Athletic Training and Sports Health Care

Original Research Supplemental Data

Athletic Trainers' Views and Experiences of Discussing Psychosocial and Mental Health Issues With Athletes: An Exploratory Study

Damien Clement, PhD, ATC, CMPC; Monna Arvinen-Barrow, PhD, C Psychol

Abstract

Purpose:

To identify the psychosocial and mental health issues athletic trainers discuss with athletes, and gain insight into athletic trainers' levels of comfort and perceived competence and responsibility while discussing these issues with athletes.

Methods:

A total of 132 athletic trainers (60 men, 72 women; 13.2% response rate) completed an online survey previously used to explore sports medicine physicians' exposure to psychosocial issues and referral practices with patient-athletes.

Results:

Athletic trainers reported competency and comfort while addressing psychosocial and mental health issues with athletes in their care, and perceived such discussion to be their responsibility.

Conclusions:

The findings in this study are favorable with the changes set forth by the National Athletic Trainers' Association Executive Committee for Education, but also highlight specific gaps in existing education and skills.

[Athletic Training & Sports Health Care. 2019;11(5):213–223.]

Abstract

Purpose:

To identify the psychosocial and mental health issues athletic trainers discuss with athletes, and gain insight into athletic trainers' levels of comfort and perceived competence and responsibility while discussing these issues with athletes.

Methods:

A total of 132 athletic trainers (60 men, 72 women; 13.2% response rate) completed an online survey previously used to explore sports medicine physicians' exposure to psychosocial issues and referral practices with patient-athletes.

Results:

Athletic trainers reported competency and comfort while addressing psychosocial and mental health issues with athletes in their care, and perceived such discussion to be their responsibility.

Conclusions:

The findings in this study are favorable with the changes set forth by the National Athletic Trainers' Association Executive Committee for Education, but also highlight specific gaps in existing education and skills.

[Athletic Training & Sports Health Care. 2019;11(5):213–223.]

Throughout the past few decades, researchers have provided evidence of psychosocial and mental health issues affecting athletes who sustained sport injuries.1–5 The most prominent and adverse issues are anger, anxiety, depression, disbelief, frustration, shock, and stress.1–5 Because these psychosocial and mental health issues are not always obvious,6 an athletic trainer's ability to recognize and refer an athlete to the appropriate mental health professional is significant.7 As a result, the National Athletic Trainers' Association (NATA) Executive Committee for Education revised its educational competencies to include content on how to appropriately manage athletes' psychosocial and mental health issues.7

The added component of “psychosocial strategies and referral” calls for athletic trainers to demonstrate competency in three general areas: theoretical background, psychosocial strategies, and mental health referrals. The latter focuses on the process of mental health referrals because it relates to increasing an athletic trainer's ability to “identify and describe the basic signs and symptoms of mental health disorders and personal or social conflict that may indicate the need for referrals to a mental health-care professional (item 13),”7 “identify and refer clients or patients in need of mental healthcare (item 12),”7 and “formulate a referral for an individual with a suspected mental health or substance abuse problem (item 16).”7

To accomplish the above, athletic trainers must be able to “communicate effectively”8 with their patient-athletes and discuss “sensitive mental and emotional issues with which shame, embarrassment, and even further emotional harm is associated.”8 The extent to which athletic trainers can do this is unknown because few studies9,10 have investigated athletic trainers' views and experiences with discussing psychosocial and mental health issues with their patient-athletes. Our research found that only a few athletic trainers thought they were prepared to discuss or intervene in psychosocial and mental health issues (ie, suicide, family matters, relationships, sexuality, alcohol, and drug use or abuse).9 Boots10 found that athletic training students reported lower levels of comfort while discussing psychosocial and mental health issues with athletes than for other athletic training domains due to limited exposure in classroom and clinical settings.

It is possible that the lack of preparedness to discuss psychosocial and mental health issues is related to athletic trainers' perceived competence of engaging in such discussions. According to the Competence Motivation Theory,11,12 individuals who feel competent in their skills are also more likely to be motivated to engage in tasks associated with said skills. When this theory is applied to athletic trainers and their ability to address the emotional well-being of their athletes, it is likely that several external factors influence perceived competence (cognition). Factors include limited supervised clinical practice in discussing psychosocial and mental health issues and referral processes13 and “few to no live interaction with patients needing intervention and referral.”14 Similarly, factors such as personality trait, anxiety, or personal beliefs about their role in addressing psychosocial and mental health issues are likely to influence athletic trainers' perceptions of their ability to engage in such tasks. Feelings of competence will, in turn, trigger affective and emotional responses (eg, anxiety or comfort), which will then influence the athletic trainer's motivation to perform a task (ie, discuss sensitive psychosocial and mental health issues with athletes). The extent to which an athletic trainer will address psychosocial and mental health issues with their athletes will influence their ability to identify, recognize, and ultimately refer their patient-athletes when necessary.

Although research on the subject is limited, athletic trainers have reported feeling underprepared to manage the psychosocial and mental health issues experienced by injured athletes,13 underscoring the need for further research. Additionally, communication between medical providers and their clients is a positive influence on adherence, treatment outcomes, and patient satisfaction.15,16 Thus, the primary aim of this study was to identify the psychosocial and mental health issues that athletic trainers typically discuss with athletes. A secondary objective was to examine athletic trainers' levels of comfort, perceived competence, and sense of responsibility in discussing these issues with athletes.

Methods

Research Design and Setting

A cross-sectional design using an online survey explored the objectives associated with the current study.

Participants

The NATA District III's secretary was contacted to solicit participation. For research purposes, NATA can generate a randomly selected national sample of athletic trainers and their e-mail addresses (N = 1,000) who maintain active membership in the organization. Athletic trainers in the sample were employed in the United States in the following settings: high school or high school clinic, clinic, college or university, professional sports team, and other.

Instrumentation

A survey initially designed to determine sports medicine physicians' exposure to psychosocial issues they encountered with patient-athletes was used for this study.17 The researchers established face and content validity using a sample of sports medicine physicians (n = 5) with expertise in the area.

Minimal changes had to be made to the original survey to make it more applicable to our current study. Namely, the occupational title of “sports medicine physician” was replaced with “athletic trainer” throughout the survey. A pilot study with athletic training graduate students, all of whom were certified athletic trainers (n = 11), was conducted to verify face and content validity of the revised measure. Results from this study consisted primarily of written feedback to indicate that the survey's content was appropriate for the intended study. Specialized language found in the measure was understood by the athletic trainer population, sections were appropriately titled, and the length and ease of completion of the survey was sufficient. The sample did identify some typographical errors on the survey, but all necessary corrections were made.

The survey consists of five sections that include demographics, injury-related issues, non-injury–related issues, interest in additional training, and referral practices. However, the referral practices section was excluded because it did not align with the purpose of the study. Demographic information obtained included gender, ethnicity, level of education, employment setting, and number of years practicing as an athletic trainer. The section on injury-related issues consists of four separate subsections (frequency, comfort level, perceived competence, and belief it was their responsibility). Within these subsections, we asked the respondents to report on four separate Likert scales: (1) the frequency they discuss (1 = never, 4 = often); (2) their comfort level in discussing (1 = not at all comfortable, 5 = completely comfortable); (3) their perceived competence in discussing (1 = not at all competent, 5 = completely competent); and (4) belief it was their responsibility to discuss 20 issues related to injury and rehabilitation (1 = disagree completely, 5 = agree completely). The questions asked about injury-related issues are presented in Table A (available in the online version of this article).

Survey Itemsa

Table A:

Survey Items

For the section on non-injury–related issues, participants also reported on the same four subsections detailed above for the injury-related section. Within this section, we asked the respondents to report on four separate Likert scales: (1) the frequency they discuss (1 = never, 4 = often); (2) their comfort level in discussing (1 = not at all comfortable, 5 = completely comfortable); (3) their perceived competence in discussing (1 = not at all competent, 5 = completely competent); and (4) belief it was their responsibility to discuss 13 non-injury–related issues that could result from injury and rehabilitation. The fourth section of the survey consists of a Likert scale question requesting respondents rate their interest in receiving additional training to help athletes manage psychosocial issues and mental health issues they may present with (1 = not at all interested, 5 = extremely interested). Questions asked about non-injury–related issues are presented in Table A.

Procedures

Prior to the commencement of data collection, institutional review board approval was received from the primary researcher's institution. Once approval was obtained, a cover letter describing the purpose of the study was sent to prospective participants with a link to the survey hosted by Qualtrics Online Survey Software (Qualtrics, LLC., Provo, UT). Participants were informed of their right not to participate or withdraw at any time and the confidential nature of the study. Follow-up e-mails were issued 4, 6, and 8 weeks after the initial distribution of the survey to those who had not yet completed it as identified by the Qualtrics software. We did not specifically collect identifiers, although responses were tracked by the user's e-mail address to make sure that follow-up correspondence was only sent to those who had not yet responded.

Data Analysis

Descriptive statistics (means and standard deviations) and frequencies were calculated using SPSS software (version 18.0; SPSS, Inc., Chicago, IL) for all items on the survey.

Results

Demographics

Of the 1,000 initial e-mails sent, 132 (13.2%) participants completed the online survey request. The sample included 60 men (43.8%) and 72 women (52.6%), of which 21 (15.3%) held a bachelor's degree, 95 (69.2%) held a master's degree, and 16 (11.7%) held a doctoral degree. The participants were employed in a variety of settings: high school (n = 58; 42.3%), college or university (n = 46, 33.6%), clinic (n = 30, 21.9%), other (n = 15, 10.9%), and professional sports team (n = 3, 2.2%). On average, participants had 14.3 ± 10.3 years of experience as a certified athletic trainer. The sample expressed interest in receiving additional training to help athletes manage psychosocial and mental health issues (mean = 3.9 ± 0.9).

Injury- and Non-Injury–Related Psychosocial and Mental Health Issues Discussed

Results revealed that the injury-related psychosocial and mental health issues most often discussed were concerns about the consequences of the injury (n = 69, 55.6%), dealing with stress related to injury and rehabilitation (n = 62, 50.0%), and concerns and self-doubt about not being able to perform at the same level after injury or surgery (n = 58, 46.8%). Conversely, athletic trainers did not discuss issues of addiction or dependence on painkillers (n = 49, 39.5%), depression or frustration due to weight gain as a result of injury (n = 15, 12.1%), or feelings of isolation or loneliness after injury (n = 13, 10.6%) (Table 1).

Frequency (%) With Which Issues Were Discussed With Student-Athletes

Table 1:

Frequency (%) With Which Issues Were Discussed With Student-Athletes

The athletic trainers also reported that the top three non-injury–related psychosocial and mental health issues discussed were stress or pressure (n = 45, 40.2%), family or relationship problems (n = 31, 27.7%), and burnout (n = 29, 25.9%). However, they did not discuss past or current steroid use (n = 62, 55.4%), sexual orientation (n = 56, 50.0%), or illegal recreational drug use (n = 31, 27.7%) (Table 1).

Level of Comfort in Discussing Injury- and Non-Injury–Related Issues and Mental Health Issues

In the current sample, athletic trainers reported feeling “completely comfortable” or “very comfortable” discussing the following injury-related psychological and mental health issues: fear of surgery (n = 50, 42.7%; n = 34, 29.1%), fear of reinjury (n = 47, 40.2%; n = 38, 32.5%), and concerns about the consequences of the injury (n = 42, 36.2%; n = 51, 44%) with their athletes. However, they were “not at all comfortable” discussing topics related to addiction or dependence on painkillers (n = 9, 7.7%), depression or frustration due to weight gain as a result of injury (n = 3, 2.6%), feelings of hopelessness about recovering or getting better (n = 3, 2.6%) and difficulty emotionally letting go of the injury (n = 3, 2.6%) (Table 2).

Comfort Level (%) With Which Issues Are Discussed With Student-Athletes

Table 2:

Comfort Level (%) With Which Issues Are Discussed With Student-Athletes

Additionally, participants were “completely comfortable” or “very comfortable” speaking with athletes about the following non-injury–related psychosocial and mental health issues: stress or pressure (n = 29; 26.1%); (n = 32; 28.8%), burnout (n = 22; 19.8%); (n = 35; 31.5%), and difficulty adjusting to a new environment (n = 22; 19.8%); (n = 35; 31.5%). On the other hand, they reported being “not at all comfortable” discussing sexual orientation (n = 29; 26.1%), illegal recreational drug use (n = 19; 17.1%), and past or current steroid use (n = 17; 15.3%) (Table 2).

Perceived Competence in Discussing Injury- and Non-Injury–Related Psychosocial and Mental Health Issues

The participants indicated that they felt “completely competent” or “very competent” discussing fear of re-injury (n = 30, 25.9%; n = 42, 36.2%), fear of surgery (n = 29, 25.0%; n = 44, 37.9%), and concerns about the consequences of the injury (n = 28, 23.9%; n = 40, 34.2%). They also reported being “not at all competent” in discussing addiction to or dependence on painkillers (n = 9, 7.7%), depression or frustration due to weight gain as a result of injury (n = 2, 1.7%), difficulty dealing with pain emotionally (n = 2, 1.7%), difficulty letting go emotionally (n = 2, 1.7%), and anxiety related to pain (n = 2, 1.7%) (Table 3). When asked about their perceived competence in discussing non-injury–related psychosocial and mental health issues, participants indicated that the top three areas they felt “completely competent” or “very competent” in discussing were stress or pressure (n = 16, 14.7%; n = 30, 27.5%), burnout (n = 13, 12.0%; n = 28, 25.9%), and anxiety (n = 12, 11.0%; n = 20, 18.3%). In contrast, they were “not at all competent” discussing sexual orientation (n = 28, 26.2%), past or current steroid use (n = 22, 20.2%), or illegal recreational drug use (n = 18, 16.7%) (Table 3).

Perceived Competence (%) With Which Issues Are Discussed With Student-Athletes

Table 3:

Perceived Competence (%) With Which Issues Are Discussed With Student-Athletes

Perceived Responsibility in Discussing Injury- and Non-Injury–Related Psychosocial and Mental Health Issue

The sample “agreed completely” or “agreed” that it was their responsibility to discuss fear about reinjury (n = 58, 51.3%; n = 42, 37.2%), avoidance of rehabilitation or sports-related activities (n = 54, 47.4%; n = 44, 38.6%), and unwillingness to be patient with recovery or rehabilitation and refusal to take things slowly (n = 47, 41.2%; n = 51, 44.7%). They also “disagreed completely” that it was their responsibility to discuss addiction to or dependence on painkillers (n = 5, 4.4%), depression or frustration due to weight gain as a result of injury (n = 3, 2.7%). This also extended to emotions about not being able to attain goals due to injury, emotions about the potential career-ending injury, feelings of hopelessness, anxiety related to pain, or fear about surgery (all scored n = 2, 1.8%) (Table 4).

Perceived Responsibility (%) to Discuss Issues With Student-Athletes

Table 4:

Perceived Responsibility (%) to Discuss Issues With Student-Athletes

They also “agreed completely” or “agreed” that it was their responsibility to discuss the following non-injury–related psychosocial and mental health issues: burnout (n = 27; 24.5%); (n = 44; 40.0%), disordered eating or body image (n = 27, 24.3%; n = 51, 45.9%) and exercise addiction (n = 26, 23.4%; n = 54; 48.6%). However, they “disagreed completely” that it was their responsibility to discuss sexual orientation (n = 25, 22.5%), illegal recreational drug use (n = 9, 8.1%), alcohol abuse, violence, aggression, or anger problems, and past or current steroid use (all scored n = 7, 6.3%) (Table 4).

Discussion

Results from this study reveal that roughly half of the sample discussed some basic psychosocial and mental health issues associated with athletic injuries. This group felt completely or very comfortable and competent in discussing these issues, and believed it was their responsibility to address them. Some of the more noteworthy issues discussed included concerns about consequences of injury, stress, adherence, fears associated with surgery, and reinjury. The most commonly discussed mental health issues were family problems, stress or pressure, burnout, anxiety, disordered body image, and exercise addiction.

The above findings are encouraging. According to the literature, athletes often report experiencing anxiety throughout the injury recovery process,18 and burnout has become much more prevalent among athletes.19 Furthermore, the number of female athletes who reported experiencing eating disorders has been as high as 60%.19 Thus, it is encouraging that athletic trainers appear to be discussing such issues with their athletes. Having frequent access to the athletes, athletic trainers are well positioned to identify any possible disturbances relatively quickly. However, it must be noted that anxiety and disordered eating are listed in the Diagnostic and Statistical Manual of Mental Disorders and require attention from trained and licensed mental health professionals. As such, the authors hope that these discussions translate into treatment referrals, because specialized care for athletes experiencing these mental health issues would require “ongoing and long-term counseling.”20

Conversely, athletic trainers reported a tendency to not discuss or feel comfortable or competent to discuss and did not feel it was their responsibility to discuss substance abuse behaviors (ie, alcohol, illegal recreational drug or steroid use, or addiction or dependence on painkillers), emotional disturbances (ie, feelings of isolation or alone following an injury, depression or frustration due to weight gain as a result of injury, feelings of hopelessness about recovering or getting better, or difficulty coping with pain), or sexual orientation.

These results are in contrast to what we would expect athletic trainers to address. With the exception of sexual orientation, all are psychosocial issues or mental health disorders as outlined in item 13 (emotional disturbances) and item 15 (substance abuse behaviors) competency areas. However, these results appear to be similar to those found among other allied health care professionals. Existing research has identified that allied health care practitioners sometimes hesitate to discuss substance abuse with their patients due to fear of alienation.21 Nurses feel they need more training to increase their confidence in being able to discuss emotional disturbances (eg, depression and depressive type symptoms) with their patients.22

The above findings are slightly troublesome to the authors of this study. Existing research23 has shown that depression and substance abuse are two of the more common mental health issues presented by athletes following sport injury. Equally, research has identified that psychosocial issues such as emotional difficulties in coping with persistent pain,24 and feelings of isolation,25 hopelessness,26 and loneliness25,27 are often associated with injury. When coupled with other factors such as substance abuse,28 there is the potential risk for suicide.28 Given the significance of existing research findings, it is important for athletic trainers29 to support the emotional needs of athletes to assist in the early detection of serious mental health problems. With regard to the psychosocial strategies competency requirements, athletic trainers should be expected to discuss these issues to the extent of their ability to identify the need for possible referral.

As it relates to athletic trainers' current practices in discussing a range of injury- and non-injury–related psychosocial and mental health issues with their athletes, we believe the emergent patterns can be explained through the perceived Competency Motivation Theory.30 Athletic training educators play a significant role in the development of this relationship. By creating an educational environment that facilitates athletic training students' intrinsic motivation and is task-oriented instead of outcome-oriented, anxieties associated with the task are reduced. Additionally, emphasis on constructive feedback will allow opportunities for reinforcement. Students' perceptions of their competence will increase (cognitive appraisal), which will lead to increased feelings of comfort (emotional response), consequently resulting in increased motivation to discuss these areas (behavioral response). This cognitive-affective-behavioral sequence of action31,32 could ultimately influence their perceived responsibility to discuss these issues with athletes. If educational programs do not help build perceptions of competence (cognitive appraisal), students are not likely to feel comfortable (emotional response) discussing (behavioral response) certain psychosocial and mental health issues with their athletes, nor consider it to be a professional responsibility.

It is necessary to foster perceived responsibility, feelings of competence, and comfort discussing required psychosocial and mental health issues during academic and clinical educational training. Although existing research indicates that athletic trainers are skilled at identifying and making referrals for a range of mental health issues,6 the authors of this study find that the results highlight a potential concern related to other competencies within the psychosocial strategies content area. Without feeling competent and comfortable discussing these issues or perceiving it to be their responsibility, it is highly unlikely that athletic trainers will be able to “identify and refer clients/patients in need of mental healthcare” (item 12) or “formulate a referral for an individual with a suspected mental health or substance abuse problem” (item 16).7

To use the referral process by Brewer et al.33 as an example, it would be nearly impossible for athletic trainers to refer athletes for treatment if they were unable to discuss psychosocial and mental health issues. The referral process recommended by Brewer et al.33 consists of four distinct steps: (1) initial assessment by “listening and asking the athlete how he/she is getting along”; (2) a consultation with “a trained mental health professional to discuss what the athlete is presenting with”; (3) a trial intervention to “provide the athlete with an alternative coping mechanism34 to see if a referral is really needed”; and (4) to facilitate the actual referral. The final step of the process is the most important and heavily dependent on the athletic trainer feeling comfortable and competent and a sense of responsibility to discuss these issues because some athletes are known to be resistant to referrals.33 Thus, athletic trainers need to be “sensitive to potential concerns that may arise” and to be able to “explain in plain language the reason for referral and describe what is generally involved in working with a mental health professional.”35

Despite some of the significant findings, the current study was not without its limitations. First, the response rate was 13.2%, which was lower than anticipated given that three follow-up e-mails were sent to participants who had yet to respond to the survey. The authors believe that two main factors may have contributed to the low response rate: (1) the online nature of the study and (2) the focal topic of the study (investigating psychosocial and mental health issues and referrals), which may have been of interest to only a small number of athletic trainers due to its sensitive nature. Furthermore, the quantitative nature of the study did not allow participants to expand on the reasons for their scores with regard to why they discuss/do not discuss, feel/do not feel comfortable and competent, and perceive/do not perceive it to be their responsibility to discuss various psychosocial and mental health issues. The exclusive reliance on self-report was also a limitation of the study because it is possible that those who participated may have favorably represented their opinions regarding psychosocial and mental health issues. Finally, only some aspects of the psychosocial competencies were included in this study with respect to the entire psychosocial strategies content area.

Given the above, future research in this area should use a qualitative or mixed methods approach to identify athletic trainers' preparedness to address psychosocial and mental health issues that athletes may present with. More specifically, a qualitative approach using focus groups, one-on-one interviews, or real life experiences recounted by recently certified and experienced athletic trainers could be beneficial. Similarly, using longitudinal research designs that assess athletic trainers' views and/or lived experiences through mixed-method designs at different stages of their career could also be used to determine their willingness to discuss, comfort level, or perceived competence changes over time. A large, cross-sectional survey with quantitative items designed specifically using the psychosocial strategies content area as its framework is another method that could be used to determine the extent to which athletic training students are exposed to all of the competencies associated with the area. Finally, a comparison of those certified before and after the Commission on Accreditation of Athletic Training Education made significant changes to their psychosocial competency requirements would be recommended.

Implications for Clinical Practice

Results from this study show that some athletic trainers are willing to discuss, feel comfortable and competent to discuss, and perceive it to be their responsibility to discuss some psychosocial and mental health issues with their athletes. However, there are issues not being addressed. Research findings show that injured athletes are increasingly presenting with several psychosocial and mental health issues, warranting further examination of what should be included in athletic trainers' competencies. Although this research study did not directly assess the effectiveness of the competencies, results suggest that the psychosocial strategies competency curriculum should be redesigned in a way that fosters athletic training students' feelings of competence and comfort in discussing a range of psychosocial and mental health issues with their patients. In addition, the authors believe that the NATA Executive Committee for Education should also make some recommendations as to how certain content areas should be taught. Because there are currently no guidelines on how this should be done,14 adopting pedagogical strategies used in physical therapy programs could be a good place to start. For example, a case-based role-playing approach36,37 could be used to teach athletic training students how to effectively make referrals. This process involves different steps38 that start with the students being given a case to review. On review, mock patients would be interviewed by students regarding the specifics of their presenting conditions. Students would then discuss the information collected as a group to develop a plan of action that they would present to the class. Finally, the students would have to role play the referral scenario with a mock patient, presenting all of the pertinent information to explain why such a referral should be made. This approach, particularly if delivered in an inter-professional education context, would help the development of students' clinical decision-making skills because it mimics a real-life environment.39 Because of the similarities between athletic training and physical therapy, we believe this approach could be mutually beneficial for both professions.

Alternatively, for actively practicing athletic trainers, Cervero40 suggests that continuing education can be used to improve their professional practice. Ideally, the authors of this study believe that athletic trainers can engage in both formal and informal continuing education activities to increase feelings of competence and comfort in discussing psychosocial and mental health issues with patients.41 More specifically, Armstrong and Weidner41 suggest that formal continuing education activities would include, but not be limited to, attending workshops, seminars, and conferences that explore a range of psychosocial and mental health issues. On the other hand, informal continuing education activities could include journal clubs “meeting weekly or bimonthly with clinicians and colleagues to discuss articles related to psychosocial and mental health issues” or grand rounds with professionals who specialize in psychosocial and mental health issues. However, regardless of the options, it is imperative for athletic trainers to recognize their professional competencies and ensure that appropriate networks are in place should they need to make a referral for treatment to a mental health professional.

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Frequency (%) With Which Issues Were Discussed With Student-Athletes

IssueOftenSometimesRarelyNever
Injury-related
  Concerns about the consequences of the injury55.637.15.61.6
  Dealing with the stress related to injury and rehabilitation50.043.55.60.8
  Concerns and self-doubt about not being able to perform at the same level after injury or surgery46.846.85.60.8
  Fear of reinjury37.954.08.10
  Depression or frustration due to loss of conditioning after injury30.645.221.03.2
  Avoidance of rehabilitation or sport-related activities28.255.615.30.8
  Fear about surgery25.852.420.21.6
  Unwillingness to be patient with recovery or rehabilitation24.248.425.02.4
  Anxiety related to pain23.442.727.46.5
  Denial of seriousness of injury or consequences21.054.821.82.4
  Emotions (eg, anger or sadness) about not being able to attain aspirations due to athletic injury18.049.230.32.5
  Emotions about potential long-term effects of injury, reinjury, continued participation in sport14.552.429.04.0
  Difficulty emotionally dealing with pain13.746.834.74.8
  Inability to motivate self to engage in rehabilitation tasks12.937.143.56.5
  Emotions (eg, anger or sadness) about potential end of athletic career due to athletic injury10.551.634.73.2
  Depression or frustration due to weight gain as a result of injury10.533.144.412.1
  Feeling isolated or alone after injury8.931.748.810.6
  Feelings of hopelessness about recovering or getting better8.137.149.25.6
  Difficulty emotionally letting go of the injury event(s); intrusive thoughts7.336.347.68.9
  Addiction to or dependence on painkillers3.220.237.139.5
Non-injury–related
  Stress or pressure40.241.117.01.8
  Family or relationship problems27.742.027.72.7
  Burnout25.945.520.58.0
  Anxiety20.745.928.84.5
  Sexual orientation016.133.050.0
  Difficulties adjusting to new environment13.544.136.06.3
  Depression12.545.538.43.6
  Eating or body image disorder9.031.555.04.5
  Exercise addiction8.925.055.410.7
  Illegal recreational drug use3.623.245.527.7
  Violence, aggression, or anger problems3.621.453.621.4
  Alcohol abuse1.831.345.521.4
  His or her past or current steroid use0.98.934.855.4

Comfort Level (%) With Which Issues Are Discussed With Student-Athletes

IssueCompletely ComfortableVery ComfortableComfortableModerately ComfortableNot at All Comfortable
Injury-related
  Fear of surgery42.729.124.83.40
  Fear of reinjury40.232.521.46.00
  Concerns about the consequences of the injury36.244.017.22.60
  Inability to motivate self to engage in rehabilitation tasks22.236.828.212.80
  Denial of seriousness of injury or consequences24.841.023.111.10
  Concerns and self-doubt about not being able to perform at the same level after injury or surgery31.641.024.82.60
  Dealing with the stress related to injury and rehabilitation29.935.029.95.10
  Unwillingness to be patient with recovery or rehabilitation; refusal to take things slowly28.240.223.97.70
  Emotions about potential long-term effects of injury, reinjury, and continued participation in sport26.537.629.16.80
  Emotions (eg, anger or sadness) about potential end of athletic career due to athletic injury21.429.135.012.81.7
  Avoidance of rehabilitation or sport-related activities29.941.022.26.80
  Depression or frustration due to loss of conditioning after injury20.739.731.08.60
  Emotions (eg, anger or sadness) about not being able to attain aspirations due to athletic injury21.631.036.210.30.9
  Feelings of hopelessness about recovering or getting better19.735.931.610.32.6
  Feeling isolated or alone after injury21.434.231.612.00.9
  Difficulty emotionally letting go of the injury event(s); intrusive thoughts13.728.235.919.72.6
  Difficulty emotionally dealing with pain19.724.836.817.11.7
  Anxiety related to pain17.929.139.313.70
  Depression or frustration due to weight gain as a result of injury14.526.539.317.12.6
  Addiction to or dependence on painkillers9.413.733.335.97.7
Non-injury–related
  Stress or pressure26.128.832.49.92.7
  Burnout19.831.536.010.81.8
  Difficulties adjusting to new environment19.831.535.111.71.8
  Depression17.314.540.922.74.5
  Anxiety16.224.339.614.45.4
  Family or relationship problems13.622.733.626.43.6
  Eating or body image disorder11.718.037.823.49.0
  Exercise addiction10.823.435.126.14.5
  His or her past or current steroid use10.89.036.927.915.3
  Alcohol abuse9.915.336.930.67.2
  Violence, aggression, or anger problems9.015.336.031.58.1
  Illegal recreational drug use8.19.931.533.317.1
  Sexual orientation7.211.728.826.126.1

Perceived Competence (%) With Which Issues Are Discussed With Student-Athletes

IssueCompletely CompetentVery CompetentCompetentModerately CompetentNot At All Competent
Injury-related
  Fear of reinjury25.936.233.64.30
  Fear of surgery25.037.932.83.40.9
  Concerns about the consequences of the injury23.934.235.06.80
  Inability to motivate self to engage in rehabilitation tasks22.426.741.48.60.9
  Denial of seriousness of injury or consequences21.631.931.014.70.9
  Concerns and self-doubt about not being able to perform at the same level after injury or surgery20.531.638.59.40
  Dealing with the stress related to injury and rehabilitation19.730.838.510.30.9
  Unwillingness to be patient with recovery or rehabilitation; refusal to take things slowly18.832.540.28.50
  Emotions about potential long-term effects of injury, reinjury, continued participation in sport18.828.240.212.80
  Emotions (eg, anger or sadness) about potential end of athletic career due to athletic injury17.129.932.519.70.9
  Avoidance of rehabilitation or sport-related activities16.539.138.35.20.9
  Depression or frustration due to loss of conditioning after injury15.435.035.013.70.9
  Emotions (eg, anger or sadness) about not being able to attain aspirations due to athletic injury15.435.032.517.10
  Feelings of hopelessness about recovering or getting better14.537.627.419.70.9
  Feeling isolated or alone after injury14.732.836.216.40
  Difficulty emotionally letting go of the injury event(s); intrusive thoughts14.526.532.524.81.7
  Difficulty emotionally dealing with pain13.723.938.522.21.7
  Anxiety related to pain12.028.235.922.21.7
  Depression or frustration due to weight gain as a result of injury9.528.437.922.41.7
  Addiction to or dependence on painkillers5.118.836.831.67.7
Non-injury–related
  Stress or pressure14.727.542.213.81.8
  Burnout12.025.938.921.31.9
  Anxiety11.018.346.821.12.8
  Depression10.115.642.224.87.3
  Family or relationship problems9.223.933.926.66.4
  Difficulties adjusting to new environment6.431.239.420.22.8
  Eating or body image disorder6.420.239.427.56.4
  Exercise addiction4.621.141.325.77.3
  Alcohol abuse4.619.335.827.512.8
  His or her past or current steroid use4.613.833.927.520.2
  Sexual orientation3.711.227.131.826.2
  Violence, aggression, or anger problems2.820.234.931.211.0
  Illegal recreational drug use2.814.830.635.216.7

Perceived Responsibility (%) to Discuss Issues With Student-Athletes

IssueAgree CompletelyAgreeSomewhat AgreeSomewhat DisagreeDisagree Completely
Injury-related
  Fear of reinjury51.337.28.81.80.9
  Avoidance of rehabilitation or sport-related activities47.438.610.53.50
  Unwillingness to be patient with recovery or rehabilitation; refusal to take things slowly41.244.79.64.40
  Dealing with the stress related to injury and rehabilitation39.549.19.60.90.9
  Fear of surgery39.847.88.81.81.8
  Denial of seriousness of injury or consequences37.749.111.40.90.9
  Concerns and self-doubt about not being able to perform at the same level after injury or surgery37.747.713.21.80
  Inability to motivate self to engage in rehabilitation tasks36.846.513.22.60.9
  Emotions about potential long-term effects of injury, reinjury, continued participation in sport28.539.411.71.51.5
  Concerns about the consequences of the injury32.548.217.51.80
  Feelings of hopelessness about recovering or getting better31.941.617.77.11.8
  Difficulty emotionally dealing with pain30.739.525.43.50.9
  Emotions (eg, anger or sadness) about potential end of athletic career due to athletic injury29.840.424.63.51.8
  Depression or frustration due to loss of conditioning after injury27.250.016.75.30.9
  Emotions (eg, anger or sadness) about not being able to attain aspirations due to athletic injury27.242.124.64.41.8
  Feeling isolated or alone after injury26.342.124.66.10.9
  Anxiety related to pain24.846.023.04.41.8
  Difficulty emotionally letting go of the injury event(s); intrusive thoughts24.645.621.97.00.9
  Depression or frustration due to weight gain as a result of injury21.249.621.25.32.7
  Addiction to or dependence on painkillers15.839.528.911.44.4
Non-injury–related
  Burnout24.540.030.04.50.9
  Eating or body image disorder24.345.922.53.63.6
  Exercise addiction23.448.622.53.61.8
  Stress or pressure18.947.727.05.40.9
  Anxiety18.942.332.45.40.9
  His or her past or current steroid use13.545.029.75.46.3
  Depression12.648.627.99.01.8
  Difficulties adjusting to new environment10.850.531.56.30.9
  Alcohol abuse9.033.341.49.96.3
  Violence, aggression, or anger problems9.033.334.217.16.3
  Family or relationship problems9.032.438.716.23.6
  Illegal recreational drug use8.133.335.115.38.1
  Sexual orientation4.519.824.328.822.5

Survey Itemsa

Injury-Related Issues

Addiction to or dependence on painkillers

Anxiety related to pain

Avoidance of rehabilitation or sport-related activities

Concerns and self-doubt about not being able to perform at the same level after injury or surgery

Concerns that the consequences of the injury (eg, missing games or diminished performance) will disappoint others (eg, parents, coaches, or teammates)

Dealing with the stress related to injury and rehabilitation

Denial of the seriousness of injury or consequences

Depression or frustration due to loss of conditioning after injury

Depression or frustration due to weight gain as a result of injury

Difficulty emotionally dealing with pain

Difficulties emotionally letting go of the injury event(s); intrusive thoughts

Emotions about potential long-term effects of injury, reinjury, continued participation in sport

Emotions (eg, anger or sadness) about not being able to attain aspirations due to athletic injury

Emotions (eg, anger or sadness) about potential end of athletic career due to athletic injury

Fear of reinjury

Fear of surgery

Feeling isolated or alone after injury

Feelings of hopelessness about recovering or getting better

Inability to motivate self to engage in rehabilitation tasks

Unwillingness to be patient with recovery or rehabilitation; refusal to take things slowly

Non-Injury–Related Issues

Alcohol abuse

Anxiety

Burnout

Depression

Difficulties adjusting to new environment

Eating or body image disorder

Exercise addiction

Family or relationship problems

Illegal recreational drug use

Sexual orientation

Stress or pressure

His or her own past or current steroid use

Violence, aggression, or anger problems

Authors

From the College of Physical Activity and Sport Sciences, West Virginia University, Morgantown, West Virginia (DC); and the Department of Kinesiology, Integrative Health Care and Performance, University of Wisconsin–Milwaukee, Milwaukee, Wisconsin (MA-B).

The authors have no financial or proprietary interest in the materials presented herein.

Correspondence: Damien Clement, PhD, ATC, CMPC, College of Physical Activity and Sport Sciences, West Virginia University, P.O. Box 6116, Morgantown, WV 26506-6116. E-mail: Damien.Clement@mail.wvu.edu

Received: April 11, 2017
Accepted: March 14, 2018
Posted Online: November 27, 2018

10.3928/19425864-20181002-01

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