub, J. K. (1989). Assessing coping strategies: A theoretically ba sed approach. Journal of Personality and Social Psychology, 56 (2), 267283. Charmaz, K. (2000). Grounded theory: Objectivist and constructivist methods. In: N. K. Denzin & Y. S. Lincoln. Eds. Handbook of Qualitative Methods. Thousand Oaks, CA : Sage Publications, 509-535.

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112 BIOGRAPHICAL SKETCH Frederick Dietrich was born in Ft Lauderdale, FL. in 1973. He grew up in Coral Springs and graduated from Coral Springs High School in 1991. He then attended the University of Florida in Gainesville, FL. on an NROTC scholarsh ip. He graduated with a bachelors degree in psychology and was then commissioned as an ensign in the United States Navy. Frederick spent ten years in the Navy as a helicopt er pilot and separated at the ra nk of lieutenant. He applied to and was accepted to the college of Health and Human Performan ce for the express purpose of achieving a masters degree in sport and exercise psychology.