Original Research
School Nurses’ Familiarity and Perceptions of Academic Accommodations for Student-Athletes Following Sport-Related Concussion
The Journal of School Nursing 2015, Vol. 31(2) 146-154 ª The Author(s) 2014 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/1059840514540939 jsn.sagepub.com
Michelle L. Weber, ATC1, Cailee E. Welch, PhD, ATC1, John T. Parsons, PhD, ATC2, and Tamara C. Valovich McLeod, PhD, ATC, FNATA1
Abstract The purpose of this study was to evaluate school nurses’ familiarity and perceptions regarding academic accommodations for student-athletes following sport-related concussion. School nurses (N ¼ 1,246) accessed the survey School Nurses’ Beliefs, Attitudes and Knowledge of Pediatric Athletes with Concussions (BAKPAC-SN). The BAKPAC-SN contained several questions pertaining to concussion management and academic accommodations. There were significant differences regarding personal experience as well as familiarity of academic accommodations (p < .001) between school nurses who work at a school that employs an athletic trainer and school nurses who work at a school that does not employ an athletic trainer. There were significant weak positive relationships between years of experience and familiarity with academic accommodations (r ¼ .210, p < .001), 504 plans (r ¼ .243, p < .001), and individualized education plans (r ¼ .205, p < .001). School nurses employed at a single school were significantly more familiar with academic accommodations (p ¼ .027) and 504 plans (p ¼ .001) than school nurses employed at multiple schools. Health care professionals should collaborate to effectively manage a concussed patient and should consider academic accommodations to ensure whole-person health care. Keywords concussion management, IEPs, 504 plans
Introduction The topic of sport-related concussion has become increasingly more popular due to the number of concussive injuries and the concern for both short- and long-term health issues (Borich et al., 2013; Saffary, Chin, & Cantu, 2012). The Center for Disease Control and Prevention estimates that approximately 1.6 to 3.8 million sport-related concussions occur annually (Langlois, Rutland-Brown, & Wald, 2006). Additionally, Marar, McIlvain, Fields, and Comstock (2012) reported that for every 10,000 high school athletic exposures, approximately 2.5 concussions occur. Sustaining a concussion can lead to a number of health-related problems. While all concussion-related health problems are important, second impact syndrome, concussion relatedsuicide, and chronic traumatic encephalopathy have been receiving the majority of attention in both lay media and the medical literature (Marshall, 2012). Since the occurrence rate of concussions is increasing and there is the potential for short- and long-term health-related issues, the effects of concussions are being scrutinized to a greater extent.
An emerging area of concern is the increased occurrence of concussions among children and adolescents. It has been reported that approximately 136,000 concussions occur annually among high school athletes (Gessel, Fields, Collins, Dick, & Comstock, 2007), representing approximately 15% of all sport-related injuries at the high school level (Meehan III, d’Hemecourt, Collins, & Comstock, 2011). These data are concerning, especially considering that student-athletes’ primary ‘‘jobs’’ are to be students (Master, Gioia, Leddy, & Grady, 2012), and research has shown that symptoms of a concussion can affect the process of learning (Halstead & Walter, 2010; Lee & Perriello, 2009;
1 2
A. T. Still University, Mesa, AZ, USA National Collegiate Athletic Association, Indianapolis, IN, USA
Corresponding Author: Cailee E. Welch, PhD, ATC, Department of Interdisciplinary Health Sciences, A. T. Still University, 5850 E. Still Circle, Mesa, AZ 85206, USA. Email: [email protected]
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McCrory, Collie, Anderson, & Davies, 2004; McCrory et al., 2013; McGrath, 2010; Rains & Robinson, 2010). Concussion may not only involve an increase in symptoms and impaired cognition and balance but can also affect academic performance in school-age patients. Due to the amount of time a student-athlete spends in the classroom, appropriate concussion management, including assessment of school readiness, is necessary. To aid in this process, health care providers managing concussion should adopt a collaborative and multifaceted team approach, which allows for an evaluation of the need for academic accommodations in the recovery process. The concussion management team should comprise an athletic trainer (AT), directing (team) physician, primary care provider, athletic director, parents, coaches, school nurses, school counselors, teachers, social workers, and even psychologists (Diaz & Wyckoff, 2013; Halstead & Walter, 2010; McGrath, 2010; Piebes, Gourley, & Valovich McLeod, 2009). All members are included to ensure the management strategies take into account the student-athlete’s overall safety and well-being, both at the school and at home. As the sole health care providers at the typical secondary school, ATs and school nurses should collaborate in the management of a sport-related concussion. While ATs generally provide care during after-school physical activity, school nurses can be integral to the concussion management process by recognizing the red flags of concussion symptoms during normal school hours and implementing academic accommodations (Diaz & Wyckoff, 2013). Both formal and informal accommodations are available to support the concussed student-athlete. Informal accommodations can include being allowed to take an exam in a different classroom due to sensitivity to noise, whereas formal accommodations consist of 504 plans and individualized education plans (IEPs). Academic accommodations may be necessary for a studentathlete following a sport-related concussion to help minimize the effects that a concussion might have on academic performance (McGrath, 2010). However, school nurses’ familiarity of and role in the implementation of academic accommodations for student-athletes following sport-related concussion are relatively unknown.
consent was assumed upon voluntary submission of their survey responses (indicated by clicking ‘‘submit’’).
Method Study Design and Target Population
Collaboration with ATs. Participants who indicated they collaborate with a state-licensed or nationally certified AT were asked to complete this subsection. The collaboration with ATs subsection included a series of questions to address school nurses’ communication practices with ATs (i.e., type and frequency of communication), whether the care and management of student-athletes with a sport-related concussion was shared between the two health care professionals, whether the school at which he or she was employed had football and whether concussion-related education had been previously completed.
The purpose of this study was to examine school nurses’ familiarity and perceptions of academic accommodations for student-athletes following a sport-related concussion. This study utilized a cross-sectional survey design to gather data. The target population for this investigation was school nurses’ employed in the secondary school setting. Approximately 8,000 school nurses were solicited via the National Association of School Nurses (NASN) to participate in this study. Prior to data collection, the University Institutional Review Board approved this study as exempt research. Participants’
Instrumentation Survey development. The survey used for this investigation was part of The Beliefs, Attitudes and Knowledge of Pediatric Athletes with Concussions (BAKPAC) survey series, which was developed by the research team. A review of the literature was completed to gain understanding of the concussion management, collaboration, and the role of the school nurse prior to survey development. Along with the school nurse version of the BAKPAC survey (BAKPAC-SN), other versions of the survey were structured to gain information regarding ATs’ (BAKPAC-AT; Mayfield, Welch, Parsons, & Valovich McLeod, In press; Mayfield, Welch, Weber, Parsons, & Valovich McLeod, In press) and physicians’ (BAKPAC-PHYS) practices regarding concussion management and care, concussion referral, and academic accommodations. The BAKPAC-SN was divided into four subsections, which included collaboration with ATs (9 items), concussion management and care practices (22 items), concussion referral (19 items), and academic accommodations (13 items). For the purposes of this article, only two (collaboration with ATs and academic accommodations) of the four subsections will be discussed. In addition to the survey subsections, participants were asked to respond to several personal and school demographic questions. The survey comprised several question structures such as 4-point Likert-type scale items, binary items, multiple-choice questions, and open-ended response questions. Due to the nature of the questions inquiring about the participants’ perceptions and current practice patterns, a reliability analysis to determine internal consistency was not conducted. However, a content validity assessment of the BAKPAC, completed by three concussion experts (i.e., neuropsychologist, pediatric primary care sports medicine physician, and concussion researcher), revealed the survey was a valid instrument (Mayfield, Welch, Parsons, et al., in press). Additionally, a survey expert within the NASN main office assessed the BAKPAC-SN for face and content validity prior to survey distribution.
Academic accommodations. The academic accommodations subsection assessed school nurses’ familiarity with academic
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accommodations, IEPs, and 504 plans. Similar to the BAKPAC-AT survey (Mayfield, Welch, Parsons, et al., in press), this subsection also asked school nurses to respond to questions that assessed participants about their perceived role in the academic support team, if any, at their secondary school, the structure and personnel involved in such an academic support team, and their previous experiences with student-athletes who have received academic accommodations following a sport-related concussion.
Procedures The survey was created and administered utilizing Qualtrics Survey Software (Qualtics Lab, Inc., Provo, UT). School nurses were sent a link via e-mail asking to complete the online survey. The e-mail contained an introduction to the survey with purpose of the study, estimated completion time, a URL link to survey, and contact information for the primary investigators. Data collection occurred during a 4-week period between October and November 2013. One reminder e-mail was sent 2 weeks following the initial e-mail request to remind individuals to complete the survey. Once the participant clicked submit indicating completion, an automatically generated e-mail created through Qualtrics Survey Software was sent thanking the participant for their time and effort.
Table 1. Participant Demographics. School Nurses, N ¼ 1,073 Characteristic Gender Male Female Missing Years of school nurse exp. 0–2 years 3–5 years 6–10 years 11–15 years 16–20 years 21þ years Highest education level High school diploma Associate’s degree Bachelor’s degree Master’s degree Doctorate degree (e.g., PhD, EdD) Clinical doctorate degree (e.g., DNP) Missing
n
%
6 817 250
0.6 76.1 23.3
43 99 213 200 150 118
4.0 9.2 19.9 18.6 14.0 11.0
7 97 440 270 6 3 250
.7 9.0 41.0 25.2 .6 .3 23.3
Note. N ¼ 1,073; exp ¼ experience; PhD ¼ doctor of philosophy; EdD, doctor of education; DNP ¼ Doctor of Nursing Practice.
Data Analysis Data analysis was conducted utilizing IBM SPSS Statistics (Version 21.0.0, IBM Corp., Armonk, NY). Descriptive statistical analysis was conducted to report means, frequencies, and standard deviations. The independent variables included employment of an AT (with AT and without AT), employment model (single school and multiple schools), and years of experience as a school nurse. The dependent variables included participants’ responses to questions within the academic accommodations subsection. Mann–Whitney U tests were conducted to determine if a significant relationship existed between familiarity of academic accommodations those school nurses working with or without an AT and familiarity depending on years of experience. A Spearman’s r correlation was performed determining whether a correlation existed between familiarity of academic accommodations and years of experience.
Results From the convenience sample of 8,000 school nurses, 1,246 individuals accessed the survey (survey access response rate ¼ 15.6%). However, 160 school nurses did not complete any questions and 13 participants reported they were not currently serving as a school nurse and were excluded from data analysis. Therefore, 1,073 school nurses, representing all 50 states and District of Columbia, completed at least one part of the survey. A total of 836 of the 1,073 respondents completed the survey in its entirety for a survey completion
response rate of 77.9%. Participants consisted of 6 males and 817 females (250 missing responses), and the average age of participants was 52.6 + 8.2 years. Participant and school demographics are displayed in Tables 1 and 2, respectively. Experience with academic accommodations. Overall, school nurses were moderately to very familiar with academic accommodations (3.52/4.0 + 0.73), IEPs (3.54/4.0 + 0.70), and 504 plans (3.5/4.0 + 0.73). On average, participants reported that 59.4% of student-athletes with concussions under their care have received academic accommodations. Interestingly, only 27.7% of participants always (14.4%, n ¼ 180) or almost always (13.3%, n ¼ 166) recommend academic accommodations following a sport-related concussion, while 10.5% (n ¼ 131) rarely recommend and 13.4% (n ¼ 167) never recommend academic accommodations following a sportrelated concussion. Table 3 displays respondents’ level of agreement regarding specific BAKPAC items from the academic accommodations subsection. Academic support. Twenty-five percent of participants (n ¼ 312) reported the secondary school for which they serve as school nurse had an academic support team for concussed student-athletes, while 30.7% (n ¼ 383) indicated the school did not; 14.7% (n ¼ 183) of participants did not know if their school had an academic support team. Of the 45.4% of respondents who responded either their school did not have an academic support team or they were not sure if the school had such a team, only 28.5% (n ¼ 355) believed a school
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Table 2. Secondary School Demographics. School Nurses, N ¼ 1,073 Characteristic Type of school Public school Public charter Private parochial Private charter Private Boarding Other Missing Enrollment 5,000 students Missing Level Preschool Elementary Middle Junior High Other Presence of football Yes No Missing
n
%
693 10 22 1 48 6 43 250
64.6 0.9 2.1 0.1 4.5 0.6 4.0 23.3
59 137 299 228 60 19 7 14 250
5.5 12.8 27.9 21.2 5.6 1.8 0.7 1.3 23.3
194 356 381 199 521 57
18.1 33.2 35.5 18.5 48.6 5.3
717 327 29
66.8 30.5 2.7
should have an academic support team for concussed student-athletes. Figure 1 provides a breakdown of the personnel involved for those schools that did have an academic support team for concussed student-athletes. Employment of an AT. Of the school nurses surveyed, 49.1% (n ¼ 612) reported their school employs a state-licensed or nationally certified AT. There were significant differences regarding personal experience with a concussed studentathlete who has received academic accommodations (p < .001) as well as familiarity of academic accommodations (p < .001) between school nurses who work at a school that employs an AT (with an AT) and school nurses who work at a school that does not employ an AT (without an AT). Sixtyfive percent (n ¼ 398) of school nurses with an AT had personally encountered a concussed student-athlete under their care that received academic accommodations, compared to only 42.0% (n ¼ 201) of school nurses without an AT. Furthermore, school nurses with an AT were very familiar with academic accommodations (3.61 + 0.66), while school nurses without an AT were moderately familiar with academic accommodations (3.41/4.0 + 0.79). Notably,
36.9% (n ¼ 226) of school nurses with an AT indicated the school has an academic support team for concussed studentathletes, compared to the 18.1% (n ¼ 86) of school nurses without an AT. Employment model. Four hundred forty-eight school nurses reported they were employed as a school nurse at a single school, while 383 indicated they were employed to serve as a school nurse for multiple schools. There were significant differences regarding familiarity of academic accommodations (p ¼ .027) and 504 plans (p ¼ .001) between school nurses employed at a single school and school nurses employed at multiple schools. School nurses were moderately to very familiar with academic accommodations (3.58/4.0 + 0.68) and 504 plans (3.64/4.0 + 0.63), while school nurses employed at multiple schools were only moderately familiar (academic accommodations ¼ 3.49/4.0 + 0.74; 504 plans ¼ 3.46/4.0 + 0.78). Years of experience. Significant weak positive relationships were found between years of experience and familiarity with academic accommodations (r ¼ .210, p < .001), IEPs (r ¼ .243, p < .001), and 504 plans (r ¼ .205, p < .001). The more years of experience a participant had as a school nurse, the more familiar they were with academic accommodations, IEPs, and 504 plans. There was also a significant weak negative correlation between the number of years of experience as a school nurse and perceptions of whether an AT has the ability to assist with a student-athlete’s return to the classroom following a sport-related concussion (r ¼ .07, p ¼ .028). The more years of experience a participant had as a school nurse, the less they agreed ATs had the ability to assist with a student-athlete’s return to the classroom.
Discussion The purpose of this study was to evaluate school nurses’ familiarity and perceptions of academic accommodations for student-athletes following a sport-related concussion. Our main findings indicate that the majority of school nurses were familiar with academic accommodations, 504 plans, and IEPs. Interestingly, school nurses who were employed at a school with a nationally certified or licensed AT were more familiar with academic accommodations and also had greater personal experience with concussed student-athletes who had received academic accommodations than school nurses who were employed at a school without an AT. Additionally, school nurses with more years of experience were slightly more familiar with academic accommodations, IEPs, and 504 plans. Since proper management of a concussion is imperative to prevent premature return to activity, it is necessary that all members of the concussion management team, including school nurses, recognize the importance of academic accommodations and understand the implementation process. A premature return to activity may result in long-
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Table 3. Results From Survey Questions on Concussion Beliefs and Level of Agreement. Level of Agreement, % (n) Survey Question A school nurse has the ability to assist with a student-athlete’s return to the classroom following a sport-related concussion An athletic trainer has the ability to assist with a student-athlete’s return to the classroom following a sport-related concussion Concussions can affect school performance Student-athletes with active concussions are eligible for special considerations under the Americans with Disabilities Act
Strongly Agree
Agree
Disagree
Strongly Disagree
51.4% (552)
25.3% (272)
3% (3)
2.5% (27)
26.9% (289)
32.9% (353)
16.1% (173)
6.3% (68)
73.9% (793) 40.0% (429)
5.8% (62) 31.1% (334)
0.1% (1) 7.9% (85)
2.5% (27) 3.3% (35)
Figure 1. Percentage of respondents who indicated the personnel involved in the secondary school academic support team for concussed student-athletes.
term health consequences such as second impact syndrome, postconcussive syndrome, and a potential for repeat injuries (Harmon et al., 2013). Thus, proper management can help prevent some of these long-term health concerns. Cognitive and physical rest are the cornerstones of concussion management, because each component allows time for the brain to heal (Guskiewicz et al., 2004; Harmon et al., 2013; McCrory et al., 2013; McGrath, 2010; Valovich McLeod & Gioia, 2010). Unfortunately, cognitive rest or support for the student-athlete in the classroom can sometimes be overlooked (Valovich McLeod & Gioia, 2010). Researchers have recently identified that returning to cognitive activity after sustaining a concussion can potentially lead to a prolonged recovery (Brown et al., 2014). Additionally, it has been suggested that cognitive activity can sometimes worsen the symptoms (e.g., headache, sensitivity to light, sensitivity to noise, etc.) associated with a concussion (Guskiewicz et al., 2004; Meehan III et al., 2011; Moser & Schatz, 2012) and thus could impact learning (Halstead & Walter, 2010; Lee & Perriello, 2009; McCrory et al.,
2004; McCrory et al., 2013; McGrath, 2010; Piebes et al., 2009; Rains & Robinson, 2010). Cognitive rest is strongly recommended following a concussion and should include anything that requires attention and concentration. For the adolescent athlete, these activities may include, but are not limited to, schoolwork, reading, watching television, using a computer, text messaging, and playing video games (Halstead & Walter, 2010; Master et al., 2012; McCrory et al., 2009, 2013). In the academic setting, cognitive rest can successfully be achieved for studentathletes following a sport-related concussion by incorporating formal or informal academic accommodations. Academic accommodations can occur in many forms and can range from temporary, informal alterations to the school day (e.g., permission to wear sunglasses, extra time on homework assignments, etc.) to formal program changes supported by the American with Disabilities Act (‘‘Individualized Education Programs–Special Education Research,’’ 2006). Sometimes, something as simple as being permitted to wear sunglasses to class to reduce the effects of photophobia is
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sufficient (Lee & Perriello, 2009). Other times, more significant and formal accommodations, such as IEPs, are needed to ensure a successful return to academics (Piebes et al., 2009). Two governmental plans exist to aid in support for students with disabilities in the classroom, of which concussed student-athletes can be categorized into. These are the 504 plans and IEPs and can be utilized in the situation of a concussed student-athlete who may need formal alteration to classroom activity to aid in recovery after a concussion injury (‘‘All about the IEP,’’ 2010; ‘‘Individualized Education Programs–Special Education Research,’’ 2006; Master et al., 2012; Piebes et al., 2009). An IEP is created to customize an education program under The Individuals with Disabilities Education Act. IEPs may, but are not limited to, include special education, services provided (e.g., audiology services, recreation, medical services, physical therapy, transportation, etc.), if/when state assessments may be taken, when services are given, and for how long (‘‘All about the IEP,’’ 2010; ‘‘Frequently asked questions about Section 504 and the Education of Children with Disabilities,’’ 2013). An IEP for a concussed student-athlete may resemble being removed from the classroom due to sensitivity to light and noise and being placed in a classroom for special education. Additionally, the studentathlete may be allowed to delay the completion of state assessments because this task also increases symptoms. The 504 plan is described by the U.S. Department of Education as protecting individuals with disabilities in activities and program from institutions, including public schools that receive federal aid (‘‘Frequently asked questions about Section 504 and the Education of Children with Disabilities,’’ 2013). Under this description, it is understood that the schools provide education to each individual, regardless of the severity of their condition (‘‘All about the IEP,’’ 2010; ‘‘Frequently asked questions about Section 504 and the Education of Children with Disabilities,’’ 2013). Additionally, the plan requires that students with disabilities receive a proper education and could include education in regular classrooms, with supplementary services if needed and/or special education-related services (‘‘Frequently asked questions about Section 504 and the Education of Children with Disabilities,’’ 2013). For a concussed student-athlete, a 504 plan is likely to be implemented after it has been determined that their injury will effect their lifelong learning. 504 Plans can include suggestions such as excused absences from class, extensions of assignment deadlines, delaying or staggering of exams, excuse from specific assignments, additional exam taking time, accommodation for oversensitivity to light and/or noise, excuse from practice and physical education activities, taking exams in a different location from classroom to minimize distractions, written instructions, built in rest periods throughout the day, outlining and creating steps for assignments, creating a list of items to complete, privileged classroom seating, and use of reader, notetaker, and/or tutor.
Perception of Academic Accommodations To our knowledge, the BAKPAC-SN is the first study aimed to assess school nurses’ familiarity and perceptions of academic accommodations for student-athletes after sustaining a sport-related concussion. Our results indicate the majority of school nurses believed they should be involved in the facilitation of academic accommodations for concussed student-athletes. This suggests that school nurses perceive themselves to be appropriately adequate in implementing academic accommodations. It also suggests that the school nurses feel prepared to collaborate with others in the concussion management team in order to successfully implement academic accommodations. School nurses practicing at multiple schools were found to be moderately familiar, whereas school nurses overall were moderately to very familiar with academic accommodations and 504 plans. This may be attributed to school nurses at multiple schools are only able to provide basic services, whereas those at one, single site are able to provide more in-depth services. In brief, the school nurse is responsible for the health care of students and staff, oversees the delivery of school health services, completes health screenings, and coordinates referral for a medical home or to a private health care professional (Board et al., 2011). With all of these duties to complete at every school site, providing academic accommodations for concussed student-athletes may be a more in-depth service and be unrealistic for a school nurse covering many school sites. Regardless of the actions required for academic accommodations, a collaborative team approach is essential. A school nurse and AT are often the primary health care providers at the secondary school setting. Working together to ensure the safety and well-being of the student-athlete is assessed both during and after school. An AT is a health care professional who works in conjunction with a physician to ensure and promote physical activity and participation for patients. Additionally, ATs have education and training in the areas of injury prevention, immediate and emergency care, therapeutic intervention, and rehabilitation of injuries and conditions (‘‘Defining Athletic Training,’’ 2013). Even after injury, athletes oftentimes ‘‘check-in’’ with the AT. The AT can relay information to the school nurse about how that student-athlete reports doing in the classroom (i.e., if concussion symptoms worsen throughout the day, if able to complete school work, or which activities increase symptoms). The AT can often recognize symptoms reported from the student-athlete, such as photophobia, and then approach the school nurse with potential needs for accommodations (i.e., being able to wear sunglasses in class). Additionally, the school nurse may come into contact with a studentathlete with a concussion during the day, who is having trouble within the classroom. The school nurse can then relay to the AT, and symptoms that the student-athlete reports which open the lines of communication. This way the AT would
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know first that the student-athlete needed to return to learn before even considering returning to play when they become symptom free. Our results indicated that those school nurses with more years of experience were less likely to believe that an AT had a role to assist the student-athlete’s return to the classroom. This could be due to feelings of independence of the school nurses with more experience. Another reason for this result could be that it was estimated that 42% of high schools in the nation had access to an AT in 2009 (Lowe & Pulice, 2009). This statistic relays the lack of AT presence within the secondary setting, therefore, the school nurse may never have had exposure to this profession within their career span. Previous research has reported that ATs’ were minimally familiar with 504 plans (1.81 + 1.34) and IEPs (2.11 + 1.35; Kay et al., 2014). Results from this study conclude that the majority of school nurses are familiar with these entities. Therefore, there is a potential for school nurses to be able to provide the AT with guidance for implementation of academic accommodations, 504 plans, and IEPs. Additionally, the school nurse can serve as a resource for other members (teachers, parents, physicians, etc.) of the concussion management team with questions regarding these academic accommodation tools.
Implications for Practice In order to ensure knowledge of academic accommodations, interprofessional collaboration and proper concussion management is implemented for a concussed student-athlete, and education opportunities on the subjects should occur. These education opportunities can occur through postprofessional or continuing education opportunities. Opportunities include seminars at national meetings, position statements, webinars, or built into curriculum for postprofessional degrees. Additionally, results indicated that the more experience a school nurse had, the more familiar they were with academic accommodations, IEPs, and 504 plans. These findings demonstrate the need to continually provide education in this area for all school nurses but especially those in academic programs or newly employed at the secondary school level. The evidence about concussion is constantly evolving, and it is important for school nurses to be abreast of the most current information and best practices. If this education is not present, there is a potential for premature turn to activity and no support within the classroom for the concussed student-athlete. Overall, education for all medical professionals within the concussion management team on the subjects of academic accommodations such as what academic accommodations are (i.e., IEPs, 504 plans, and implementation), interprofessional collaboration, and concussion management is essential for proper return-to-learn and return-to-play completion. Due to school nurses’ familiarity with academic accommodations, it is possible that school nurses serve as a lead
team member on an academic accommodations team. With other members of the team such as school counselors, teachers, and the school nurse, each member can ensure that academic accommodations are made for the studentathlete with a concussive injury. Additionally, the school nurse can serve as a liaison between other medical professionals and the academic professionals of the school (school counselor, teachers, etc.). The school nurse may also be able to educate others or answer questions regarding concussion management and academic accommodations for members of the concussion management team including medical professionals, academic figures of the school, parents, and coaches.
Limitations and Future Directions This study is not without limitations. The BAKPAC-SN was sent to a convenience sample of school nurses on the NASN member list. Instructions asked for those school nurses practicing at the secondary school setting, however, it is possible that participants did not fully read inclusion criteria before beginning the survey. Additionally, school nurses who were not members of the NASN were not invited to participate in survey completion. We obtained over 1,000 responses, however, may have limited the overall representation of school nurses who provide care to student-athletes in the secondary school.
Implications for Future Research Future research should be conducted to assess the beliefs, attitudes, knowledge, and familiarity of academic accommodations within a variety of health care providers and other members of the concussion management team for concussed student-athletes. This information can be useful in determining what is known or perceived about academic accommodations and can assist in a successful return-tolearn process.
Conclusions Of the school nurses surveyed, the majority were familiar with academic accommodations. Because cognitive rest is a cornerstone in concussion management, it is essential that school nurses are aware of when a student-athlete sustains a concussion and work together with other medical professionals, including ATs, to support in the return-to-learn process. Academic accommodations can help aide in the process of supporting a student-athlete with a sportrelated concussion when needed. Collaboration with other health care professionals and the utilization of academic accommodations, as needed, helps to ensure wholeperson health care for a student-athlete who has sustained a sport-related concussion.
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Acknowledgments The authors acknowledge the National Association of School Nurses (NASN) for their support and cooperation in obtaining the mailing lists for this study.
Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
References All about the IEP. (2010). Retrieved from http://nichcy.org/ schoolage/iep/team Board, C., Bushmiaer, M., Davis-Alldritt, L., Fekaris, N., Morgitan, J., Murphy, K., & Yow, B. (2011). Role of the school nurse: Position statement. Retrieved from the NASN: National Association of School Nurses website: http://www.nasn.org/PolicyAdvocacy/ PositionPapersandReports/NASNPositionStatementsFullView/ tabid/462/ArticleId/87/Role-of-the-School-Nurse-Revised-2011 Borich, M., Cheung, K., Jones, P., Khramova, V., Gavrailoff, L., Boyd, L., & Virji-Babul, N. (2013). Concussion: Current concepts in diagnosis and management. Journal of Neurologic Physical Therapy, 37, 7. Brown, N., Mannix, R., O’Brien, M., Gostine, D., Collins, M., & Meehan III, W. (2014). Effect of cognitive activity level on duration of post-concussion symptoms. Pediatrics, 133, 1–6. Defining athletic training. (2013). Retrieved from http://www. bocatc.org/about-us/defining-athletic-training. Diaz, A., & Wyckoff, L. (2013). NASN Position statement: Concussions– The role of the school nurse. NASN School Nurse, 28, 110–111. Frequently asked questions about section 504 and the education of children with disabilities. (2013). Protecting Students With Disabilities. Retrieved from http://www2.ed.gov/about/offices/list/ ocr/504faq.html Gessel, L. M., Fields, S. K., Collins, C. L., Dick, R. W., & Comstock, R. D. (2007). Concussions among United States high school and collegiate athletes. Journal of Athletic Training, 42, 495–503. Guskiewicz, K., Bruce, S., Cantu, R., Ferrara, M., Kelly, J., McCrea, M., . . . Valovich McLeod, T. (2004). National athletic trainers’ association position statement: Managment of sportrelated concussion. Journal of Athletic Training, 39, 280–297. Halstead, M., & Walter, K. (2010). American academy of pediatrics. Clinical report–sport-related concussion in children and adolescents. Pediatrics, 126, 597–615. doi:10.1542/peds.20102005 Harmon, K., Drezner, J., Gammons, M., Guskiewicz, K., Halstead, M., Herring, S., . . . Roberts, W. (2013). American medical society for sports medicine position statement: Concussion in sport. British Journal of Sports Medicine, 47, 15–26. doi:10.1136/ bjsports-2012-091941
Individualized Education Programs—Special Education Research. (2006). Retrieved from http://www2.ed.gov/programs/specediep/index.html Kay, M. C., Welch, C. E., Weber, M. L., Mayfield, R. M., Parsons, J. T., & Valovich McLeod, T. C. (2014). The comparison of athletic trainers’ and school nurses’ familiarity and perceptions of academic accommodations following sport-related concussion. Poster presented at the Mesa-Interdiciplinary Research Committee Research Symposium, Mesa, AZ. Langlois, J., Rutland-Brown, W., & Wald, M. (2006). The epidemiology and impact of traumatic brain injury. Journal of Head and Trauma Rehabilitation, 21, 375–378. Lee, M., & Perriello, V., Jr. (2009). Adolescent concussions–management guidelines for schools. Conneticut Medicine, 73, 171–173. Lowe, R., & Pulice, J. (2009). Mandating athletic trainers in high schools. Retrieved from the National Athletic Trainers’ Association website: http://www.nata.org/sites/default/files/mandatingathletic-trainers-in-high-schools.pdf Marar, M., McIlvain, N., Fields, S., & Comstock, R. (2012). Epidemiology of concussions among united states high school athletes in 20 sports. American Journal of Sports Medicine, 40, 747–755. Marshall, C. (2012). Sports-related concussion: A narrative review of the literature. Journal of the Canadian Chiropractic Association, 56, 299–310. Master, C., Gioia, G., Leddy, J., & Grady, M. (2012). Importance of ‘return-to-learn’ in Pediatric and Adolescent Concussion. Pediatric Annals, 41, 1–6. doi:10.3928/00904481-20120827-09 Mayfield, R., Welch, C., Parsons, J., & Valovich McLeod, T. (in press). Secondary school athletic trainers’ familiarity with and perceptions of academic accommodations following sportrelated concussion. Journal of Athletic Training. Mayfield, R., Welch, C., Weber, M., Parsons, J., & Valovich McLeod, T. (In press). Athletic trainers’ management practices and referral patterns for adolescent athletes following sportrelated concussion. Sports Health. McCrory, P., Collie, A., Anderson, V., & Davis, G. (2004). Can we manage sport related concussion in children the same as in adults? British Journal of Sports Medicine, 38, 516–519. doi: 10.1136/bjsm.2004.014811 McCrory, P., Meeuwisse, W., Aubry, M., Cantu, B., Dvorak, J., Echemendia, R., . . . Turner, M. (2013). Consensus statement on concussion in sport: The 4th international conference on concussion in sport held in Zurich, November 2012. British Journal of Sports Medicine, 47, 250–258. doi:10.1136/bjsports-2013-092313 McCrory, P., Meeuwisse, W., Johnston, K., Dvorak, J., Aubry, M., Molloy, M., & Cantu, R. (2009). Consensus statement on soncussion in sport 3rd international conference on soncussion in sport held in Zurich, November 2008. Clinical Journal of Sport Medicine, 19, 185–200. doi:10.1097/JSM.0b013e3181a501db McGrath, N. (2010). Supporting the student-athlete’s return to the classroom after a sport-related concussion. Journal of Athletic Training, 45, 8. Meehan III, W., d’Hemecourt, P., Collins, C., & Comstock, D. (2011). Assessment and management of sport-related
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concussions in United States high schools. American Journal of Sports Medicine, 39, 2304–2310. Moser, R., & Schatz, P. (2012). A case for mental and physical rest in youth sports concussion: It’s never too late. Frontiers in Sports Neurology, 3, 171. Piebes, S., Gourley, M., & Valovich McLeod, T. (2009). Caring for student-atheltes following a concussion. Journal of School Nursing, 25, 2. Rains, C., & Robinson, B. (2010). School nurses and athletic trainers team up on concussion managment. NASN School Nurse, 25, 5. Saffary, R., Chin, L., & Cantu, R. (2012). Sports medicine: Concussions in sports. American Journal of Lifestyle Medicine, 2, 8. Valovich McLeod, T., & Gioia, G. (2010). Cognitive rest: The often neglected aspect of concussion management. Athletic Therapy Today, 12, 1–3.
Author Biographies Michelle L. Weber, ATC, is studying for her Masters degree in the Post-Professional Athletic Training Program at A.T. Still University, Mesa, AZ, USA. Cailee E. Welch, PhD, ATC, is an Assistant Professor of Athletic Training in the Department of Interdisciplinary Health Sciences at A.T. Still University, Mesa, AZ, USA. John T. Parsons, PhD, ATC, is the Director of the Sports Science Institute with the National Collegiate Athletic Association, Indianapolis, IN, USA. Tamara C. Valovich McLeod, PhD, ATC, FNATA, is a Professor and Director of the Post-Professional Athletic Training Program in the Department of Interdisciplinary Health Sciences at A.T. Still University, Mesa, AZ, USA.
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School Nurses’ Familiarity and Perceptions of Academic Accommodations for Student-Athletes Following Sport-Related Concussion
The Journal of School Nursing 2015, Vol. 31(2) 146-154 ª The Author(s) 2014 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/1059840514540939 jsn.sagepub.com
Michelle L. Weber, ATC1, Cailee E. Welch, PhD, ATC1, John T. Parsons, PhD, ATC2, and Tamara C. Valovich McLeod, PhD, ATC, FNATA1
Abstract The purpose of this study was to evaluate school nurses’ familiarity and perceptions regarding academic accommodations for student-athletes following sport-related concussion. School nurses (N ¼ 1,246) accessed the survey School Nurses’ Beliefs, Attitudes and Knowledge of Pediatric Athletes with Concussions (BAKPAC-SN). The BAKPAC-SN contained several questions pertaining to concussion management and academic accommodations. There were significant differences regarding personal experience as well as familiarity of academic accommodations (p < .001) between school nurses who work at a school that employs an athletic trainer and school nurses who work at a school that does not employ an athletic trainer. There were significant weak positive relationships between years of experience and familiarity with academic accommodations (r ¼ .210, p < .001), 504 plans (r ¼ .243, p < .001), and individualized education plans (r ¼ .205, p < .001). School nurses employed at a single school were significantly more familiar with academic accommodations (p ¼ .027) and 504 plans (p ¼ .001) than school nurses employed at multiple schools. Health care professionals should collaborate to effectively manage a concussed patient and should consider academic accommodations to ensure whole-person health care. Keywords concussion management, IEPs, 504 plans
Introduction The topic of sport-related concussion has become increasingly more popular due to the number of concussive injuries and the concern for both short- and long-term health issues (Borich et al., 2013; Saffary, Chin, & Cantu, 2012). The Center for Disease Control and Prevention estimates that approximately 1.6 to 3.8 million sport-related concussions occur annually (Langlois, Rutland-Brown, & Wald, 2006). Additionally, Marar, McIlvain, Fields, and Comstock (2012) reported that for every 10,000 high school athletic exposures, approximately 2.5 concussions occur. Sustaining a concussion can lead to a number of health-related problems. While all concussion-related health problems are important, second impact syndrome, concussion relatedsuicide, and chronic traumatic encephalopathy have been receiving the majority of attention in both lay media and the medical literature (Marshall, 2012). Since the occurrence rate of concussions is increasing and there is the potential for short- and long-term health-related issues, the effects of concussions are being scrutinized to a greater extent.
An emerging area of concern is the increased occurrence of concussions among children and adolescents. It has been reported that approximately 136,000 concussions occur annually among high school athletes (Gessel, Fields, Collins, Dick, & Comstock, 2007), representing approximately 15% of all sport-related injuries at the high school level (Meehan III, d’Hemecourt, Collins, & Comstock, 2011). These data are concerning, especially considering that student-athletes’ primary ‘‘jobs’’ are to be students (Master, Gioia, Leddy, & Grady, 2012), and research has shown that symptoms of a concussion can affect the process of learning (Halstead & Walter, 2010; Lee & Perriello, 2009;
1 2
A. T. Still University, Mesa, AZ, USA National Collegiate Athletic Association, Indianapolis, IN, USA
Corresponding Author: Cailee E. Welch, PhD, ATC, Department of Interdisciplinary Health Sciences, A. T. Still University, 5850 E. Still Circle, Mesa, AZ 85206, USA. Email: [email protected]
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McCrory, Collie, Anderson, & Davies, 2004; McCrory et al., 2013; McGrath, 2010; Rains & Robinson, 2010). Concussion may not only involve an increase in symptoms and impaired cognition and balance but can also affect academic performance in school-age patients. Due to the amount of time a student-athlete spends in the classroom, appropriate concussion management, including assessment of school readiness, is necessary. To aid in this process, health care providers managing concussion should adopt a collaborative and multifaceted team approach, which allows for an evaluation of the need for academic accommodations in the recovery process. The concussion management team should comprise an athletic trainer (AT), directing (team) physician, primary care provider, athletic director, parents, coaches, school nurses, school counselors, teachers, social workers, and even psychologists (Diaz & Wyckoff, 2013; Halstead & Walter, 2010; McGrath, 2010; Piebes, Gourley, & Valovich McLeod, 2009). All members are included to ensure the management strategies take into account the student-athlete’s overall safety and well-being, both at the school and at home. As the sole health care providers at the typical secondary school, ATs and school nurses should collaborate in the management of a sport-related concussion. While ATs generally provide care during after-school physical activity, school nurses can be integral to the concussion management process by recognizing the red flags of concussion symptoms during normal school hours and implementing academic accommodations (Diaz & Wyckoff, 2013). Both formal and informal accommodations are available to support the concussed student-athlete. Informal accommodations can include being allowed to take an exam in a different classroom due to sensitivity to noise, whereas formal accommodations consist of 504 plans and individualized education plans (IEPs). Academic accommodations may be necessary for a studentathlete following a sport-related concussion to help minimize the effects that a concussion might have on academic performance (McGrath, 2010). However, school nurses’ familiarity of and role in the implementation of academic accommodations for student-athletes following sport-related concussion are relatively unknown.
consent was assumed upon voluntary submission of their survey responses (indicated by clicking ‘‘submit’’).
Method Study Design and Target Population
Collaboration with ATs. Participants who indicated they collaborate with a state-licensed or nationally certified AT were asked to complete this subsection. The collaboration with ATs subsection included a series of questions to address school nurses’ communication practices with ATs (i.e., type and frequency of communication), whether the care and management of student-athletes with a sport-related concussion was shared between the two health care professionals, whether the school at which he or she was employed had football and whether concussion-related education had been previously completed.
The purpose of this study was to examine school nurses’ familiarity and perceptions of academic accommodations for student-athletes following a sport-related concussion. This study utilized a cross-sectional survey design to gather data. The target population for this investigation was school nurses’ employed in the secondary school setting. Approximately 8,000 school nurses were solicited via the National Association of School Nurses (NASN) to participate in this study. Prior to data collection, the University Institutional Review Board approved this study as exempt research. Participants’
Instrumentation Survey development. The survey used for this investigation was part of The Beliefs, Attitudes and Knowledge of Pediatric Athletes with Concussions (BAKPAC) survey series, which was developed by the research team. A review of the literature was completed to gain understanding of the concussion management, collaboration, and the role of the school nurse prior to survey development. Along with the school nurse version of the BAKPAC survey (BAKPAC-SN), other versions of the survey were structured to gain information regarding ATs’ (BAKPAC-AT; Mayfield, Welch, Parsons, & Valovich McLeod, In press; Mayfield, Welch, Weber, Parsons, & Valovich McLeod, In press) and physicians’ (BAKPAC-PHYS) practices regarding concussion management and care, concussion referral, and academic accommodations. The BAKPAC-SN was divided into four subsections, which included collaboration with ATs (9 items), concussion management and care practices (22 items), concussion referral (19 items), and academic accommodations (13 items). For the purposes of this article, only two (collaboration with ATs and academic accommodations) of the four subsections will be discussed. In addition to the survey subsections, participants were asked to respond to several personal and school demographic questions. The survey comprised several question structures such as 4-point Likert-type scale items, binary items, multiple-choice questions, and open-ended response questions. Due to the nature of the questions inquiring about the participants’ perceptions and current practice patterns, a reliability analysis to determine internal consistency was not conducted. However, a content validity assessment of the BAKPAC, completed by three concussion experts (i.e., neuropsychologist, pediatric primary care sports medicine physician, and concussion researcher), revealed the survey was a valid instrument (Mayfield, Welch, Parsons, et al., in press). Additionally, a survey expert within the NASN main office assessed the BAKPAC-SN for face and content validity prior to survey distribution.
Academic accommodations. The academic accommodations subsection assessed school nurses’ familiarity with academic
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accommodations, IEPs, and 504 plans. Similar to the BAKPAC-AT survey (Mayfield, Welch, Parsons, et al., in press), this subsection also asked school nurses to respond to questions that assessed participants about their perceived role in the academic support team, if any, at their secondary school, the structure and personnel involved in such an academic support team, and their previous experiences with student-athletes who have received academic accommodations following a sport-related concussion.
Procedures The survey was created and administered utilizing Qualtrics Survey Software (Qualtics Lab, Inc., Provo, UT). School nurses were sent a link via e-mail asking to complete the online survey. The e-mail contained an introduction to the survey with purpose of the study, estimated completion time, a URL link to survey, and contact information for the primary investigators. Data collection occurred during a 4-week period between October and November 2013. One reminder e-mail was sent 2 weeks following the initial e-mail request to remind individuals to complete the survey. Once the participant clicked submit indicating completion, an automatically generated e-mail created through Qualtrics Survey Software was sent thanking the participant for their time and effort.
Table 1. Participant Demographics. School Nurses, N ¼ 1,073 Characteristic Gender Male Female Missing Years of school nurse exp. 0–2 years 3–5 years 6–10 years 11–15 years 16–20 years 21þ years Highest education level High school diploma Associate’s degree Bachelor’s degree Master’s degree Doctorate degree (e.g., PhD, EdD) Clinical doctorate degree (e.g., DNP) Missing
n
%
6 817 250
0.6 76.1 23.3
43 99 213 200 150 118
4.0 9.2 19.9 18.6 14.0 11.0
7 97 440 270 6 3 250
.7 9.0 41.0 25.2 .6 .3 23.3
Note. N ¼ 1,073; exp ¼ experience; PhD ¼ doctor of philosophy; EdD, doctor of education; DNP ¼ Doctor of Nursing Practice.
Data Analysis Data analysis was conducted utilizing IBM SPSS Statistics (Version 21.0.0, IBM Corp., Armonk, NY). Descriptive statistical analysis was conducted to report means, frequencies, and standard deviations. The independent variables included employment of an AT (with AT and without AT), employment model (single school and multiple schools), and years of experience as a school nurse. The dependent variables included participants’ responses to questions within the academic accommodations subsection. Mann–Whitney U tests were conducted to determine if a significant relationship existed between familiarity of academic accommodations those school nurses working with or without an AT and familiarity depending on years of experience. A Spearman’s r correlation was performed determining whether a correlation existed between familiarity of academic accommodations and years of experience.
Results From the convenience sample of 8,000 school nurses, 1,246 individuals accessed the survey (survey access response rate ¼ 15.6%). However, 160 school nurses did not complete any questions and 13 participants reported they were not currently serving as a school nurse and were excluded from data analysis. Therefore, 1,073 school nurses, representing all 50 states and District of Columbia, completed at least one part of the survey. A total of 836 of the 1,073 respondents completed the survey in its entirety for a survey completion
response rate of 77.9%. Participants consisted of 6 males and 817 females (250 missing responses), and the average age of participants was 52.6 + 8.2 years. Participant and school demographics are displayed in Tables 1 and 2, respectively. Experience with academic accommodations. Overall, school nurses were moderately to very familiar with academic accommodations (3.52/4.0 + 0.73), IEPs (3.54/4.0 + 0.70), and 504 plans (3.5/4.0 + 0.73). On average, participants reported that 59.4% of student-athletes with concussions under their care have received academic accommodations. Interestingly, only 27.7% of participants always (14.4%, n ¼ 180) or almost always (13.3%, n ¼ 166) recommend academic accommodations following a sport-related concussion, while 10.5% (n ¼ 131) rarely recommend and 13.4% (n ¼ 167) never recommend academic accommodations following a sportrelated concussion. Table 3 displays respondents’ level of agreement regarding specific BAKPAC items from the academic accommodations subsection. Academic support. Twenty-five percent of participants (n ¼ 312) reported the secondary school for which they serve as school nurse had an academic support team for concussed student-athletes, while 30.7% (n ¼ 383) indicated the school did not; 14.7% (n ¼ 183) of participants did not know if their school had an academic support team. Of the 45.4% of respondents who responded either their school did not have an academic support team or they were not sure if the school had such a team, only 28.5% (n ¼ 355) believed a school
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Table 2. Secondary School Demographics. School Nurses, N ¼ 1,073 Characteristic Type of school Public school Public charter Private parochial Private charter Private Boarding Other Missing Enrollment 5,000 students Missing Level Preschool Elementary Middle Junior High Other Presence of football Yes No Missing
n
%
693 10 22 1 48 6 43 250
64.6 0.9 2.1 0.1 4.5 0.6 4.0 23.3
59 137 299 228 60 19 7 14 250
5.5 12.8 27.9 21.2 5.6 1.8 0.7 1.3 23.3
194 356 381 199 521 57
18.1 33.2 35.5 18.5 48.6 5.3
717 327 29
66.8 30.5 2.7
should have an academic support team for concussed student-athletes. Figure 1 provides a breakdown of the personnel involved for those schools that did have an academic support team for concussed student-athletes. Employment of an AT. Of the school nurses surveyed, 49.1% (n ¼ 612) reported their school employs a state-licensed or nationally certified AT. There were significant differences regarding personal experience with a concussed studentathlete who has received academic accommodations (p < .001) as well as familiarity of academic accommodations (p < .001) between school nurses who work at a school that employs an AT (with an AT) and school nurses who work at a school that does not employ an AT (without an AT). Sixtyfive percent (n ¼ 398) of school nurses with an AT had personally encountered a concussed student-athlete under their care that received academic accommodations, compared to only 42.0% (n ¼ 201) of school nurses without an AT. Furthermore, school nurses with an AT were very familiar with academic accommodations (3.61 + 0.66), while school nurses without an AT were moderately familiar with academic accommodations (3.41/4.0 + 0.79). Notably,
36.9% (n ¼ 226) of school nurses with an AT indicated the school has an academic support team for concussed studentathletes, compared to the 18.1% (n ¼ 86) of school nurses without an AT. Employment model. Four hundred forty-eight school nurses reported they were employed as a school nurse at a single school, while 383 indicated they were employed to serve as a school nurse for multiple schools. There were significant differences regarding familiarity of academic accommodations (p ¼ .027) and 504 plans (p ¼ .001) between school nurses employed at a single school and school nurses employed at multiple schools. School nurses were moderately to very familiar with academic accommodations (3.58/4.0 + 0.68) and 504 plans (3.64/4.0 + 0.63), while school nurses employed at multiple schools were only moderately familiar (academic accommodations ¼ 3.49/4.0 + 0.74; 504 plans ¼ 3.46/4.0 + 0.78). Years of experience. Significant weak positive relationships were found between years of experience and familiarity with academic accommodations (r ¼ .210, p < .001), IEPs (r ¼ .243, p < .001), and 504 plans (r ¼ .205, p < .001). The more years of experience a participant had as a school nurse, the more familiar they were with academic accommodations, IEPs, and 504 plans. There was also a significant weak negative correlation between the number of years of experience as a school nurse and perceptions of whether an AT has the ability to assist with a student-athlete’s return to the classroom following a sport-related concussion (r ¼ .07, p ¼ .028). The more years of experience a participant had as a school nurse, the less they agreed ATs had the ability to assist with a student-athlete’s return to the classroom.
Discussion The purpose of this study was to evaluate school nurses’ familiarity and perceptions of academic accommodations for student-athletes following a sport-related concussion. Our main findings indicate that the majority of school nurses were familiar with academic accommodations, 504 plans, and IEPs. Interestingly, school nurses who were employed at a school with a nationally certified or licensed AT were more familiar with academic accommodations and also had greater personal experience with concussed student-athletes who had received academic accommodations than school nurses who were employed at a school without an AT. Additionally, school nurses with more years of experience were slightly more familiar with academic accommodations, IEPs, and 504 plans. Since proper management of a concussion is imperative to prevent premature return to activity, it is necessary that all members of the concussion management team, including school nurses, recognize the importance of academic accommodations and understand the implementation process. A premature return to activity may result in long-
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Table 3. Results From Survey Questions on Concussion Beliefs and Level of Agreement. Level of Agreement, % (n) Survey Question A school nurse has the ability to assist with a student-athlete’s return to the classroom following a sport-related concussion An athletic trainer has the ability to assist with a student-athlete’s return to the classroom following a sport-related concussion Concussions can affect school performance Student-athletes with active concussions are eligible for special considerations under the Americans with Disabilities Act
Strongly Agree
Agree
Disagree
Strongly Disagree
51.4% (552)
25.3% (272)
3% (3)
2.5% (27)
26.9% (289)
32.9% (353)
16.1% (173)
6.3% (68)
73.9% (793) 40.0% (429)
5.8% (62) 31.1% (334)
0.1% (1) 7.9% (85)
2.5% (27) 3.3% (35)
Figure 1. Percentage of respondents who indicated the personnel involved in the secondary school academic support team for concussed student-athletes.
term health consequences such as second impact syndrome, postconcussive syndrome, and a potential for repeat injuries (Harmon et al., 2013). Thus, proper management can help prevent some of these long-term health concerns. Cognitive and physical rest are the cornerstones of concussion management, because each component allows time for the brain to heal (Guskiewicz et al., 2004; Harmon et al., 2013; McCrory et al., 2013; McGrath, 2010; Valovich McLeod & Gioia, 2010). Unfortunately, cognitive rest or support for the student-athlete in the classroom can sometimes be overlooked (Valovich McLeod & Gioia, 2010). Researchers have recently identified that returning to cognitive activity after sustaining a concussion can potentially lead to a prolonged recovery (Brown et al., 2014). Additionally, it has been suggested that cognitive activity can sometimes worsen the symptoms (e.g., headache, sensitivity to light, sensitivity to noise, etc.) associated with a concussion (Guskiewicz et al., 2004; Meehan III et al., 2011; Moser & Schatz, 2012) and thus could impact learning (Halstead & Walter, 2010; Lee & Perriello, 2009; McCrory et al.,
2004; McCrory et al., 2013; McGrath, 2010; Piebes et al., 2009; Rains & Robinson, 2010). Cognitive rest is strongly recommended following a concussion and should include anything that requires attention and concentration. For the adolescent athlete, these activities may include, but are not limited to, schoolwork, reading, watching television, using a computer, text messaging, and playing video games (Halstead & Walter, 2010; Master et al., 2012; McCrory et al., 2009, 2013). In the academic setting, cognitive rest can successfully be achieved for studentathletes following a sport-related concussion by incorporating formal or informal academic accommodations. Academic accommodations can occur in many forms and can range from temporary, informal alterations to the school day (e.g., permission to wear sunglasses, extra time on homework assignments, etc.) to formal program changes supported by the American with Disabilities Act (‘‘Individualized Education Programs–Special Education Research,’’ 2006). Sometimes, something as simple as being permitted to wear sunglasses to class to reduce the effects of photophobia is
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sufficient (Lee & Perriello, 2009). Other times, more significant and formal accommodations, such as IEPs, are needed to ensure a successful return to academics (Piebes et al., 2009). Two governmental plans exist to aid in support for students with disabilities in the classroom, of which concussed student-athletes can be categorized into. These are the 504 plans and IEPs and can be utilized in the situation of a concussed student-athlete who may need formal alteration to classroom activity to aid in recovery after a concussion injury (‘‘All about the IEP,’’ 2010; ‘‘Individualized Education Programs–Special Education Research,’’ 2006; Master et al., 2012; Piebes et al., 2009). An IEP is created to customize an education program under The Individuals with Disabilities Education Act. IEPs may, but are not limited to, include special education, services provided (e.g., audiology services, recreation, medical services, physical therapy, transportation, etc.), if/when state assessments may be taken, when services are given, and for how long (‘‘All about the IEP,’’ 2010; ‘‘Frequently asked questions about Section 504 and the Education of Children with Disabilities,’’ 2013). An IEP for a concussed student-athlete may resemble being removed from the classroom due to sensitivity to light and noise and being placed in a classroom for special education. Additionally, the studentathlete may be allowed to delay the completion of state assessments because this task also increases symptoms. The 504 plan is described by the U.S. Department of Education as protecting individuals with disabilities in activities and program from institutions, including public schools that receive federal aid (‘‘Frequently asked questions about Section 504 and the Education of Children with Disabilities,’’ 2013). Under this description, it is understood that the schools provide education to each individual, regardless of the severity of their condition (‘‘All about the IEP,’’ 2010; ‘‘Frequently asked questions about Section 504 and the Education of Children with Disabilities,’’ 2013). Additionally, the plan requires that students with disabilities receive a proper education and could include education in regular classrooms, with supplementary services if needed and/or special education-related services (‘‘Frequently asked questions about Section 504 and the Education of Children with Disabilities,’’ 2013). For a concussed student-athlete, a 504 plan is likely to be implemented after it has been determined that their injury will effect their lifelong learning. 504 Plans can include suggestions such as excused absences from class, extensions of assignment deadlines, delaying or staggering of exams, excuse from specific assignments, additional exam taking time, accommodation for oversensitivity to light and/or noise, excuse from practice and physical education activities, taking exams in a different location from classroom to minimize distractions, written instructions, built in rest periods throughout the day, outlining and creating steps for assignments, creating a list of items to complete, privileged classroom seating, and use of reader, notetaker, and/or tutor.
Perception of Academic Accommodations To our knowledge, the BAKPAC-SN is the first study aimed to assess school nurses’ familiarity and perceptions of academic accommodations for student-athletes after sustaining a sport-related concussion. Our results indicate the majority of school nurses believed they should be involved in the facilitation of academic accommodations for concussed student-athletes. This suggests that school nurses perceive themselves to be appropriately adequate in implementing academic accommodations. It also suggests that the school nurses feel prepared to collaborate with others in the concussion management team in order to successfully implement academic accommodations. School nurses practicing at multiple schools were found to be moderately familiar, whereas school nurses overall were moderately to very familiar with academic accommodations and 504 plans. This may be attributed to school nurses at multiple schools are only able to provide basic services, whereas those at one, single site are able to provide more in-depth services. In brief, the school nurse is responsible for the health care of students and staff, oversees the delivery of school health services, completes health screenings, and coordinates referral for a medical home or to a private health care professional (Board et al., 2011). With all of these duties to complete at every school site, providing academic accommodations for concussed student-athletes may be a more in-depth service and be unrealistic for a school nurse covering many school sites. Regardless of the actions required for academic accommodations, a collaborative team approach is essential. A school nurse and AT are often the primary health care providers at the secondary school setting. Working together to ensure the safety and well-being of the student-athlete is assessed both during and after school. An AT is a health care professional who works in conjunction with a physician to ensure and promote physical activity and participation for patients. Additionally, ATs have education and training in the areas of injury prevention, immediate and emergency care, therapeutic intervention, and rehabilitation of injuries and conditions (‘‘Defining Athletic Training,’’ 2013). Even after injury, athletes oftentimes ‘‘check-in’’ with the AT. The AT can relay information to the school nurse about how that student-athlete reports doing in the classroom (i.e., if concussion symptoms worsen throughout the day, if able to complete school work, or which activities increase symptoms). The AT can often recognize symptoms reported from the student-athlete, such as photophobia, and then approach the school nurse with potential needs for accommodations (i.e., being able to wear sunglasses in class). Additionally, the school nurse may come into contact with a studentathlete with a concussion during the day, who is having trouble within the classroom. The school nurse can then relay to the AT, and symptoms that the student-athlete reports which open the lines of communication. This way the AT would
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know first that the student-athlete needed to return to learn before even considering returning to play when they become symptom free. Our results indicated that those school nurses with more years of experience were less likely to believe that an AT had a role to assist the student-athlete’s return to the classroom. This could be due to feelings of independence of the school nurses with more experience. Another reason for this result could be that it was estimated that 42% of high schools in the nation had access to an AT in 2009 (Lowe & Pulice, 2009). This statistic relays the lack of AT presence within the secondary setting, therefore, the school nurse may never have had exposure to this profession within their career span. Previous research has reported that ATs’ were minimally familiar with 504 plans (1.81 + 1.34) and IEPs (2.11 + 1.35; Kay et al., 2014). Results from this study conclude that the majority of school nurses are familiar with these entities. Therefore, there is a potential for school nurses to be able to provide the AT with guidance for implementation of academic accommodations, 504 plans, and IEPs. Additionally, the school nurse can serve as a resource for other members (teachers, parents, physicians, etc.) of the concussion management team with questions regarding these academic accommodation tools.
Implications for Practice In order to ensure knowledge of academic accommodations, interprofessional collaboration and proper concussion management is implemented for a concussed student-athlete, and education opportunities on the subjects should occur. These education opportunities can occur through postprofessional or continuing education opportunities. Opportunities include seminars at national meetings, position statements, webinars, or built into curriculum for postprofessional degrees. Additionally, results indicated that the more experience a school nurse had, the more familiar they were with academic accommodations, IEPs, and 504 plans. These findings demonstrate the need to continually provide education in this area for all school nurses but especially those in academic programs or newly employed at the secondary school level. The evidence about concussion is constantly evolving, and it is important for school nurses to be abreast of the most current information and best practices. If this education is not present, there is a potential for premature turn to activity and no support within the classroom for the concussed student-athlete. Overall, education for all medical professionals within the concussion management team on the subjects of academic accommodations such as what academic accommodations are (i.e., IEPs, 504 plans, and implementation), interprofessional collaboration, and concussion management is essential for proper return-to-learn and return-to-play completion. Due to school nurses’ familiarity with academic accommodations, it is possible that school nurses serve as a lead
team member on an academic accommodations team. With other members of the team such as school counselors, teachers, and the school nurse, each member can ensure that academic accommodations are made for the studentathlete with a concussive injury. Additionally, the school nurse can serve as a liaison between other medical professionals and the academic professionals of the school (school counselor, teachers, etc.). The school nurse may also be able to educate others or answer questions regarding concussion management and academic accommodations for members of the concussion management team including medical professionals, academic figures of the school, parents, and coaches.
Limitations and Future Directions This study is not without limitations. The BAKPAC-SN was sent to a convenience sample of school nurses on the NASN member list. Instructions asked for those school nurses practicing at the secondary school setting, however, it is possible that participants did not fully read inclusion criteria before beginning the survey. Additionally, school nurses who were not members of the NASN were not invited to participate in survey completion. We obtained over 1,000 responses, however, may have limited the overall representation of school nurses who provide care to student-athletes in the secondary school.
Implications for Future Research Future research should be conducted to assess the beliefs, attitudes, knowledge, and familiarity of academic accommodations within a variety of health care providers and other members of the concussion management team for concussed student-athletes. This information can be useful in determining what is known or perceived about academic accommodations and can assist in a successful return-tolearn process.
Conclusions Of the school nurses surveyed, the majority were familiar with academic accommodations. Because cognitive rest is a cornerstone in concussion management, it is essential that school nurses are aware of when a student-athlete sustains a concussion and work together with other medical professionals, including ATs, to support in the return-to-learn process. Academic accommodations can help aide in the process of supporting a student-athlete with a sportrelated concussion when needed. Collaboration with other health care professionals and the utilization of academic accommodations, as needed, helps to ensure wholeperson health care for a student-athlete who has sustained a sport-related concussion.
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Acknowledgments The authors acknowledge the National Association of School Nurses (NASN) for their support and cooperation in obtaining the mailing lists for this study.
Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
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Author Biographies Michelle L. Weber, ATC, is studying for her Masters degree in the Post-Professional Athletic Training Program at A.T. Still University, Mesa, AZ, USA. Cailee E. Welch, PhD, ATC, is an Assistant Professor of Athletic Training in the Department of Interdisciplinary Health Sciences at A.T. Still University, Mesa, AZ, USA. John T. Parsons, PhD, ATC, is the Director of the Sports Science Institute with the National Collegiate Athletic Association, Indianapolis, IN, USA. Tamara C. Valovich McLeod, PhD, ATC, FNATA, is a Professor and Director of the Post-Professional Athletic Training Program in the Department of Interdisciplinary Health Sciences at A.T. Still University, Mesa, AZ, USA.
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