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upporting The Injured Athlete: Coaches’ Perspectives On Providing Social Support upporting The Injured Athlete: Coaches’ Perspectives On Providing Social Support Supporting The Injured Athlete: Coaches’ Perspectives On Providing Social Support Stefanee Opal Maurice West Virginia University, stmaurice@mail.wvu.edu Follow this and additional works at: https://researchrepository.wvu.edu/etd Part of the Sports Studies Commons Recommended Citation Maurice, Stefanee Opal, "Supporting The Injured Athlete: Coaches’ Perspectives On Providing Social Support" (2019). Graduate Theses, Dissertations, and Problem Reports. 4017. https://researchrepository.wvu.edu/etd/4017 This Dissertation is protected by copyright and/or related rights. It has been brought to you by the The Research Repository @ WVU with permission from the rights-holder(s). You are free to use this Dissertation in any way that is permitted by the copyright and related rights legislation that applies to your use. For other uses you must obtain permission from the rights-holder(s) directly, unless additional rights are indicated by a Creative Commons license in the record and/ or on the work itself. This Dissertation has been accepted for inclusion in WVU Graduate Theses, Dissertations, and Problem Reports collection by an authorized administrator of The Research Repository @ WVU. For more information, please contact researchrepository@mail.wvu.edu. Graduate Theses, Dissertations, and Problem Reports 2019 SUPPORTING THE INJURED ATHLETE: COACHES’ PERSPECTIVES ON PROVIDING SOCIAL SUPPORT Stefanee Opal Maurice Follow this and additional works at: https://researchrepository.wvu.edu/etd Part of the Sports Studies Commons SUPPORTING THE INJURED ATHLETE: COACHES’ PERSPECTIVES ON PROVIDING SOCIAL SUPPORT Stefanee Maurice Dissertation submitted to the College of Physical Activities and Sport Sciences at West Virginia University in partial fulfillment of the requirements for the degree of Doctor of Philosophy in Sport and Exercise Psychology Dana K. Voelker, Ph.D., Chair Clayton R. Kuklick, Ph.D. Damien Clement, Ph.D. Jack C. Watson, II, Ph.D. Department of Sport Sciences Morgantown, WV 2019 Keywords: rehabilitation, coach-athlete relationship, sport injury, coaching Copyright 2019 Stefanee Maurice Abstract SUPPORTING THE INJURED ATHLETE: COACHES’ PERSPECTIVES ON PROVIDING SOCIAL SUPPORT by Stefanee Maurice Injury is an inevitable facet of sport participation, and injured athletes require support from coaches. However, research on injured athletes highlights a lack of support from coaches. Building on the conceptual model proposed by Maurice et al., this study uses the International Sport Coaching Framework (ISCF) to examine ways contextual coaching knowledge is used to support athletes throughout rehabilitation. Previous research has focused on the knowledge types but has neither addressed the integration of the knowledges in a single study nor examined them in an injury context. A generic qualitative approach was used to examine 13 NCAA DI coaches’ perception of their role during rehabilitation, their use of ISCF knowledge types, and perceived barriers when supporting injured athletes. Analyzed using deductive coding strategies, coaches reported integrating the knowledge types when supporting their injured athletes. Coaches’ perceived roles and barriers were also addressed by the knowledge types. Coaches emphasized their role during the rehabilitation process was to continue communicating with their athletes and know their players well enough to push them to return to play without furthering their athletes’ injuries. Barriers perceived by coaches in their efforts to provide support came from rules developed by universities and NCAA limiting ways coaches could offer support. Coaches cited injured athletes as barriers, explaining that athletes are not always honest with coaches about injury severity and afraid to admit they are injured. Results of this study can be used to help coaches identify effective uses of coaching knowledge to improve injured athletes’ rehabilitation experiences. ACKNOWLEDGMENTS iii The completion of this dissertation would not have been possible without the numerous sources of social support I found. First, I would like to thank my chair, Dr. Dana Voelker, for her continuous support and guidance throughout this process. Dr. Voelker has been dedicated to helping me get to the finish line and I am so appreciative of all she has done to get me here. I would also like to thank my committee members Drs. Kuklick, Watson, and Clement for their time and expertise that has helped me get to this point. The staff within the college have been instrumental sources of both informational and emotional support throughout the entire process. I would like to express my gratitude to faculty in the counseling department and in the department of sport sciences, and my supervisors at the Carruth Center for supporting over the years and through this project. I would also like to acknowledge the funding support of the NCAA Graduate Student Research Grant and the coaches who took part in this study. To my students and colleagues at Cal Poly, thank you for all you have done to support me and my research. I am so lucky to have found such a supportive home in academia. Through the many ups and downs of completing this project, I was fortunate to have the unwavering support of friends like Megan Byrd, Carra Johnson, Meghan Halbrook, Tammy Sheehy, Ashley Samson, and so many others. I would also like to thank my family for their continuous support of my educational pursuits and always believing in me. iv Table of Contents Abstract ............................................................................................................................... ii Acknowledgements ............................................................................................................ iii Table of Contents ............................................................................................................... iv List of Figures .................................................................................................................... vi List of Tables ..................................................................................................................... vii Introduction ..........................................................................................................................1 International Sport Coaching Framework ..........................................................................3 Coaches’ Provision of Social Support................................................................................4 Integrating Coaching Knowledge into Injury Rehabilitation .............................................7 Gaps, Limitations, and Study Purpose ...............................................................................8 Methods ................................................................................................................................9 Researcher Positionality ....................................................................................................9 Study Design ................................................................................................................... 10 Participants ...................................................................................................................... 11 Procedures ....................................................................................................................... 12 Data Analysis .................................................................................................................. 15 Results ................................................................................................................................ 17 Professional Knowledge .................................................................................................. 17 Professional Knowledge of Resources ........................................................................ 18 Professional Knowledge of Injury Prevention ............................................................. 20 Professional Knowledge on Phases of Injury Rehabilitation ....................................... 21 Professional Knowledge on Injured Athletes’ Sustained Involvement ........................ 22 Professional Knowledge on Athlete Welfare............................................................... 23 Interpersonal Knowledge ................................................................................................. 26 Interpersonal Knowledge on Communicating with Injured Athletes ........................... 26 Interpersonal Knowledge on Perceiving Athletes as Barriers ...................................... 29 Intrapersonal Knowledge ................................................................................................. 30 Intrapersonal Knowledge on Personal Coaching Experiences ..................................... 30 Intrapersonal Knowledge on Personal Athletic Experiences ....................................... 32 An Extreme Case ............................................................................................................. 34 Discussion .......................................................................................................................... 35 Coaches’ Roles During Athletes’ Injury Experience ....................................................... 35 Coaches’ Use of the ISCF Knowledge Types to Support Injured Athletes ...................... 37 Coaches’ Perceived Barriers to Providing Social Support to Injured Athletes ................. 42 Limitations ...................................................................................................................... 44 Practical Implications ...................................................................................................... 45 Future Research ............................................................................................................... 49 Conclusion .......................................................................................................................... 51 References .......................................................................................................................... 53 Appendix A: Literature Review .......................................................................................... 68 Psychological and Emotional Responses to Injury ...................................................... 68 Stages of Injury Rehabilitation .................................................................................... 72 v Injury Response Model ............................................................................................... 73 Social Support ................................................................................................................. 74 Types of Social Support .............................................................................................. 75 Emotional ............................................................................................................... 75 Informational .......................................................................................................... 75 Tangible .................................................................................................................. 76 Role of Social Support in Injury Rehabilitation ............................................................... 77 Coaches as a Source of Social Support ............................................................................ 79 International Sport Coaching Framework ................................................................... 83 Professional Knowledge ......................................................................................... 84 Interpersonal Knowledge ........................................................................................ 85 Intrapersonal Knowledge ........................................................................................ 86 Athlete Outcomes........................................................................................................ 87 Coach-Athlete Relationships ....................................................................................... 88 Appendix B: Assumptions, Key Terms, and Limitations .................................................... 90 Assumptions .................................................................................................................... 90 Definition of Key Terms .................................................................................................. 90 Limitations ...................................................................................................................... 91 Appendix C: Researcher Positionality ................................................................................ 92 Appendix D: Data Collection ............................................................................................. 96 Semi-Structured Interview Guide .................................................................................... 96 Appendix E: Tables ............................................................................................................ 97 Appendix F: Figures ......................................................................................................... 103 vi List of Figures Figure 1. Integrated model of response to sport injury ...................................................... 103 vii List of Tables Table 1. Participant demographic information .................................................................... 97 Table 2. Interview questions aligned with the International Sport Coaching Framework ... 98 Table 3. Code map of iterations of analysis for Professional Knowledge ........................... 99 Table 4. Code map of iterations of analysis for Interpersonal Knowledge ........................ 101 Table 5. Code map of iterations of analysis for Intrapersonal Knowledge ........................ 102 COACH PROVIDED SOCIAL SUPPORT FOR INJURED ATHLETES 1 SUPPORTING THE INJURED ATHLETE: COACHES’ PERSPECTIVES ON PROVIDING SOCIAL SUPPORT Approximately one million injuries were sustained by athletes participating in sport in the National Collegiate Athletic Association (NCAA) between 2009 and 2014 (Kerr et al., 2015). Injury is an inevitable reality when participating in sport (Chalmers, 2002), and coaches must be prepared to help athletes through injury rehabilitation. Initial evidence suggests coaches believe their primary role during their athletes’ injury rehabilitation is helping them return to competition (Podlog & Eklund, 2007b). More specifically, Fernandes et al. (2014) highlighted the importance of coaches taking a holistic approach to improving injury outcomes for athletes, extending beyond physical rehabilitation to include both social (e.g., helping athletes stay involved with their team) and psychological factors (e.g., managing expectations, referring them to a sport psychology consultant). This holistic approach helps athletes to make a full recovery, ensuring the injury is physically healed and the athlete is psychologically ready to return to sport safely. Social support is one tool available to coaches that helps them to address athletes’ emotional, psychological, and social needs related to injury and has frequently been cited as one of the most important psychosocial factors during athletes’ rehabilitation (Yang, Peek-Asa, Lowe, Heiden, & Foster, 2010). Social support is defined as “an exchange of resources between at least two individuals perceived by the provider or the recipient to be intended to enhance the well-being of the recipient” (Shumaker & Brownell, 1984, p. 13). Johnston and Carroll (1998) found both emotional and informational support from coaches was especially important to athletes as they finished rehabilitation and began re-integrating into practice and competition. Further, Podlog and Dionigi (2010) reported coaches used social support strategies such as goal setting, cognitive reframing, and continued team involvement to improve injured athletes’ sense of competence, COACH PROVIDED SOCIAL SUPPORT FOR INJURED ATHLETES 2 autonomy, and relatedness throughout rehabilitation. Awareness of athletes’ needs and knowledge on specific approaches are crucial to effectively supporting athletes whose responses to injury may be highly variable and dependent on the individual. The integrated model of response to sport injury (Wiese-Bjornstal, Smith, Shaffer, & Morrey, 1998) offers a framework from which to explore the psychological response to athletic injury. Specifically, the integrated model demonstrates the dynamic nature of injury rehabilitation; both personal factors (e.g., injury severity, injury type, gender, age, athletic identity) and situational factors (e.g., type of sport, coach influence, social support provision, rehabilitation environment) influence athletes’ cognitive appraisal of their injury, which informs both emotional and behavioral responses. Within the model, social support and coach influences are recognized as situational factors that can positively or negatively affect how athletes evaluate their injuries. When athletes negatively appraise their injuries, they may experience greater frustration, depression, and anxiety, which can hinder their desire to comply with rehabilitation protocols (Clement, Arvinen-Barrow, & Fetty, 2015; Johnston & Carroll, 1998). Social support research highlights a need for not only a greater amount of support being offered by coaches, but also better-quality support as well (Abgarov, Jeffery-Tosoni, Baker, & Fraser-Thomas, 2012; Ruddock-Hudson, O’Halloran, & Murphy, 2012; Ruddock-Hudson, O’Halloran, & Murphy, 2014). In one study on college athletes’ injury experiences, athletes reported their coaches doubted the severity of their injuries and that discussing their injuries with their coaches was challenging (Abgarov et al., 2012). Similarly, Ruddock-Hudson et al. (2012) found professional footballers reported a lack of support from coaches and desired more interactions with coaches during rehabilitation. Additionally, these athletes described their coaches as pushing them to return to play rather than taking the time to rehabilitate. In the COACH PROVIDED SOCIAL SUPPORT FOR INJURED ATHLETES 3 Ruddock-Hudson et al. (2014) study of professional footballers, the athletes reported coaches offered support immediately following the injury, which dramatically declined once athletes began rehabilitation. Although these studies suggest coaches do not offer support that is both needed and desired by athletes during injury rehabilitation, there are a dearth of solutions for improving these circumstances. Perhaps some of the frustration athletes experienced comes from the difference between their expectations for how their coaches should support them and what coaches are truly capable of providing. For example, Ruddock-Hudson et al. (2012) found a small number of the athletes in their study recognized coaches need to balance simultaneous and competing demands, such as coaching their team while supporting their injured athletes. A critical need exists to examine how coaches perceive the provision of social support to injured athletes and how their coaching knowledge may impact their willingness and ability to do so effectively. Maurice, Kuklick, and Anderson (2017) proposed using the International Sport Coaching Framework (ISCF; ICCE, 2014) to examine how coaches use specific forms of coaching knowledge to navigate athletes’ injury experiences, specifically regarding their attitudes and behaviors towards providing social support during athletes’ rehabilitation. International Sport Coaching Framework The ISCF was developed by the International Council for Coaching Excellence (ICCE, 2014) and highlights the knowledge effective coaches should possess to promote positive athlete outcomes, such as competence, confidence, connection, and character (Côté & Gilbert, 2009). Knowledge is categorized into three types: professional, interpersonal, and intrapersonal. Professional knowledge refers to tactical and procedural understanding (Cassidy, Jones, & Potrac, 2009), which may include providing information about the injury or specific activities athletes can engage in that will not aggravate their injuries further. Professional knowledge may also COACH PROVIDED SOCIAL SUPPORT FOR INJURED ATHLETES 4 assist coaches in referring athletes to other professionals who can help. Interpersonal knowledge refers to the social aspect of coaching (Bowes & Jones, 2006). Coaches can implement interpersonal knowledge with their injured athletes to gain a better understanding of the social support needs of their athletes, which are dependent upon the type of stressor experienced (i.e., optimal matching hypothesis; Cutrona, 1990; Cutrona & Russell, 1990). Social support from coaches that is misaligned with athletes’ needs can be perceived by athletes as non-supportive and represent a poor use of interpersonal knowledge. Lastly, intrapersonal knowledge refers to coaches’ ability to reflect and be introspective (Côté & Gilbert, 2009). Coaches can use intrapersonal knowledge to improve their interactions with injured athletes and help create a safe and positive environment for athletes to recover from their injuries. Despite the reality that injury is an inevitable facet of sport (Chalmers, 2002), there is a lack of research examining coaches as a component of the rehabilitation experience. By using the ISCF and its three knowledge types as a framework, researchers can begin to gain insight into coaches’ expectations and experiences with injury and potentially offer explanations for why athletes have felt unsupported by their coaches (Maurice et al., 2017). Coaches’ Provision of Social Support Several studies have examined how coaches have engaged with their injured athletes during their recovery. In a study of eight professional coaches of high-performance athletes (i.e., national to Olympic level), Podlog and Dionigi (2010) found coaches acknowledged the difficulties their athletes faced (i.e., re-injury anxiety, lack of confidence or time pressure). The coaches also identified strategies that helped them support injured athletes, such as forming a treatment team, having open communication, and offering social support. Coaches within this study expressed the value of social support as a critical component of the recovery process for COACH PROVIDED SOCIAL SUPPORT FOR INJURED ATHLETES 5 their athletes and a need to take a more individualized approach to help athletes return to practice and competition (i.e., using interpersonal knowledge). Within the provision of social support, coaches needed to not only tailor their approach to their specific athletes (i.e., interpersonal knowledge), they also helped the athletes adjust and manage their training plans (i.e., professional and intrapersonal knowledge). Though the professional coaches in this study appeared to be incorporating elements of the ISCF coaching knowledge when working with their injured athletes, these coaches represent the behaviors of only eight coaches at an elite level of sport and these views may not transfer to coaches’ views at other levels of sport (e.g., high school, college). Further, evidence suggests a discrepancy exists between the degree of social support coaches believe they provide and the amount of social support injured athletes report receiving from coaches (Corbillon, Crossman, & Jamieson, 2008; Gould, Udry, Bridges, & Beck, 1997; Udry, Gould, Bridges, & Tuffey, 1997). For example, some professional coaches have explained their primary role in injury rehabilitation is to prepare athletes for a return to competition (Podlog & Eklund, 2007b) while athletes have expressed that coaches frequently leave them to make their own decisions about how to best return from injury (Udry et al., 1997). Injured athletes who are without social support during their rehabilitation may experience higher levels of depression (Clement & Shannon, 2011), and athletes who are dissatisfied with the social support they received are likely to experience psychological distress (Green & Weinberg, 2001). Udry et al. (1997) interviewed members of the U.S. Ski Team who had sustained season-ending injuries and found these athletes perceived their coaches to be the most negative influence during their rehabilitation period. Specifically, these athletes felt ignored during their recovery as coaches reduced or stopped communication with them entirely. In other instances, the athletes COACH PROVIDED SOCIAL SUPPORT FOR INJURED ATHLETES 6 felt coaches were insensitive to injuries and reported coaches thought they were a problem and did not believe fully in the extent of injuries. Additionally, the athletes explained their coaches did not express confidence in their ability to return from injuries and were often unavailable to help during rehabilitation, which left the athletes to manage their recovery on their own. This study, however, focused solely on the interpretations of the athletes without giving voice to coaches. Many of the studies reporting a lack of social support from coaches (e.g., Abgarov et al., 2012; Ruddock-Hudson et al., 2012; Ruddock-Hudson et al., 2014) have not included coaches. By focusing solely on athletes, researchers cannot fully explain why coaches do not offer social support that athletes find beneficial. Injured athletes have reported seeking out and receiving social support most frequently from their athletic trainers (Clement & Shannon, 2011; Robbins & Rosenfeld, 2001; Yang et al., 2010), which may be due to the quantity of time spent with athletic trainers during injury recovery or the perceived unavailability of coaches who are focused on participating athletes (Ruddock-Hudson et al., 2014). When athletes have reported receiving support from their coaches, they most frequently cited their coaches as providing informational support (Johnston & Carroll, 2000; Johnston & Carroll, 1998; Corbillon et al., 2008; Rosenfeld, Richman, & Hardy, 1989). Informational support may include education about the injury, feedback about their return timeframe, or their role on the team. Injured athletes have reported coaches do not care about their recovery and remain distant while the injured athletes recover (Udry et al., 1997), which suggests coaches may not be offering enough emotional support. Tangible support may be more difficult for coaches to provide due to organizational restrictions (i.e., NCAA). Robbins and Rosenfeld (2001) suggested, in some cases, coaches did not offer extra support for injured athletes because it may be perceived as unfair to the rest of their team, even if coaches were COACH PROVIDED SOCIAL SUPPORT FOR INJURED ATHLETES 7 aware that the addition of support would have been helpful. Thus, it appears essential for coaches to help injured athletes create a network that includes many people who can meet their diverse social support needs. Integrating Coaching Knowledge into Injury Rehabilitation For athletes rehabilitating an injury, maintaining a connection to their coaches is an essential part of progressing effectively through the stages of rehabilitation (i.e., occurrence of injury, rehabilitation, return to competition) and returning to competition (Bianco, 2001; Podlog & Dionigi, 2010). In the initial injury stage, athletes who sustain an injury first experience an emotional response characterized by uncertainty about the remainder of their season or their ability to continue participating in their sport (Johnston & Carroll, 2000; Madrigal & Gill, 2014; McDonald & Hardy, 1990). Using interpersonal knowledge, coaches can be a source of emotional support for athletes and assist athletes in maintaining their connections to the team. In the second stage, athletes receive a diagnosis and begin their rehabilitation (Bianco, 2007). Athletes rehabilitating an injury are susceptible to feelings of grief (Evans & Hardy, 1995; Tracey, 2003) and low self-esteem (Deroche, Stephan, Brewer, & Le Scanff, 2007) as they are now physically removed from their sport environment. Coaches, then, may find time becomes a barrier as they attempt to engage with injured athletes who are not active in practices and games. Coaches may have the opportunity to demonstrate their professional knowledge as it relates not only to the specific injury but also to the injury recovery process. However, it can be argued offering specific information on the injury itself is outside the bounds of coaching competency and perceived as a barrier by coaches. Finally, in the third stage, athletes finish their rehabilitation and return to their sport. During the last phase, athletes can experience doubts about their physical competence and negative psychological responses, such as re-injury COACH PROVIDED SOCIAL SUPPORT FOR INJURED ATHLETES 8 anxiety (Houston, Cross, Saliba, & Hertel, 2014; Podlog & Eklund, 2007a). Coaches can use intrapersonal knowledge by engaging in reflection with injured athletes to highlight the effort put in and the progress athletes have made throughout the process of rehabilitation. Due to the degree of influence coaches have on their athletes, there is great potential for coaches to actively support athletes throughout the stages of rehabilitation by using various coaching knowledge types and promoting positive outcomes (Bianco, 2007). Gaps, Limitations, and Study Purpose Coaches may be under the impression they are already providing social support to their injured athletes (Podlog & Dionigi, 2010), but as research has shown (e.g., Abgarov et al., 2012), athletes are not satisfied with the support coaches are providing. Dissatisfaction with coaches’ quantity and quality of social support has the potential to create negative consequences for injured athletes. Much of the research on social support for injured athletes has been from the perspective of the athletes and has not included coaches (e.g., Abgarov et al., 2012; Corbillon et al., 2008; Ruddock-Hudson et al., 2014). The research that has examined coaches’ perspectives on injury rehabilitation (e.g., Podlog & Eklund, 2007b; Podlog & Dionigi, 2010) was completed almost a decade ago and did not use a framework specific to coaching. There also remains a dearth of literature on coaches at the collegiate level, which represents a competitive environment dependent upon preventing injuries and returning athletes to play quickly. In National Collegiate Athletic Association (NCAA) Division I (DI) sports, arguably the most competitive of any collegiate sport division, the pressure placed on athletes can be as intense as some professional sports leagues (Beron & Piquero, 2016; Huml, 2018). NCAA DI athletics are operated like a business despite athletes being labeled as amateurs and receiving little compensation in return for the stressors they endure, such as injury (Sanderson & Siegfried, 2018). In the business of college athletics, coaches’ COACH PROVIDED SOCIAL SUPPORT FOR INJURED ATHLETES 9 jobs often depend on their teams’ success. It is in the interest of college coaches, and their athletic departments, to keep their athletes healthy to produce the best results. Given the unique context of NCAA DI sport, it is vital to create environments that both support athletes’ well-being and allow coaches to use their knowledge and experiences to support their athletes. Until college coaches have been studied, researchers and those involved in college athletics will continue to have an incomplete understanding on how coaches can effectively interact with their injured athletes. The purpose of this study was to explore collegiate coaches’ knowledge related to the provision of social support to injured athletes throughout the phases of rehabilitation and return to competition. Using the ISCF as a guiding framework, this study had three primary goals: (1) gain insight into how coaches perceived their role in providing social support throughout the injury recovery process, (2) explore how coaches used the ISCF knowledge types in the context of supporting injured athletes, and (3) explore what coaches perceived to be barriers to their delivery of effective social support. Researcher Positionality Methods The researcher’s epistemology is that of a social constructivist. Social constructivism recognizes the impact culture and context have on an individual and how they experience the world and create their own meaning (Crotty, 1998; Fish, 1990). Social constructivists do not see an absolute truth, but rather they acknowledge all meaningful realities are socially constructed and influenced by culture (Crotty, 1998). The participants in this study were examined, not with an absolute truth of what is right and wrong, but with an appreciation for their culture and context to gain insight into how this shaped their views of coaching injured athletes. The COACH PROVIDED SOCIAL SUPPORT FOR INJURED ATHLETES 10 researcher recognized that the coaches’ reality and her own reality are the result of social processes and are limited to the context in which they were experienced. Study Design A generic qualitative approach, also referred to as an eclectic design, was used to explore coaches’ perceptions regarding their roles in the injury recovery process, the ways they use the ISCF knowledge types, and barriers they perceive in supporting their injured athletes. The exploratory approach needed to address the purpose of the current study does not fit neatly into one specific methodology. Merriam (1988) described studies using the generic qualitative approach as those that “simply seek to discover and understand a phenomenon, a process, or the perspectives and worldviews of the people involved” (p. 11). Percy, Kostere, and Kostere (2015) described the need for generic qualitative approaches when “the researcher has a body of pre knowledge/pre-understandings” about the topic in question that the researcher “wants to be able to more fully describe from the participants’ perspective” (p. 78). In the case of the current study, the researcher has knowledge of the research suggesting that athletes do not feel fully supported by their head coaches and is using this exploration to gain the perspective of head coaches and the ways they use their coaching knowledge in the context of athletic injury. Generic qualitative approaches also seek to gain a broader range of experiences from a more diverse sample, supporting the current study’s focus on maximum variation sampling (Percy et al., 2015). According to Cooper and Endacott (2007) and Caelli, Ray, and Mill (2003), generic qualitative approaches should have an explicit focus on their theoretical position to enhance the rigor of the studies. As a social constructivist, it was important for the researcher in the current study to focus on how coaches used their ISCF knowledge types within their unique context and culture. Thus, a generic qualitative approach was most appropriate for this inquiry. COACH PROVIDED SOCIAL SUPPORT FOR INJURED ATHLETES 11 Participants Participants were 13 NCAA DI head coaches (Mage = 45.85, SD = 11.2) including five women (Mage = 38.6, SD = 12.7) and eight men (Mage = 50.4, SD = 7.87) from 13 DI universities in the United States. Five coaches (2 female, 3 males) came from mid-sized universities (student population of 3,000-9,999) and eight (3 females, 5 males) from large universities (student population of at least 10,000). Four coaches were from universities without a football program (2 female, 2 male), four from universities with football programs in the Football Championship Subdivision (1 female, 3 males), and five from universities with football programs in the Football Bowl Subdivision (2 females, 3 males). The participants’ head coaching experience at the DI level ranged from 1 to 23 years (M = 9.1 years) and four to 31 years (M = 18.5 years) in any NCAA division. The sports coached by men within this sample included men’s and women’s basketball, baseball, football, women’s golf, women’s ice hockey, and men’s and women’s tennis. Sports coached by women within this sample included men’s and women’s swimming and diving, women’s gymnastics, women’s rowing, women’s soccer, and women’s volleyball (see Table 1 for more demographic information). The coaches in this study had experience in coaching athletes who had sustained an injury and returned to participation within the past year. The injured athlete must have sustained at least a minor injury causing time-loss from their sport (e.g., 4-7 days; Hagglund, Walder, Bahr, & Ekstrand, 2005), defined as “a physical complaint resulting from sports participation that forces the athlete to interrupt or modify his usual training plan for at least one training unit” during their competitive season (Malisoux, Frisch, Urhausen, Seil, & Theisen, 2013, p. 2896). Coaches were excluded from the study if their most recent athlete injury experience occurred more than one year ago, their athlete did not return to competition following an injury, or if their COACH PROVIDED SOCIAL SUPPORT FOR INJURED ATHLETES 12 only experience with injury was a head injury, season-ending, or career-ending injury. Head injuries were excluded from this study due to differences in athletes’ cognitive and emotional responses compared to those experiencing musculoskeletal injuries (Hutchison, Comper, Mainwaring, & Richard, 2011; Hutchison, Mainwaring, Comper, Richards & Bisschop, 2009). Procedures After receiving Institutional Review Board approval, participants were contacted for recruitment using a purposive sampling approach. The researcher used the United States Census Bureau’s regions to seek out maximum variation within the sample. There are nine regions total (Pacific, Mountain, South Atlantic, Middle Atlantic, New England, West South Central, East South Central, West North Central, and East North Central) that were used to identify NCAA DI coaches for participation. The researcher contacted 188 head coaches across the nine regions via email with information about the study and details for inclusion criteria if they wished to participate. The researcher attempted to contact the selected coaches via email and telephone up to three times in a 10-day period before moving onto another coach in the region. The number of coaches contacted per region ranged from two to 68. Due to their low numbers, female coaches were identified and contacted first and in the following order: those who coached men’s teams, co-ed teams, and women’s teams. From there, male coaches were identified and contacted to achieve maximum variation within the sample (e.g., varied ages, sport and gender of athletes coached). Using the maximum variation sampling strategy to achieve a heterogeneous sample was desirable in this study because of the dearth of research on coaches and injury; it was important to first gain the perspective of a diverse group who had varied coaching experiences rather than focus on one specific demographic of coaches. Interviewing the sample of coaches within this study using the maximum variation sampling strategy allowed the researcher to COACH PROVIDED SOCIAL SUPPORT FOR INJURED ATHLETES 13 uncover a broader spectrum of coach experiences (Miles et al., 2014). The final sample included 13 coaches who volunteered to participate (6.9% response rate); all met eligibility criteria. Coaches who agreed to participate in the study were sent a cover letter detailing what their participation would entail and how they would be compensated for their time (i.e., coaching book). The researcher conducted interviews lasting 10 to 57 minutes over the phone or a video chat service, such as Skype, which were audio-recorded. The mode of communication for each interview was determined by the participant based on their interest and comfort level. Eleven of the coaches were traveling to practice or competitions while being interviewed and chose to be interviewed over the phone. Data were collected using a semi-structured interview guide (Bellamy, Ostini, Martini, & Kairuz, 2016; Mertens, 1998). The semi-structured interview guide provided the researcher with flexibility to probe participant responses further while allowing her to maintain a level of consistency throughout her participant interviews. Each interview began by developing rapport with the coaches and building trust by explaining the researcher’s interest in giving coaches a voice in the literature as well as describing her family’s history in coaching. The interview questions were developed based on the core components of the ISCF, addressing multiple knowledge types (i.e., professional, interpersonal, and intrapersonal knowledge), and the stages of rehabilitation (see Table 2 for interview guide mapped onto the ISCF). Social constructivism shaped the format of the interview questions to elicit responses from coaches that would provide insight into both their specific social context and how their interactions and experiences shape their understanding of their world (Cushion, 2011; Crotty, 1998). The audio recordings and transcripts were kept in Filelocker, a software service that encrypted the files and protected participant confidentiality. The participants were reminded at both the start and close of the COACH PROVIDED SOCIAL SUPPORT FOR INJURED ATHLETES 14 interviews their confidentiality was of the utmost importance to the researcher. Participants were given the opportunity to choose their own pseudonyms so their identities may be protected in any representation of the data. Data collection spanned several months, throughout which the data was also transcribed and coded. After interviews were transcribed and the researcher began coding the interviews, participants were contacted again to engage in member reflections (Smith & McGannon, 2017). Three of the 13 coaches responded to the researcher’s follow-up to conduct member reflections. Member reflections were used to create a shared dialogue between the participant and the researcher about the analysis of the results. The member reflections allowed the participants to ask questions about the interpretation of the data as well as opportunities to evaluate and provide feedback and on the researcher’s findings (Tracy, 2010). The member reflections were a co participatory process that furthered the researcher’s understanding of the data. During this conversation, the coaches were also given the opportunity to add to the information they provided in their initial interview. The researcher prompted the participants with member reflection questions, which provided the participants an opportunity to give an opinion after hearing the researcher’s interpretations and shape the emerging analysis (Tracy, 2013). For example, after explaining her interpretation of the coaches’ perceptions of athletes as barriers to coaches’ delivery of social support, the researcher asked the participants what they thought of the interpretation and what that means to the participants in their specific context (i.e., within their team). The member reflections were not about verification but rather were intended to further the researcher’s interpretations of the findings and yield further insight. From these member reflections, the researcher learned that the coaches found value and meaning in the researcher’s interpretations of the data (Tracy, 2013). Conducting member reflections rather than member COACH PROVIDED SOCIAL SUPPORT FOR INJURED ATHLETES 15 checks allowed the researcher to engage in both epistemological constructionism (i.e., as knowledge is socially constructed, knowledge is not free from theory and understandings prior to engaging with participants) and ontological relativism (i.e., the perception of reality is dependent upon the mind experiencing it) (Smith & McGannon, 2017), which complemented her social constructivist epistemology. Upon the completion of member reflections, all coaches who participated in the study were given a coaching book in appreciation of their volunteer participation. Data Analysis The current study used the ISCF knowledge types as a guiding framework to conduct a thematic analysis of the data. The researcher first familiarized herself with the data by listening to the audio recordings of the coach interviews and reading the transcripts for accuracy and familiarity. While engaging with the data, the researcher created analytic memos (Miles, Huberman, & Saldaña, 2014) to denote interpretations of the data from collection through analysis. The interpretations noted in the memos pertained to how interview responses aligned with components of the ISCF and initial patterns within each coach’s unique context (i.e., sport, experiences). As a social constructivist, it was of value to take note of how coaches explained, and ascribed meaning to, the culture of their team, such as the way coaches engage differently with male and female athletes. The ISCF knowledge types were used as a guide for coding, which occurred in two cycles: (1) deductive in vivo coding and (2) focused coding. Deductive in vivo coding was selected as the method of analysis over inductive coding because of the need to identify codes connected to the existing framework (i.e., ISCF). The researcher used deductive in vivo coding during the initial coding process to identify the presence or omission of the ISCF knowledge COACH PROVIDED SOCIAL SUPPORT FOR INJURED ATHLETES 16 types. In vivo coding is appropriate when the researcher wants to honor the voices and the language used by the participants (Saldaña, 2013; Stringer, 1999). As a social constructivist, it was essential for the researcher to select a coding approach focused on the language used by the participants to better understand their lived experiences, such as the way they addressed concepts like perceived responsibility in their role as the head coach or descriptions of relationships with their athletes. Saldaña (2013) explains that in vivo coding allows a researcher to highlight the most significant ways the participant speaks about a phenomenon by coding components such as action verbs, impactful nouns, clever phrases, and/or repetition of words and phrases. One participant was analyzed separately as an extreme case due to distinct dissimilarities in the interview content and process as compared to the remaining participants. These distinctions are examined and described in further detail at the end of the results section. First cycle coding resulted in a list of codes related to each of the ISCF knowledge types. Second cycle coding consisted of the method of focused coding (Charmaz, 2006), which allowed the researcher to use the most frequent and salient codes to create categories, subthemes, and themes related to how coaches perceived their roles in the recovery process, the ways coaches used their ISCF knowledge types to support their athletes, and the barriers perceived by coaches as impeding their delivery of effective social support. A detailed map of these iterations is provided in Tables 3 through 5. During this process, the researcher continued to construct her understanding of the lived experiences of the coaches and the ways they made sense of their interactions. To enhance credibility, critical friends (Smith & McGannon, 2017) were used to process the researcher’s biases after she created codes, sub-themes, and themes from the data. The use of critical friends allowed for varying perspectives to view the data and were used for “challenging and developing interpretations made by any one researcher as they construct, not COACH PROVIDED SOCIAL SUPPORT FOR INJURED ATHLETES 17 find or discover through consensus, a coherent and theoretically sound argument to construct, support and defend the case they are making” (Smith & McGannon, 2017, p. 13). The researcher used two levels of critical friend engagement throughout the analysis. The first critical friend has experience in qualitative inquiry and has conducted research on the psychology of injury; her role as a critical friend began when the sub-themes and themes were first developed by the researcher. This individual challenged the researcher’s interpretations of the data to consolidate, clarify, and organize the sub-themes and themes. The second critical friend has experience in qualitative research and the coaching literature. This individual was engaged following the development of an initial theme structure and challenged the researchers’ interpretations to achieve additional theme refinement, clarity, and parsimony (e.g., Are these ideas distinct? What makes them so? How might this theme be re-labeled to more clearly reflect the contents of the data?). Each critical friend was used to clarify the researcher’s process and basis for interpretation, including impressions and interpretations. Both critical friends and the researcher maintained records of these conversations for the audit trail and later reflection by the researcher. Results The results are organized according to the ISCF knowledge types (i.e., professional, interpersonal, and intrapersonal), which were used as a framework for the analysis. Themes and subthemes are described within each knowledge type with key quotes from coaches. Professional Knowledge Five themes characterized coaches’ demonstration of professional knowledge in the context of athletes’ injuries: (a) using resources, (b) injury prevention, (c) phases of injury rehabilitation, (d) sustaining injured athletes’ involvement, and (e) athlete welfare. See Table 3 for the iterations of analysis for professional knowledge. COACH PROVIDED SOCIAL SUPPORT FOR INJURED ATHLETES 18 Professional knowledge of resources. The ability to recognize when to use a resource, and which resource is the most appropriate, is an important demonstration of professional knowledge as it relates to injured athletes. Relative to professional knowledge of resources, two sub-themes were identified: (a) the network roles that need to be fulfilled to support injured athletes and (b) the accessibility of resources for supporting injured athletes. Within the first sub-theme, coaches described the network of individuals needed to fully support their injured athletes, such as doctors and sport psychology consultants. All 13 coaches emphasized the importance of having a network of professionals (e.g., athletic trainers, doctors, and sport psychologists) as resources to help them support their injured athletes. Howard, a baseball coach, described the need to “rely on the medical professional. And most importantly, for Division I, or any coach, you have to listen to the medical professional.” Howard further expressed: As a coach, I have no medical expertise; none. I understand baseball and I understand movements related to baseball and things that need to happen, but structurally and medically, I don't, so I always lean on professionals to guide me if I'm unaware. Many of the coaches relied on athletic trainers, sometimes described as medical professionals, as their primary resource when athletes sustained injuries and expressed the value of using their athletic training staff when designing training plans. All the coaches discussed the importance of listening to their athletic trainers and trusting they have athletes’ best interests in mind, as demonstrated by women’s soccer coach, Lauren: Listen to your medical staff, if they're telling you to do something, don't overrule them. As much as sometimes I want to strangle my AT, she's not trying to sabotage us and she's COACH PROVIDED SOCIAL SUPPORT FOR INJURED ATHLETES 19 not trying to control my decisions, she's trying to give me all the information I need to make the best one. The coaches also addressed the value of sport psychology consultants as members of a support team. All the coaches reported having access to sport psychology services, but Claire (gymnastics), Kevin (women’s basketball), Lauren (women’s soccer), Noah (men’s and women’s tennis) and Owen (men’s basketball) were the only coaches making referrals for these services. Coaches who made referrals to sport psychology services understood the role sport psychology has during recovery, as Noah, a men’s and women’s tennis coach, explained: If you have somebody in your department to refer them to where they can get that help, because many times it's not the injury that's affecting the player after they're back on the fields or the courts, it's the psychological hurdle that they have to get over. Within the second sub-theme, coaches described the accessibility of resources for supporting injured athletes. For some coaches, the lack of medical resources available impacted their ability to find support for their athletes (e.g., informational support for their injury). Noah (men’s and women’s tennis) discussed this in his interview, “we were under-equipped in the sports medicine department. Very small room, very few people working in there to service the sport. So, a lot of times we couldn't get in to see him when we needed to.” David (women’s soccer) reported, “we don't have that overall access over a 12-hour day to all facilities, where we can schedule what works for us so that we can maintain that strength so that we limit some of those injuries.” The way resources were allocated varied based on the sport and athletes’ status on the team. Mason (football) explained: “I guarantee, the number 10 guy would get [the MRI]. And the number 101 guy would wait until it was paid for by their insurance, which I think is wrong.” Coaches, such as Noah (men’s and women’s tennis) and David (women’s soccer), were COACH PROVIDED SOCIAL SUPPORT FOR INJURED ATHLETES 20 attempting to use their professional knowledge to support their athletes, but were limited to the resources available to them. Professional knowledge of injury prevention. Relative to the theme of professional knowledge of injury prevention, coaches described the importance of using and staying current on proper training techniques and helping athletes with the mental aspects of injury. Many coaches noted a lack of medical knowledge but were knowledgeable of injury prevention (e.g., fatigue, poor training) and applying instructional techniques to reduce injury incidence. For example, Lauren (women’s soccer) explained, “we are very strict on teaching correct technique because although it doesn't completely eradicate injury, it minimizes it and there's plenty of research on that.” David (women’s soccer), expressed his concerns about his athletes’ being fatigued during competition: I know that the longer you leave someone in a situation where they start to fatigue, the more likely it is that they're going to pick up an injury, because they can't play at the same level when they get fatigued as they did when they first went into a game. Many of the coaches felt prepared and educated on how to use preventive approaches to injury, such as addressing training techniques, but felt less knowledgeable about what to do after the injury was sustained. The coaches shared candidly that their medical knowledge regarding injury is limited but they expressed a desire to continue to learn more and educate themselves about their athletes’ injuries, as expressed by Tanya (women’s volleyball): I am very candid about what I don't know and I have no problem asking our athletic trainers just, "Wow, I've never seen this before. I don't even know what you're talking about with this injury. So, can you explain it to me? Because I don't know." COACH PROVIDED SOCIAL SUPPORT FOR INJURED ATHLETES 21 Emily (women’s rowing), however, had stopped trying to learn more about injuries: “I'm not allowed to do stuff with them [injured athletes]. I have to stay hands off…But as far as me looking for more information, I've stopped doing that here because they [the university] discourage us from doing that.” Emily’s situation appeared to be unique to her university as this was not expressed by any other coach. Professional knowledge on phases of injury rehabilitation. Professional knowledge in the athletic injury context requires coaches to be aware of the phases of injury rehabilitation and the ways athletes’ needs may vary across each phase. Relative to professional knowledge of the phases of injury rehabilitation, two sub-themes were identified: (a) managing their own emotional responses to athletes’ injuries and (b) being cognizant of performance decrements that may occur as a part of the recovery process. Within the first sub-theme, coaches described a need to monitor their own emotional responses during the occurrence of injury phase of rehabilitation. Coaches recognized their reactions to athletes’ injuries often impacted their athletes’ reactions. Coaches were asked to describe how they engage with athletes throughout the phases of rehabilitation (i.e., occurrence of injury, treatment and recovery, and return to full competition). Lauren’s (women’s soccer) explanation of her reaction to injuries was like other coaches, where staying calm herself was a necessary element of keeping her athlete calm: I try to be very calm and try and just reiterate, ‘Hey, it's part of the game. You're not the first, you're not the last.’ I just try and take the emotion out of it, because it's a very emotional time. Claire, a women’s gymnastics coach, explained the importance of managing emotional responses based on injury severity: COACH PROVIDED SOCIAL SUPPORT FOR INJURED ATHLETES 22 If it's something that happens in practice and it's a one-time impact kind of injury, we obviously go to the athlete right away and give them the care that they need. If it's an over time kind of thing, we usually check in periodically, and work with them on what makes the most sense for them to do that day, whether it's rehab, or if they have to alter practice in any way. Within the second sub-theme, coaches described the importance of acknowledging the ways athletes’ performance may decline because of their inability to participate in practice and training during the treatment and recovery phases of rehabilitation. Owen (men’s basketball), noted: Yeah, I think the main thing when those guys get hurt is when they come back, their conditioning is not as good as it was before they left. And so physically they struggle a little bit just kind of getting their bodies back on a little bit. Noah (men’s and women’s tennis) echoed this sentiment: We know that they're more than likely not going be hitting exactly like they were, or performing exactly like they were before the injury, based on how long it was. And we also know that they could get extra critical, or disappointed, or negative towards their game, when it's not coming right back. Professional knowledge on injured athletes’ sustained involvement. Relative to professional knowledge on injured athletes’ sustained involvement, all the coaches stressed the importance of keeping athletes involved with the team after they have become injured. Coaches described strategies they use to incorporate their injured athletes into practice. Doing this allowed athletes to maintain contact with their team and for some, get physical conditioning. The COACH PROVIDED SOCIAL SUPPORT FOR INJURED ATHLETES 23 coaches shared a belief that being around the team would keep athletes involved with the team’s progress. Kevin (women’s basketball) explained: I want them to be at practice and I want them around the team. Just not be away from them, so I expect them at practice…I make them take notes, make sure they know what’s going on so they don’t get behind. Some coaches provided challenges for injured athletes to keep them engaged, such as Claire (women’s gymnastics): We've given one of our athletes a challenge, and she needs to reach out to three different people during practice, and encourage them. So, giving them ways that they can become really good teammates during this time and not all the focus is just on the rehab... I think that's really key for getting them mentally out of the struggles of the injury. Coaches described the value of maintaining a social connection to their teammates by giving injured athletes new roles on the team. Coaches shared their technique of assigning injured athletes new roles to keep them engaged in practice, such as Lauren (women’s soccer): A big help has been just giving them other roles, so they have a specific role at practice. So even if it's things like, "Hey, I need the waters. Can you help me set practice up?" Go through the practice plan with them, just so they feel like they're part of it. Ultimately, coaches seemed to prefer athletes do their rehabilitation exercises during team training times to still be involved in the team activities. Professional knowledge on athlete welfare. Coaches expressed the importance of keeping their players safe. Relative to professional knowledge on athlete welfare, two sub themes were identified: (a) how to make the right decision about return to play and (b) having a person-first focus. COACH PROVIDED SOCIAL SUPPORT FOR INJURED ATHLETES 24 Within the first sub-theme, coaches described the importance of trusting both their athletes and medical staff regarding readiness to return. When it came to making decisions about returning to play, coaches frequently described the need to keep their athletes’ welfare in mind. Howard, a baseball coach, shared: My responsibility is to have a good understanding of each player's ability to deal with things…And like I said, we got measures in place to protect these young kids and make sure they're not in any danger, and hopefully, we'll continue to monitor and keep those types of things from happening. In some cases, coaches had to sit down with athletes and remind them to focus on recovering, like Allison, a men’s and women’s swimming and diving coach: A true athlete's going to want to, after an injury, get back as soon as possible, but you have to be willing to say, "No, you're not ready," and say, "Just give it another week or two weeks." And that's kind of what you have to do with those ones. Tanya (women’s volleyball) explained: I think it's a huge responsibility of the coach to acknowledge that and really dial back and figure out a way to progress that player back, where it's not rushing them and yet still pushing them… I think it's our responsibility as the coach to really dictate how we get them back without stressing them out, feeling, "Oh my gosh, I have to get back this quickly, I need to be back on the floor, my team needs me." All of that, I think, it's our responsibility to keep the athletes safe. Within the second sub-theme, coaches described a need to focus on their athletes as a person and not on their win-loss record while their injured athletes recover. Allison (men’s and COACH PROVIDED SOCIAL SUPPORT FOR INJURED ATHLETES 25 women’s swimming and diving) extended the notion of keeping athletes safe and treating them as people: Know at the end of the day, they [athletes] and their well-being and them...They as a person, is more important than your win-loss record, and I think sometimes coaches get caught up in that and I know there's all dif