Psychosocial Concerns Following Trauma in High School Student Athletes: Experiences of Certified Athletic Trainers

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Introduction
Certified athletic trainers serve as focal members of the sports medicine team and are often the first healthcare provider many student-athletes consult for assistance (Bejar et al., 2019;Zakrajsek et al., 2018).Clement and Arvinen-Barrow (2021) revealed that athletic trainers were named primary members of the multi-disciplinary healthcare team by athletes due to their constant contact and social support, indicating that athletic trainers play a crucial role in the recovery of an injured athlete.In addition, due to their regular contact with adolescent athletes, high school athletic trainers are uniquely positioned to identify and address psychological concerns in their student-athletes (Bejar et al., 2019;Zakrajsek et al., 2018).Although athletic trainers are not qualified mental healthcare professionals to diagnose mental illnesses, they are trained healthcare providers to recognize, address, and refer student-athletes who display basic signs and symptoms of mental health concerns (Clement & Arvinen-Barrow, 2019;Neal et al., 2015;Zakrajsek et al., 2018).
Certified athletic trainers have the professional responsibility to appreciate the role of mental health and optimize their athletes' psychological well-being (National Athletic Trainers' Association [NATA], 2011; Neal et al., 2015).The athletic trainer's role in caring for psychological issues is to detect mental health risk factors, identify signs and symptoms of psychosocial concerns, and provide basic and specialized psychological techniques when necessary (Zakrajsek et al., 2018).Athletic trainers must also implement effective psychological interventions and referral strategies for student-athletes displaying characteristics of mental health or substance abuse problems (NATA, 2011;Neal et al., 2015).However, athletic trainers reportedly lack the training, skills, and comfort to recognize, discuss, address, and refer psychosocial concerns, further contributing to the high prevalence of mental health disorders in the secondary school setting (Clement & Arvinen-Barrow, 2019;Neal et al., 2015;Zakrajsek et al., 2018).
Athletic trainers are responsible for recognizing abnormal social and emotional behaviors (Walker et al., 2016) and referring patients with early signs of psychological distress to avoid delaying necessary mental health services (Neal et al., 2015).In clinical practice, athletic trainers are guided by expert opinion with consensus statements and inter-association recommendations to manage student-athletes with psychosocial concerns (Neal et al., 2015) rather than scientific evidence.However, supporting secondary school athletes with underlying psychosocial issues (Taube, 2015), recognizing psychosocial concerns (Stiller-Ostrowski & Ostrowski, 2009), and selecting psychosocial strategies for athletes were identified as some of the most challenging skills for athletic trainers (Cormier & Zizzi, 2015).
The increasing prevalence of mental health disorders in student-athletes warrants further investigation into factors limiting athletic trainers' competence and their experiences with psychosocial and mental health issues in clinical practice (Clement & Arvinen-Barrow, 2019).The Commission on Accreditation of Athletic Training requires athletic trainers to demonstrate proficiency in several competencies, such as examining, identifying, supporting, and referring to psychosocial concerns (CAATE, 2022;Clement & Arvinen-Barrow, 2019).However, the accrediting body does not mandate how program directors fulfill these requirements, resulting in potential discrepancies in learning outcomes, clinical competence, and providers' comfort in managing psychological concerns (Cormier & Zizzi, 2015).Many newly certified athletic trainers attributed their lack of preparedness to limited exposure and discussion about psychosocial challenges in the classroom and clinical settings (Clement & Arvinen-Barrow, 2019).Moreover, Washington (2016) reported that athletic training program directors ranked the psychosocial content area the lowest for all required clinical standards.Cormier and Zizzi (2015) determined that when athletic trainers received appropriate training in psychosocial strategies during clinical workshops, they were more likely to report superior knowledge, implementation, and positive attitudes related to the psychosocial content area.Thus, pedagogical approaches need to be integrated into athletic training education programs to address the insufficiencies in clinical proficiencies and increase athletic trainers' confidence and competence with mental health issues (Clement & Arvinen-Barrow, 2019).Furthermore, athletic training programs need to reevaluate and redesign their curriculum to enhance athletic trainers' readiness to address psychosocial concerns (Clement & Arvinen-Barrow, 2019) and consider incorporating more educational opportunities related to psychology, communication, and decision-making to enhance athletic trainers' ability to identify and refer psychosocial issues in student-athletes (Neal et al., 2015).The requisite for curriculum reform warrants future research to further understand the experiences and perceptions of athletic trainers related to psychosocial concerns, interventions, and referral strategies athletes may experience (Clement & Arvinen-Barrow, 2019, 2021).

Purpose
This qualitative phenomenological study aimed to explore the lived experiences of certified athletic trainers' preparedness to address psychosocial concerns in high school student-athletes.The research study explored how athletic trainers believed their academic and clinical practice experiences with mental health concerns influenced their preparation to administer psychosocial interventions and referral strategies in the secondary school setting.Understanding these experiences, as portrayed by practicing athletic trainers, may reveal new meanings and appreciations associated with the psychosocial content area training and implementation in clinical practice (Neubauer et al., 2019).The research study also investigated athletic trainers' experiences with instructional strategies best suited for the transfer of learning for psychosocial intervention and referral content area.The subjective data collected from practicing certified athletic trainers identified psychosocial concerns, interventions, and referral strategies commonly used in the high school setting and athletic trainers' views on instructional strategies believed to be influential and promote knowledge transfer into clinical practice.

Research Questions
This qualitative phenomenological study answered the following research questions: RQ1.What are certified athletic trainers' lived experiences with high school student-athletes displaying injury and non-injury-related psychosocial concerns?RQ2.What are certified athletic trainers' experiences of preparedness to address psychosocial concerns in high school student-athletes?

RQ3.
What training do certified athletic trainers believe is necessary to address psychosocial concerns in high school student-athletes?

Method
A qualitative methodology was used to explore the experiences of certified athletic trainers with psychosocial concerns in high school student-athletes following trauma and their level of preparedness to address these issues.A phenomenological research design was best suited for this study because it aimed to explore the lived experiences of certified athletic trainers' preparedness to address psychosocial concerns in high school student-athletes.The selected study design allowed for in-depth interviews to examine retrospective accounts and experiences subjectively, followed by a comprehensive analysis of the text to acquire a deeper understanding of the participants' perspectives of the phenomena (Qutoshi, 2018).
The phenomenological study focused on the lived experiences of certified athletic trainers related to their preparedness to address psychosocial concerns in high school student-athletes.Athletic trainers work with patients in various settings such as: colleges, universities, high schools, professional sports, clinics, hospitals, military, occupational health, and performing arts (NATA, 2015).This study concentrated on the secondary or high school setting to explore the essence of athletic trainers' experiences addressing psychosocial concerns in high school student-athletes.
The sample included state-licensed and Board of Certification-certified athletic trainers employed solely in a high school setting with experience addressing psychosocial concerns in the student-athletes under their care.The sample size for the research study included 12 participants to increase the transferability of the results to the high school setting.A purposive, criterion sampling was utilized to acquire subjects eligible for participation (Moser & Korstjens, 2017).

Instrument
A semistructured interview protocol comprised of open-ended questions related to athletic trainers' experiences with psychosocial concerns in student-athletes and their level of preparedness to address these issues was utilized for this study.This qualitative phenomenological study gathered basic demographic information at the beginning of the virtual interview, followed by additional open-ended questions inquiring about athletic trainers' views of necessary training from the participants' perspective.Finally, participants had the opportunity to expand upon their answers and share any final details from their experiences and interpretations.Table 1 shows an alignment table containing the interview questions and research questions.

Results
Qualitative data from all 12 participants were coded and analyzed using an interpretive phenomenological analysis to identify themes within the participants' narratives.Six major themes and one subtheme were derived from the data., 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12 During the data collection, 12 certified athletic trainers employed in the high school setting were interviewed using a semistructured interview protocol to answer three research questions regarding athletic trainers' experiences of preparedness addressing psychosocial concerns in high school student-athletes: six major themes and one subtheme derived from the interpretative phenomenological analysis of the data.Themes were identified as: (1) interactions with psychosocial concerns, (1a) athletic trainers' perceptions of experiences, (2) use of psychosocial strategies, (3) collaboration with the interprofessional team, (4) training and preparation, (5) enhance education and exposure, and (6) knowledge of psychosocial techniques.Maslow's hierarchy of needs conceptualized a model addressing how individuals are motivated to satisfy specific needs to achieve their full potential, which was the conceptual framework used in this study (Maslow, 1943).Maslow's hierarchy of needs contained a seven-tiered model of human needs: physiological, safety, love and belonging, esteem, cognitive, aesthetic, and self-actualization (Maslow, 1970a).
In addition, Maslow's hierarchy of needs indicated clinicians need to become confident, competent, and knowledgeable of the psychosocial content area to implement appropriate psychosocial techniques and referral strategies within their scope of practice, thereby fulfilling self-actualization in their clinical role (Maslow, 1943(Maslow, , 1970a)).
The themes identified in this study aligned with the research questions.Furthermore, the themes are supported by the available literature and the model conceptualized by Maslow that healthcare providers must fulfill their prepotent needs for esteem, cognition, and aesthetics before attaining self-actualization in their profession (Stefan et al., 2020).Maslow further asserted that the perceived lack of knowledge and preparation reported by practicing athletic trainers related to the psychosocial content area prevents them from addressing psychosocial concerns to their personal and professional standards, thus contributing to a lack of self-fulfillment in their position (Maslow, 1943(Maslow, , 1970a)).
RQ1.What are certified athletic trainers' lived experiences with high school student-athletes displaying injury and non-injury-related psychosocial concerns?
The first research question was designed to explore participants' experiences addressing psychosocial concerns in high school student-athletes during their professional practice.Three major themes emerged from the data: interactions with psychosocial concerns, use of psychosocial strategies, and collaboration with the interprofessional team, as well as one subtheme, athletic trainers' perceptions of experiences.The experiences shared by participants reiterated the themes shared by the available literature, such that athletic trainers provided care by recognizing, supporting, and referring to injury and non-injury-related concerns and served as a contact person when collaborating with professionals licensed to provide mental health care (Bejar et al., 2019;Chang et al., 2020).Athletic trainers also appreciated and acknowledged the need for foundational knowledge of concerns related to the psychosocial content area to perform optimally within their role as healthcare providers.The lack of comfort and confidence expressed by some participants aligned with Maslow's (1943, 19070a) contention that individuals failing to satisfy their need for confidence and comfort in their experiences with psychosocial concerns results in unsatisfactory experiences.Athletic trainers must satisfy the need to know and appreciate their role in addressing psychosocial concerns in student-athletes to consummate all required professional responsibilities and competency standards.Athletic trainers need to gain confidence and comfort with psychosocial content and be more prepared to address psychosocial concerns in student-athletes to satisfy their lower-level growth needs to gain feelings of adequacy, competence, and self-confidence for more positive experiences (Maslow, 1943(Maslow, , 1970b)).

RQ2.
What are certified athletic trainers' experiences of preparedness to address psychosocial concerns in high school student-athletes?
The second research question was designed to evaluate with participants the training they received to prepare for their professional practice related to psychosocial concerns and the influence it had on their professional abilities.One major theme materialized from the data, training, and preparation.Despite didactic exposure to psychosocial interventions and referral strategies, many athletic trainers felt underprepared to implement psychosocial interventions or discuss and address mental health issues with student-athletes.Athletic trainers that felt their academic or clinical training did not prepare them to address psychosocial concerns led them to seek out alternative avenues of learning.The participants of this study were motivated to fulfill their need for adequacy, competence, and self-confidence by acquiring more knowledge and experience related to the psychosocial content area through continuing education, additional training, personal research, and professional experiences (Maslow, 1943(Maslow, , 1970b)).

RQ3.
What training do certified athletic trainers believe is necessary to address psychosocial concerns in high school student-athletes?
The third research question was designed to determine what training participants recommended to enhance future athletic training students' professional knowledge related to the psychosocial content area.Two major themes emerged from the data, enhanced education and exposure and knowledge of psychosocial techniques.These themes aligned well with Maslow's (1943Maslow's ( , 1970a) ) notion that good athletic trainers will continue to be motivated to satisfy their lack of knowledge, comfort, and competence related to the psychosocial content area before feeling actualized in their professional position.The participants of this study have acknowledged an appreciation for the psychosocial topic highlighting its need in academic and clinical training.Participants also identified components lacking and helpful in their own academic and clinical training with the hopes the results can be used to help other professionals acquire the opportunity to satisfy their esteem and cognitive needs to work towards self-actualization within their professional position.

Discussion
The purpose of this qualitative phenomenological study was to explore the lived experiences of certified athletic trainers' preparedness to address psychosocial concerns in high school student-athletes.The specific sample for this study was secondary school certified athletic trainers with lived experiences addressing psychosocial concerns in high school student-athletes.Participants were also graduates of accredited athletic training education programs to ensure exposure to the psychosocial content area.Six themes and one subtheme emerged from this study that the available literature has supported regarding athletic trainers' preparation experiences and the psychosocial content area.
Future research is necessary to expand on the findings from this study.An additional study utilizing a larger sample of certified athletic trainers may reveal a greater insight into athletic trainers' preparation experiences related to the psychosocial content area in the high school setting.A similar study could be conducted using a mixed methods design to further examine components of high school athletic trainers' experiences, quantify their perceptions of preparedness, and establish statistical significance between newly certified and more experienced athletic trainers.
The results of this study revealed that an athletic trainer with more than six years of experience may feel more unprepared to address psychosocial concerns in high school student-athletes compared to a novice athletic trainer who reported higher levels of perceived preparedness following academic training.Additional qualitative inquiry is recommended to explore the experiences of more experienced (six years or more) high school certified athletic trainers' preparedness to better understand practicing athletic trainers' experiences, interpretations of their perceptions, and recommendations to enhance training related to the psychosocial content area.
Practicing certified athletic trainers reported a lack of preparation and competence to discuss and address psychosocial concerns due to limited discussion and exposure to psychosocial concerns in the classroom and clinical settings (Clement & Arvinen-Barrow, 2019;Zakrajsek et al., 2018).Although athletic training academic programs have recently experienced a curriculum reform, the findings of this study offer influential strategies to enhance educational preparation that align with recommendations from other studies (Clement & Arvinen-Barrow, 2019;Mazerolle et al., 2018;Walker et al., 2016;Welch Bacon et al., 2022;Zakrajsek et al., 2018).Providing athletic training students with more academic education and clinical exposure is beneficial to prepare prospective athletic trainers for their professional practice.Furthermore, it is beneficial to enhance athletic training students' knowledge of psychosocial techniques to provide future athletic trainers with better resources and strategies to support student-athletes under their care.Lastly, evaluating the professional and continuing education requirements for practicing athletic trainers may be beneficial to require practicing athletic trainers to have more training in the psychosocial content area to enhance athletic trainers' competence to address psychosocial concerns and further reduce the increasing presence of mental health concerns in adolescent athletes.

Conclusion
In summary, the growing prevalence of psychosocial disorders among adolescent student-athletes in the United States is concerning, requiring increased awareness and action from members of the athletic care network.Secondary school certified athletic trainers are uniquely positioned to recognize, refer, and support high school student-athletes who display signs and symptoms of psychosocial concerns.Certified athletic trainers have a professional responsibility to appreciate the role of mental health, detect risk factors, and provide psychosocial strategies to support student-athletes under their care.Although accredited athletic training education programs require students to receive didactic exposure to the psychosocial content area, many practicing athletic trainers report a lack of preparation to address psychosocial concerns in their professional practice.Limited exposure and interventions in the classroom and clinical setting contributed to few athletic trainers feeling prepared to discuss and address mental health concerns in high school student-athletes.
This study addressed this issue by examining certified athletic trainers' experiences with psychosocial concerns, their academic and clinical preparation experiences, and their views of effective training interventions to enhance athletic trainers' professional practice related to the psychosocial content area.This study is important because exploring athletic trainers' professional experiences with psychosocial concerns provides insight into the concerns secondary school athletic trainers must be prepared to address in their professional setting.Additionally, examining athletic trainers' clinical practice and academic experiences and views of the psychosocial content area can inform pedagogical interventions to improve athletic training education.The findings of this study also support ways to improve practicing athletic trainers' competence, preparedness, and confidence in the psychosocial content area to enhance patient care and reduce mental health concerns in high school student-athletes.
Understanding these experiences, as portrayed by practicing clinicians, can help certified athletic trainers and athletic training educators understand common psychosocial concerns addressed in clinical practice and ways to enhance training programs.This qualitative phenomenological study was designed to explore the lived experiences of certified athletic trainers' preparedness to address psychosocial concerns in high school student-athletes.Secondary school athletic trainers play a meaningful role in managing psychosocial concerns.Thus, they must have foundational knowledge relative to the psychosocial content area to prepare for their large breadth of potential interactions with psychosocial concerns, use of psychosocial strategies, and collaboration with the interprofessional team when addressing psychosocial concerns in high school student-athletes.By implementing more scenario-based instruction and increasing clinical exposure, athletic training academic training programs can better prepare students for their professional practice.Practicing athletic trainers must seek mental health continuing education courses and related professional training opportunities to enhance their preparation, competence, and confidence to address psychosocial concerns in student-athletes.Moreover, clinicians are inherently motivated to satisfy their need for knowledge and competence to further appreciate their role in managing psychosocial concerns in student-athletes to consummate all professional responsibilities and become self-actualized in their position.Therefore, governing bodies in the athletic training profession may consider evaluating athletic trainers' role in supporting student-athletes and providing professional guidance for the secondary school setting, along with possible credential reform to establish if athletic trainers need additional mental health training to satisfy their certification or licensure requirements.

Table 2 .
Themes and Participants The major themes identified were: Interactions with Psychosocial Concerns with a subtheme of Athletic Trainers' Perceptions of Experiences, Use of Psychosocial Strategies, Collaboration with the Interprofessional Team, Training and Preparation, Enhance Education and Exposure, and Knowledge of Psychosocial Techniques.Table 2 presents a summary of the themes.