Unreasonable Expectations

As college sports participation grows, ATCs become responsible to an expanding array of people and programs. Head athletic trainers need to know when administrators ask the impossible and how to negotiate with ADs when this situation occurs.

By Shelly Wilson

Shelly Wilson is an assistant editor at Training & Conditioning.

Training & Conditioning, 11.7, October 2001, http://www.momentummedia.com/articles/tc/tc1107/expectations.htm

Today's ATCs are responsible for more than ever. College sports participation has increased by more than 20 percent in the last 15 years, along with increases in the number of sports sponsored by colleges and universities. Add to that the advent of non-traditional seasons, individual skill and instruction sessions, and volunteer workouts, and you'd hope that athletic training staffs have grown as profoundly.

But rare is the athletic training program that is fully staffed. More common are staffs that have learned to work harder and complain less--getting by with what they have while being forced to do all they can in the areas of coverage, injury treatment, rehab, counseling, and injury prevention.

Some say, however, the time has come for athletic trainers to stop stoically enduring unreasonable expectations. In other words, it's time to let your athletic director know, loud and clear, that understaffing has reached its brink, that it's no longer manageable.

"Athletics has changed very fast, and support services are lagging behind," says Rick Zappala, MS, ATC, Head Athletic Trainer at Hofstra University, who this year added a full-time athletic trainer and one graduate assistant to his staff. "And to some extent, shame on us for letting them lag behind."

"ATCs often are so passionate about their jobs and long-suffering because that's the way it's always been done," adds Sandra Shultz, PhD, ATC, CSCS, Assistant Professor and Interim Coordinator of Graduate Programs in Athletic Training and Sports Medicine at the University of Virginia. "But it's gotten to a point where the activities and participation levels exceed that capacity to flex. To grin and bear it and not say a word is not beneficial to anyone."

"Certified athletic trainers are problem solvers who are known to be extremely hard-working, task-oriented individuals," observes Robb Williams, MEd, ATC, CSCS, Director of Sports Medicine at Villanova University, who recently increased his staff to five full-timers and five interns. "Staffing coverage concerns, and the daily healthcare delivery for the student-athlete population has to be a priority. Each component of the sports medicine program must be consistently evaluated and tweaked for continued improvement."

Consequently, working with your AD to solve staffing and coverage challenges should be a first instinct, not a last resort. The following is designed to help you quantify the extent of your staffing problems and make your case to administration.

The first question you should ask yourself is whether you and your staff are providing adequate healthcare for your student-athletes. It seems that the answer would be obvious, but ATCs buried in the frenetic daily grind need to stop and ponder this question. Here are some quick flags that may indicate when athletic demands are outpacing resources:

Your program is always in reaction mode. If your staff is continually making adjustments for impromptu practices, skill session changes, and additions, and they are unable to follow any kind of set schedule, you are in reaction mode. "One of the first flags you should look for is whether the tail is wagging the dog," says Steve Cole, ATC, Head Athletic Trainer at The College of William & Mary, who just hired two full-time interns. "If your coaches are the tail wagging the coverage dog, you have a problem. Because if you have 21 head coaches who ignore your staffing situation when they implement programs, you will fail."

Your program is in coverage mode. "If you don't have sufficient staff and you're always out covering practices, then you're in coverage mode," says Cole. "And in coverage mode, the emphasis becomes, 'Be there in case something happens.' Administrators are going to say, 'Well that's where our greatest liability risk is.' But if your staff overemphasizes coverage, you will fall short on providing treatment and rehabilitation."

The result is often unsatisfied patients. "If a kid gets hurt and she is not getting better because she needs treatment you can't give to her," says Cole, "then she's upset, coaches are upset, and parents are upset."

You heavily rely on the aid of student athletic trainers. The change to a curriculum track has limited the manner and frequency with which student athletic trainers can be used as staff, yet more and more ATCs want the use of student athletic trainers curtailed even further. "I think students have been over-utilized and put in a position of replacing certified ATCs," says Shultz. "And they don't have that experience or qualification. Using student athletic trainers as a cheap labor force has been the easy way out for administrations."

The athletic training room and campus are home. "If you and your staff can't find a balance between your professional and personal lives, that may be a warning sign that you're being stretched too thin," says Zappala.

If any of these flags apply to your program, it's time to re-evaluate it, identify the areas where care is lacking, and approach your athletic director with ways to improve care all around.

When it comes to winning over administration to your cause, a good first step is forging a positive relationship with your AD before trouble arises. For some ATCs, this will seem impossible. Perhaps your AD has never set foot in your athletic training room, or worse, he or she, too, works in reaction mode.

The best way to overcome that great divide is to insist on regular meetings with your administrator. Not only will these sessions allow issues to be addressed in their infancy, but they also enable ADs to better understand your job, your challenges, and your program's priorities and goals. And this regular interaction will facilitate cooperation in times of program need.

Such has been the case at Hofstra, where four athletic trainer positions have been added in six years. "I have a good working relationship with my athletic director," says Zappala, "but that's something I've worked on nurturing. Our previous athletic director didn't interact with any of the staff, but in his last two years, I started pushing for regular meetings with him. And those meetings were a means to present things to him on a regular basis.

"When our new athletic director came on board, my top assistant, one assistant director of athletics, and I began meeting with him every two weeks. Those regular meetings have benefited our relationship. He respects me, he listens to me, and because I spend so much time with him, he understands my program's problems."

Cole concurs. "As the head athletic trainer, you have to push and get yourself into your AD's office and keep bringing up your issues," he says. "You can't wait for them to come to you. You have to make yourself a part of the process."

The tone that you take in presenting your case will also determine how sympathetic the administration will be to your concerns. To start, avoid being adversarial.

"To just go in and say, 'We need more staff,' is not going to be well received by an athletic director," Shultz says. "The administration is going to respond better to a focus on benefiting student-athlete health and welfare, and that should be the motivation behind your meeting."

The second key to ensuring administrative support is compiling pertinent and persuasive documentation. "You don't get help when you go in there with a very emotional plea," says Cole. "You have to show them that you've undertaken an objective process to identify the issues."

A good starting point for measuring the quality of the care you and your staff provide is to use the NCAA Sports Medicine Handbook as the minimum standard for protecting student-athlete health and safety. If you find your program is unable to meet even these conservative recommendations, you must address those areas with your administration.

Another useful document is the NATA's Recommendation and Guidelines for Appropriate Medical Coverage System worksheet. This worksheet helps determine a program's coverage needs. By augmenting the provided Health Care Units for each sport with information unique to your athletic program--such as non-traditional season length, squad sizes, and travel demands--you can arrive at an estimate of how many full-time certified athletic trainers are needed to accommodate the given workload. For many head athletic trainers, and administrators, the results are a surprise.

"We used the NATA worksheet to get an idea of what our staffing levels should be," says Laurie Freebairn, MScPT, Physical Therapist/Head Athletic Trainer at Simon Fraser University. "We should be staffed at approximately 5.6 full-time therapists for the 19 programs we have. But right now, we're at about 2.4. Pointing that out to my AD was a bit of an eye opener."

Zappala found the NATA worksheet compelling, but warns that ATCs shouldn't rely on that document as their only evidence of need. Instead, it should be used to support your argument.

"Our results showed that we needed 9.3 staff people, and at the time, we only had six," he explains. "It was a persuasive tool in that an outside agency was validating my concerns about staff shortages. But it didn't clinch the deal in any way. I think if that was the only documentation that I'd had, I'd probably still have only six people."

Other items that can help strengthen your case are records of staff hours, layouts showing all sports schedules, a cost analysis of expenses attributed to non-staff-delivered care, and feedback from student-athletes and coaches. All of these examples of objective documentation can help articulate and quantify the challenges your program is facing.

At Hofstra, one of the most convincing pieces of information Zappala presented to his AD was evidence of staff hours. "Six years ago I required that all my staff record their hours," he says. "I give them a calendar and have them record when they come in and leave each day, what days they're off, and their total hours each week.

"Athletic trainers always complain about the hours," he continues, "but I was able to go into my AD's office and say, 'Look at this. Here's what we're doing. Here's our basketball athletic trainer who has not had a day off in 42 consecutive days.' The first time the AD looked at that he said, 'I knew you guys worked long hours, but I had no idea it was that many.'"

Zappala also compiled a spreadsheet that laid out each athletic event needing coverage for a given weekend. And this, he argues, put in concrete terms a problem ADs only partially grasp. "In my case, Hofstra's administrators started to see the enormity of the problem, but only after we were able to illustrate it for them," he continues.

Financial data can further show the magnitude of demands on athletic training programs. For example, programs that emphasize coverage over treatment generally have to ship injury and rehab cases to outside providers, which drives up healthcare costs and secondary insurance premiums. A critical look at that expense line may show as much as $15,000 to $20,000 of costs that could be redirected into an additional salaried position. The same issue holds true for per diem hires. If you can show that the $20 to $25 per hour your program spends on temporary staff to cover dawn practices, rehabs, and campus contests amounts to $20,000 per year, as was the case at Hofstra, administrators will quickly see staffing as a legitimate problem that needs to be addressed.

Beneficiaries of program care can also provide evidence of your program needs. Because the size and scope of athletics constantly changes as teams are added and participation increases, Cole makes the evaluation of his program an ongoing process. As part of that, he regularly surveys student-athletes and coaches and shares that information with his AD.

"Every month we do a patient survey of student-athletes who come into the facility to find out how we're doing and if we're meeting their needs," says Cole. "And at the end of the academic year, I send a similar, more detailed survey to the coaches. This feedback from the recipients of our services helps me identify what our coverage and care issues are. Then I can sit down with my athletic administrator and say, 'Okay. Here's what we have.'"

Coaches' complaints should also be documented and forwarded to the administration. "For instance, our former basketball coach wanted his own athletic trainer, and that is part of the reason why we got additional staff this year," Zappala says. "Our volleyball program complained. Our football coach has said he needs more people. And our lacrosse coach is saying, 'Hey, I'm a Top 20 team, here. How come I don't have my own athletic trainer?'"

Finally, ATCs can take a more hard-nosed approach and play the liability card by presenting examples of lawsuits filed against other university athletic departments that mirror situations on your campus.

"The all-time angle to pursue is the liability issue," says Ethan Saliba, PhD, ATC, PT, CSCS, Head Athletic Trainer at the University of Virginia. "Every death that's out there you exploit, hat in hand, showing that ours isn't just a tape ankle and haul water kind of existence. My classic quote is: 'Rather than wait for a $20 million lawsuit to put staffing into place that should have already been there, let's put the money in now to help lessen the chance of lawsuits, help the kids, and save yourself the embarrassment.'"

Ultimately, the health and well-being of hundreds of student-athletes is in your hands. Their safety and well-being depends on your staff. As such, it's your duty to regularly determine whether there are more efficient ways to provide service to those athletes or if the time has come to expand your staff. Your administration should always be a first recourse in that process.

"The bottom line is that you are part of the same team, and you need to work together to achieve your goals," Zappala explains. "So, learn to demonstrate your concerns and take the approach of needing to provide quality care for the student-athletes. Nobody wants to argue that. That's everyone's concern."