INDIANAPOLIS, March 22, 2016 – At the second Collaborative Solutions for Safety in Sport press conference today, new recommendations, “Implementing Health and Safety Policy Changes at the High School Level from a Leadership Perspective,” were released to an audience of sports and health care professionals. The national event was held at NCAA headquarters and hosted by the National Athletic Trainers’ Association (NATA) and American Medical Society for Sports Medicine (AMSSM). The study was published online this morning in the Journal of Athletic Training, NATA’s scientific publication.
Every year, high school athletes die or are seriously injured while participating in sports. Injuries can range from acute and chronic to catastrophic. In 2015, a total of 50 fatalities were reported. The most common causes of death are cardiac conditions, head injuries, exertional heat stroke, exertional sickling and cervical spine injuries. By implementing several recommended policies, the incidence of sudden death could be reduced, especially in the high school setting.
Appropriate medical coverage, emergency action plans, automated external defibrillator (AED) availability, heat acclimatization, appropriate concussion evaluation and return-to-play guidelines are all policies to reduce the risk of sudden death in secondary school sports. Data from the National Center for Catastrophic Sport Injury Research suggests there are more fatalities and more injuries (serious and non-serious) at the high school level when compared with the collegiate setting often due to variations in medical care in secondary school sports.
“Although there are consensus statements and recommendations by professional organizations aimed at reducing incidence of injury or sudden death in high school sports, nothing is mandated at the national level,” said lead author Kelly D. Pagnotta, PhD, ATC, LAT, assistant professor, Department of Kinesiology, Temple University. One example, she said, is heat acclimatization. “Despite its efficacy in reducing sudden death related to heat stroke, very few states follow the recommended guidelines. Our study takes a retroactive look at how and why three states were able to facilitate adoption of heat guidelines, which helped to reduce injury and catastrophic outcomes,” she added. “Although the initial factors that spurred change can vary, shared leadership and communication fundamentally allowed for successful adoption of the policy.”
In 2009, NATA issued a consensus statement, Preseason Heat Acclimatization for Secondary School Athletes. In May 2011 New Jersey became the first high school athletic association in the nation to adopt the heat acclimatization policies. In Arkansas, the state legislature passed laws and the Arkansas Activity Association adopted policies in June 2012; The Georgia High School Association also passed policies in March 2012. Overall, only 14 states have policies that adhere to these guidelines: 12 more are currently working to improve their policies, while 22 states do not adhere to national recommendations and two states have no guidelines at all.
Study Design
Researchers were interested in four key questions:
- What contributed to the decision to implement the health and safety policies?
- How did the states do this successfully?
- How did they overcome any barriers?
- What resources were needed to create and implement these health and safety initiatives at the high school level?
The study design included phone interviews with representatives of high school athletic associations and other policy makers in Arkansas, Georgia and New Jersey. In addition to the interviews, data was collected through analysis of documents, websites, handbooks and other related material. By interviewing members of the high school athletic associations and medical and science advisory boards, researchers ensured multiple perspectives of the process.
Athletic trainers, members of the high school athletic association, parents and a physician participated in the study. All interviews were recorded and transcribed verbatim. Results showed that each state had a different catalyst for change (student death, empirical data or proactivity). Recommendations from national governing bodies guided the policy creation. Once the decision to implement change was made, the states had two similarities: shared leadership and open communication between medical professionals and members of the high school athletic association that helped overcome barriers.
Catalysts for Change
In Arkansas, the triggers for change were the death of a high school athlete from exertional heat stroke (EHS) and three other cases of EHS in teenagers who were treated in the same hospital during that same time. Two of those athletes survived but suffered kidney failure. These events drew national media exposure and parents’ requests for change so that this wouldn’t happen to other students.
In Georgia, sudden death initially appeared to be a major motivator for change, as was data collected on heat illness. Two athletes passed away from EHS during the summer of 2011, just prior to implementation of new guidelines. At the same time, a three-year study examining heat illness in the high school setting was being conducted and became a major catalyst for policy change and implementation. Participants said the desire to create new policies actually began two years prior to the deaths.
New Jersey was much more proactive and was the first state to implement policy. While there were no documented deaths, participants said they wanted to be proactive and create a policy to protect the student athlete. There was also concern about litigation as national policies were now public, but the state did not have policies that matched those being recommended on the national level.
“While the catalyst for change was different in each state, protecting the student athlete was the overarching reason these states chose to implement heat acclimatization polices,” said Pagnotta.
Policy Selection
Each state had access to and utilized recommended guidelines including those of NATA, the American College of Sports Medicine, National Federation of State High School Associations, NCAA and the Korey Stringer Institute. The sports medicine advisory committees presented policies to other members of the high school athletic association.
Georgia was unique in that it had data from research studies that shaped its modifications, including the use of a heat index or wet-bulb globe temperature modification. Participants noted that when the national federation adopts a policy, they can change their policy to match that.
Change Process
nce decisions to implement change were made, there was agreement to appropriate adoption of policies. States then worked together regarding challenges with barriers, shared authority, communication and leadership. In some cases, it was resistance from coaches and the time they needed to adapt to new guidelines. While some coaches were already on high school athletic association committees, this could have had serious impact but was reduced as the groups worked together to ensure clear communication; to address immediately and openly any questions and to ensure a clear line of leadership and shared authority.
“Putting the right people in the right roles was a critical part of the process,” says Pagnotta. “Our research showed that by identifying the right experts and leaders from different professions and organizations to discuss, design and implement policies – each state benefited from an integrated approach to problem solving and to ultimately implementing policies. Incorporating the needs of all stakeholders and sharing leadership responsibilities with those who previously may not have had those roles, resulted in a collaborative group effort and positive outcomes.”
Open Communication and Leadership
Participants in the study talked about the importance of maintaining open communication among all stakeholders during the change process. In Georgia, when data from its three-year study was presented, the executive board of the high school association attended to ensure all understood results. In New Jersey, identifying a figurehead to promote communication was effective in prompting change and directing contact with coaches or others in the group having questions. Other states including Texas, North Carolina, Florida and Arizona also updated their policies around the same time as Georgia and Arkansas. There were no concerns with neighboring states’ decisions but more of a collective approach to change state by state.
“Participants shared the process of creating policy between medical professionals, coaches and administrators which reduced resistance. This adaptive leadership style is indicative of a transformational leadership style – helping a group to work collectively toward a common goal,” says Pagnotta.
Together, parents, coaches, athletic trainers and others involved in high school state associations must recognize the need to protect the student athlete by implementing appropriate and recommended policies, according to the study authors. Media can influence change, and changes made at the professional level, including the NFL and its significant concussion policy changes, can have a direct and trickle-down impact on college and high school sports, according to the researchers.
Sports medicine professionals who want to initiate change must involve coaches and administrators and foster a working professional relationship. Although they may have an idea of what they want to change, it is the coaches and administrators who help to move this forward. Additionally, administrators must involve the sports medicine professionals to ensure sound, evidence-based policies. This promotes a collaborative and open channel of communication and transformational leadership and can lead to changes in policies with the student athlete’s best interest at the forefront.
The need for a governing body at the secondary school level is apparent due to the level of autonomy allowed in each state. Additionally, because of challenges working in this setting, especially in the areas of budget, medical coverage and competitiveness, the authors suggest establishing policies that are appropriate for each school. They also suggest that participants rely on these guidelines and policies to know when to take action in a particular situation. States developing policies should look to existing guidelines not only as great resources but also to add legitimacy to the state organization.
For additional resource information please visit:
Preseason Heat-Acclimatization Guidelines for Secondary School Athletics (pdf)