Although all states have legislation pertaining to youth sports concussion, most of these laws focus on return-to-play procedures; only a few address return-to-learn (RTL) accommodations for students who have experienced a concussion. To address this gap in the legislation, some states and nongovernmental organizations have developed RTL guidelines to advise school personnel, parents, and health care providers on best practices for accommodating students’ postconcussion reintegration into academic activity. In 2018, the Massachusetts Department of Public Health (MDPH) developed RTL guidelines which were disseminated to school nurses (SNs) at all public and nonpublic middle and high schools in the state. In 2020, the MDPH engaged the Injury Prevention Center at Boston Medical Center to survey Massachusetts SNs to assess the usefulness of the guidelines. The response rate was 63%; 92% found the booklet extremely useful or moderately useful; and 70% endorsed that the booklet fostered collaboration among stakeholders.
mild traumatic brain injury, concussion, school nursing, return to school, policy, traumatic brain injury, return to learn
Traumatic brain injury (TBI) results from a bump, blow, or jolt to the head that affects brain function (Peterson et al., 2014). In 2014, there were 837,000 TBI-related emergency department visits, hospitalizations, and deaths among children aged 17 years and younger in the United States (Peterson et al., 2014). Of these, 23,000 children were hospitalized and 2,529 died because of TBI alone, or in conjunction with other injuries (Peterson et al., 2014).
Most TBIs among children are mild (mTBI) and are commonly referred to as concussion. Most children with concussion recover within 7–10 days (Eisenberg et al., 2014). Nonetheless, concussion can result in serious symptoms that can affect a young person’s physical and mental status, with implications for performance of daily activities, including academics (Eisenberg et al., 2014; Halstead et al., 2013; Ransom et al., 2015; Yeates, 2010; Yeates et al., 1999). Postconcussion outcomes in children and adolescents include a range of somatic (e.g., headache and fatigue) (Taylor et al., 2010), cognitive (e.g., attention deficits, forgetfulness, and slowed processing), (Kriz et al., 2017; Sroufe et al., 2010), and affective (e.g., irritability and disinhibition) symptoms (Sady et al., 2014; Yeates et al., 1999). Learning new material or remembering previously learned material can pose challenges to students in the classroom postconcussion (Halstead et al., 2013). School environment (e.g., bright lights, computer slides, between class crowded hallways, and noisy cafeterias) can trigger or aggravate postconcussion symptoms (Halstead et al., 2013). In a study that followed 349 children and adolescents (5–18 years) with concussion, actively symptomatic students reported significantly more school-related problems than recovered peers, and greater severity of postconcussion symptoms was associated with significantly more school-related problems and significantly worse academic performance, regardless of time since injury (Ransom et al., 2015).
While acknowledging the lack of efficacy research on postconcussion intervention strategies for youth, a clinical report by the American Academy of Pediatrics (Council on Sports Medicine and Fitness and Council on School Health) affirmed the need for accommodations for students returning to school after concussion (Halstead et al., 2013). This report stated that adequate cognitive rest may help minimize worsening of symptoms and potentially facilitate quicker recovery without significant disruption of students’ lives (Halstead et al., 2013).
All 50 states currently have legislations to improve the prevention, recognition, and management of youth sports concussion, including requirements for postconcussion return-to-play (RTP) protocols. A 2016 review of these laws found that only eight of 50 state laws included provisions for return to learn (RTL). Most of these eight state laws targeted student athletes and did not necessarily mandate RTL procedures for students who acquired concussion as a result of non-sport activities, such as traffic crashes or assaults (Thompson et al., 2016), even though between 30% (Haarbauer-Krupa et al., 2018) and 70% (Hanson et al., 2019; Meehan & Mannix, 2010; Newton et al., 2020) of youth concussions do not occur during sports activities.
Whether youth sports concussion laws should be extended to include provisions for RTL is controversial, with some advocating for expanding the existing laws (Howland et al., 2021) and others arguing that such expansion is not necessary (Halstead et al., 2016). In the absence of legislative mandates for RTL procedures, some schools have, by policy or the initiative of school personnel, provided protocols for their concussed students returning to school. These protocols may take the form of “academic adjustments,” “academic accommodations,” and “academic modifications.” “Academic adjustments” refer to nonformalized environmental adjustments that do not involve classroom work (e.g., reduced exposure to light and sound stimuli). “Academic accommodations” include extra time for assignments and changes to class and exam schedules. “Academic modifications” involve more permanent changes to an educational plan, which are formalized in an Individualized Education Plan (IEP), pursuant to the Federal Individuals with Disabilities Education Act or a 504 Plan, pursuant to the Federal Rehabilitation Act and the Americans with Disabilities Act (Halstead et al., 2013). Academic adjustments written into RTL plans are best overseen and directed by school professionals with dedicated expertise and knowledge of educational law, policy, and curriculum, guiding a collaborative RTL process among the members of the concussion management team (McAvoy et al., 2020). A 2015 study of RTL procedures in public schools in Washington State (which does not provide for RTL in its youth sports concussion legislation) found that only 12% of schools reported a formal RTL policy; 67% had informal policies; and 30% of teachers reported receiving no formal concussion training, although approximately half reported having had a child with concussion in their class at some point (Lyons et al., 2017).
In 2010, Massachusetts passed Chapter 166, An Act Relative to Safety Regulations for School Athletic Programs. A year later, the Massachusetts Department of Public Health (MDPH) issued regulations pursuant to this law. These regulations specify the roles of various stakeholders, including school nurses (SNs), athletic directors (ADs), athletic trainers (ATs), coaches, parents, students, and health care providers in responding to concussion among students that participate in extracurricular sports. The regulations apply to all Massachusetts public middle and high schools serving grades six through high school graduation that have an extracurricular sports program, and any nonpublic schools that are members of the Massachusetts Interscholastic Athletic Association (MIAA).
The Massachusetts law, however, did not address RTL procedures for students with concussion. To address this gap in the law and to enhance consistency in concussion management across Massachusetts schools, the MDPH Injury Prevention and Control Program (IPCP) developed a booklet in 2018 that provides guidelines for schools on postconcussion RTL procedures (Massachusetts Department of Public Health, 2018). The booklet was develop following meetings with SNs, ATs, and medical experts who saw the need for more guidance to teachers and school administrators relative to supporting students returning to school after concussion. IPCP staff also worked with the Concussion Legacy Foundation which surveyed middle and high school teachers about their needs for instructional tools for students with mTBI. This booklet was widely distributed to public and nonpublic schools throughout the state. In 2020, the IPCP engaged the Injury Prevention Center at Boston Medical Center (IPC) to survey Massachusetts SNs to evaluate the application and usefulness of the booklet. The purpose of this study was to examine SNs’ attitudes and beliefs about the usefulness of this booklet and its component parts. Other public and private organizations have developed RTL guidelines; the present study is, to the best of our knowledge, the first to evaluate RTL guidelines from the perspective of SNs.
The 28-page booklet, Returning to School After Concussion, Guidelines for Massachusetts Schools (available online at www.mass.gov/sportsconcussion) was developed by the MDPH IPCP. The aim of the guidelines was to assist school staff in supporting students’ reintegration into the classroom (i.e., returning to learn) following mTBI. The booklet is divided into four sections: (a) graduated reentry plans: why they are important, how to develop plans, and staffing; (b) guidelines for recovery accommodations based on concussion symptoms; (c) sample tools and letter templates for informing caregivers and teachers about students’ concussions; and (d) resources for further information on concussion prevention and policies, and statewide concussion rehabilitation services.
In July 2018, the booklet was mailed to all Massachusetts middle and high school (public and nonpublic) principals and SNs serving grades 6–12, and included a cover letter written by the Director of the MDPH IPCP. This letter requested that the booklet be distributed to teachers, guidance counselors, and SNs, and provided a link by which the booklet could also be downloaded electronically.
The survey instrument for this cross-sectional evaluation was developed through an iterative process with input from IPC investigators, IPCP staff, the Director of the Boston Medical Center Pediatric Concussion Program, and the Chair of Emergency Medicine/Chief of Emergency Medicine at Boston University School of Medicine and Boston Medical Center. Twelve survey questions were developed on characteristics of respondents, characteristics of the schools (public or nonpublic), SN exposure to the booklet (receipt and reading), usefulness of the booklet, sharing of the booklet, and the impact of the booklet on stakeholder collaboration.
The survey was designed such that if a respondent indicated that they had not received the booklet they were not asked subsequent questions and were instead directed to information on how to obtain it (either in hard- or electronic-copy format). The questionnaire was pretested with six SNs who took the survey and provided feedback to the MDPH staff and IPC investigators.
The survey was conducted using Qualtrics survey software, licensed to Boston Medical Center. All sampled SNs received an email from the Director of IPCP that introduced the survey and contained a link to the questionnaire. Over a period of several months, six follow-up email response reminders from the IPCP Director were sent to SNs who had not responded to the survey.
There are 859 public and nonpublic schools that provide elementary, middle, and high school education in Massachusetts that received the booklet. We selected a 30% sample (N = 257) using the EXCEL RANDOM function. One selected school was eliminated because it had been closed and another was eliminated because it was online, and therefore, did not have a SN. Of the 255 remaining schools, 17 email addresses for the SN could not be found. Nineteen emails bounced back as undeliverable, resulting in a final sample size of (N = 219).
Data analyses were performed by IPC staff using Qualtrics, Microsoft EXCEL, and SAS 9.4. The alpha used for hypothesis testing was 0.05.
This study was reviewed by the Institutional Review Boards at the Boston University Medical Center and the MDPH.
Of the 219 SNs in our sample, 138 completed or partially completed the survey, for a response rate of 63% (138/219).
Ninety-six percent (133/138) of respondents answered the question regarding their employment category. Of these, 98.5% (131/133) indicated that they were SNs and 1.5% (2/133) indicated that they were ATs. Ninety-six percent (133/138) of respondents answered the question relative to the type of school (public or nonpublic) at which they were employed. Of these, 94% (125/133) indicated that they were employed at a public school and 6% (8/133) indicated that they were employed at a nonpublic school.
Ninety-six percent (132/138) of respondents answered the question about having received the booklet when it was originally distributed by the MDPH. Of these, 81% (107/132) affirmed that they had received the booklet and 19% (25/132) indicated that they had not received the booklet. Respondents who reported that they did not receive the booklet were informed that they had completed the survey and were referred to an address where they could access the booklet in electronic or hard copy form. Public school respondents were not significantly more likely than nonpublic school respondents to have received the survey (81% vs. 75%; χ2 = 0.204, p = .65).
Of those who indicated that they had received the booklet (N = 107), 73% (78/107) answered the question about the extent to which they had read the booklet. Of these, 59% (46/78) indicated that they had read the entire booklet and 41% (32/78) indicated that they had read only part of the booklet. None of these respondents indicated that they had not read any part of the booklet.
Seventy-three percent (78/107) of respondents that indicated that they had received the booklet answered the question about the booklet’s usefulness. The mean usefulness rating, on a scale of 1–5, where 1 indicated extremely useful and 5 indicated not at all useful, was 1.73. Of these 78 respondents, 40% (31/78) found the booklet extremely useful; 53% (41/78) found it moderately useful; 3% (2/78) found it neither useful nor useless; and 5% (4/78) found it slightly useful. None of the respondents found the booklet not at all useful (Figure 1).
We examined the relationship between overall usefulness and reading the booklet, and found that the mean usefulness rating of respondents who read the entire booklet was not significantly different than the mean usefulness rating of respondents who only read some of the booklet (1.65 vs. 1.84; t = −1.11; p = .27).
Mean scores for usefulness of each component on a 1–5 scale, where 1 indicated extremely useful and 5 indicated not at all useful, are shown in Figure 2. All of the mean scores were below 2.0, with concussion identification having the best mean usefulness score at 1.57 and sample letters having the lowest mean usefulness score at 1.96.
Identifying Concussion. Seventy-two percent (77/107) of respondents that indicated that they had received the booklet answered the question about the booklet’s usefulness for identifying concussion. The mean usefulness rating for identifying concussion was 1.57 on a scale of 1–5, where 1 indicated extremely useful and 5 indicated not at all useful. Of these 77 respondents, 55% (42/77) found the booklet to be extremely useful; 38% (29/77) moderately useful; 5% (4/77) neither useful nor useless; 1% (1/77) slightly useful; and 1% (1/77) found the booklet to be not at all useful for identifying concussion.
Writing and Coordinating the Graduated Reentry Plan. Seventy-one percent (76/107) of respondents that indicated that they had received the booklet answered the question about the booklet’s usefulness for writing and coordinating a graduated reentry plan. The mean usefulness rating for writing and coordinating the graduated reentry plan was 1.82, on a scale of 1–5, where 1 indicated extremely useful and 5 indicated not at all useful. Of these 76 respondents, 40% (30/76) found the booklet to be extremely useful; 47% (36/76) moderately useful; 7% (5/76) neither useful nor useless; 5% (4/76) slightly useful; and 1% (1/76) not at all useful.
Managing RTL. Seventy percent (75/107) of respondents that indicated that they had received the booklet answered the question about the booklet’s usefulness for managing return to learn. The mean usefulness rating for managing RTL was 1.76, on a scale of 1–5, where 1 indicated extremely useful and 5 indicated not at all useful. Of these 75 respondents, 39% (29/75) found the booklet to be extremely useful; 51% (38/75) moderately useful; 7% (5/75) neither useful nor useless; and 4% (3/75) slightly useful. None of the respondents found the booklet to be not at all useful for managing return to learn.
Accommodation for Postconcussion Effects. Seventy-one percent (76/107) of respondents that indicated that they had received the booklet answered the question about the booklet’s usefulness for accommodations for post-concussion effects. The mean usefulness rating for accommodation for postconcussion effects was 1.68, on a scale of 1–5, where 1 indicated extremely useful and 5 indicated not at all useful. Of these 76 respondents, 45% (34/76) found the booklet to be extremely useful; 46% (35/76) moderately useful; 5% (4/76) neither useful nor useless; and 4% (3/76) slightly useful. None of the respondents found the booklet to be not at all useful for accommodation of postconcussion effects.
Academic Recovery Guidelines. Seventy percent (75/107) of respondents that indicated that they had received the booklet answered the question about the booklet’s usefulness for academic recovery guidelines. The mean usefulness rating for academic recovery guidelines was 1.80, on a scale of 1–5, where 1 indicated extremely useful and 5 indicated not at all useful. Of these 75 respondents, 39% (29/75) found the booklet to be extremely useful; 48% (36/75) moderately useful; 8% (6/75) neither useful nor useless; and 5% (4/75) slightly useful. None of the respondents found the booklet to be not at all useful for academic recovery guidelines.
Sample Letters. Seventy-one percent (76/107) of respondents that indicated that they had received the booklet answered the question about usefulness of the booklet’s sample letters. The mean usefulness rating for sample letters was 1.96, on a scale of 1–5, where 1 indicated extremely useful and 5 indicated not at all useful. Of these 76 respondents, 34% (26/76) found the booklet to be extremely useful; 47% (36/76) moderately useful; 11% (8/76) neither useful nor useless; 4% (3/76) slightly useful; and 4% (3/76) found the sample letters to be not at all useful.
Postconcussion Symptom Tools. Seventy percent (75/107) of respondents that indicated that they had received the booklet answered the question about usefulness of the booklet’s postconcussion symptom tools. The mean usefulness rating for postconcussion symptom tools was 1.77, on a scale of 1–5, where 1 indicated extremely useful and 5 indicated not at all useful. Of the 75 respondents, 40% (30/75) found the booklet to be extremely useful; 51% (38/75) moderately useful; 4% (3/75) neither useful nor useless; 3% (2/75) slightly useful; and 3% (2/75) found the booklet’s postconcussion symptom tool to be not at all useful.
Respondents were asked: If you felt that certain components of the booklet were not useful, please explain why. Selected responses are listed below:
(1) I have a whole list, if space is limited and I get cut off. First, why [is it that the] point person would be a guidance person? [It] should be a nurse since we are dealing with a medical condition. So, I would change all the discussion on reentry and put the nurse as the point person. Second, add caretaker to step 1, page 11 to key individuals informing the staff. Third, you did not mention until page 11 how you learned of the concussion, I would move page 11 up to page 6 and then move 6 to page 7 and follow with the rest in same order…Sample letter to the caregivers, is that supposed to be a check off letter individualized per student or do you assume the student will have all of those things going on?
(2) Concussion can be very subjective. It is difficult to place every child in a box.
(3) Over the last 10 years of working in a middle school, this booklet is rarely used (although I have shared with many families)—doctors write their own plans and do not refer to schools for guidance.
(4) Good for review but already knew the information.
(5) Return to Learn flow chart, while helpful, is not realistic. We do not have any access to share assessments w/ student’s physician. The nurse informs teachers of physical restrictions but there should be another arrow indicating guidance counselor to manage academic/social-emotional care.
(6) It gives guidelines to support our plans/protocols.
(7) For many school nurses, from what I understand, the weak link is the PCPs or other clinician from outside the school who is managing the return. I don’t see myself as qualified or authorized to assess what the restrictions are for a child. We follow the instructions that come from the outside caregiver. Those are inconsistent and sometimes very obviously off the mark. In those cases, I really try to give feedback to parents and the kids if they’re older. But it’s not like the authority I have to exclude a child with fever, for example. The problem is that we don’t have a responsive pipeline on the outside applying clear criteria and providing detailed guidance. Kids often return to school and then finally see a clinician a few days later and then we get a restriction notice. That’ doesn’t make any sense.
(8) Letters to families need to be available in Spanish.
(9) I find the MD that diagnoses the student sends their own protocol and therefore we as nurses are not involved in the initial plan.
Respondents were asked to identify all the stakeholders with whom they had shared the booklet. There were 209 responses to this question. Of these, 17% (35/209) indicated that they had shared the booklet with parents of students at their school; 13% (28/209) with students at their school; 16% (33/209) with guidance counselors at their school; 12% (26/209) with administrative staff at their school; 12% (25/209) with coaches at their school; 7% (15/209) with ATs at their school; 11% (24/209) with ADs at their school; 1% (3/209) with students’ health care providers; and 10% (20/209) with others, including teachers, physical education staff, and other SNs (Figure 3).
Seventy-two percent (77/107) of respondents that indicated that they had received the booklet answered the question about whether the booklet facilitated collaboration among stakeholders (i.e., parents, students, guidance counselors, administrative staff, coaches, ATs, ADs, and external health care providers). Of these, 70% (54/77) answered yes; 8% (6/77) answered no; and 22% (17/77) answered not sure.
Respondents were asked, “is there anything regarding the return-to-learn guidelines for students with concussions that you believe was not covered in the booklet?” Selected responses are reported below:
(1) The biggest challenge we face with students returning after concussion is that the school (nurses, athletics, teachers, guidance, administration) [are] all on the same page but the students and families do not follow self-care/restrictions outside the school day so the recovery is delayed significantly. Emphasis to families about the importance of concussion recovery care at home/outside of school is crucial.
(2) Dealing with the anxiety of being away from a regular work then beginning that again.
(3) The topics are covered well, but the fact is … all guidance for how and when a child returns to school comes from their PCPs. This booklet has always been a nice complimentary piece to what doctors give families.
(4) This is a useful tool. The difficulty lies in the implementation and getting consistency and follow through with all invested parties. Each case is so individual, and it takes a lot of consistent follow up. It is helpful to have guidelines.
(5) Need more complete directives from physicians who see students with concussion symptoms and better follow up from parents and students.
(6) The issues are more with local PCPs using these guidelines in the community.
Most state youth sports concussion legislations, including that of Massachusetts, focuses on RTP (i.e., return to play [sports]) protocols and only a few state laws specify provisions for RTL (Thompson et al., 2016). While some of these laws may have evolved with regard to RTL, our previous research on the Massachusetts law indicates that primary care physicians and school counselors are not always familiar with mandated procedures and/or the literature on best practices for postconcussion school reintegration (Howland et al., 2018; 2020; O’Hara et al., 2020).
If effectively and widely disseminated, a booklet such as the one assessed herein has a substantial potential value, statewide and nationally, for filling gaps in youth concussion legislation and enhancing consensus and consistency to stakeholder management of student concussion. It is evident from the results of the present survey that the booklet achieved its core aims of providing SNs, and other school personnel, with useful guidelines for managing students’ postconcussion RTL. Respondents found the booklet useful as indicated by scores on the overall usefulness scale, and on scales assessing individual components of the booklet. Many respondents indicated that they shared the booklet with other stakeholders. Additionally, most respondents indicated that the booklet facilitated collaboration with other stakeholders.
The impact of the booklet, however, depends on exposure to its content. Our results indicate that 19% of respondents did not receive the booklet because of both difficulty maintaining an accurate SN contact list and potential turnover in Massachusetts. It is possible that some respondents were not employed at their current school when the booklet was mailed. It is also possible that some of the booklets were forward to ADs and ATs at the schools, instead of to SNs. We recommend that a dissemination plan be developed by the MDPH to ensure that all stakeholders, including nonschool-based parents and primary care physicians, are aware of the booklet and can easily access its content.
It is noteworthy that of the 15 open-ended responses, half referenced disconnect between SNs and students’ physicians relative to postconcussion management. This finding is consistent with findings from our previous studies evaluating the implementation of the Massachusetts youth sports concussion law (Howland et al., 2018; 2020; O’Hara et al., 2020).
It is also interesting that only 70% of respondents affirmed that the guidelines booklet was useful for facilitating collaboration across stakeholders. A primary purpose of the guidelines was to inform not only SNs, but also students, their parents, other caregivers, and other school personnel about return to school procedures. Twenty-two percent of respondents indicated that they were not sure whether this purpose was fulfilled. Further research, such as focus groups, might be useful for understanding the perceived strengths and weaknesses of the booklet.
There are several issues that may compromise the validity of findings. First, despite aggressive follow-up, the overall response rate was 63%; thus, findings may not be representative of all SNs in the state. Second, of those who did respond, only 70%–73% answered many of the questions. Both issues may be attributable to the fact that the much of the survey follow-up period overlapped with the COVID-19 pandemic which closed the schools and disrupted the routines of SNs. Third, we did not collect data on why some SNs did not read the whole booklet, but we suspect that some may have skipped sections about which they were knowledgeable and focused on sections containing information with which they were less familiar.
Regardless of the mandates of any given state’s legislation on youth sports concussion, SNs play a critical role in managing students’ post-mTBI school reentry. SNs are often the most informed school personnel about best practices in concussion care, and therefore, frequently serve as the concussed students’ advocate for RTS accommodations. A concise document, such as the booklet evaluated herein, that can be understood by nonmedical stakeholders, can be a valuable tool for SNs in building consensus and collaboration when managing students’ postconcussion school reintegration.
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
This research was made possible through funding from the Massachusetts Department of Public Health through CDC grant NU17CE924835. The thoughts and opinions in this report do not necessarily reflect the opinions of the Massachusetts Department of Public Health.
Julia Campbell https://orcid.org/0000-0002-2674-1830
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1 Department of Emergency Medicine, Boston Medical Center, Boston, MA, USA
2 Department of Emergency Medicine, Boston University School of Medicine, Boston, MA, USA
3 Injury Prevention Center, Boston Medical Center, Boston, MA, USA
4 Massachusetts Department of Public Health, Boston, MA, USA
5 Departments of Pediatrics and Neurology, Boston Medical Center, Boston, MA, USA
Corresponding Author:Jonathan Howland, PhD, MPH, Department of Emergency Medicine, Boston Medical Center, 800 Harrison Ave., BCD Building, 2nd floor, Boston, MA 02118, USA.Email: jhowl@bu.edu
