The Journal of School Nursing2024, Vol. 40(6) 675–687© The Author(s) 2023Article reuse guidelines:sagepub.com/journals-permissionsDOI: 10.1177/10598405231160249journals.sagepub.com/home/jsn
Abstract
Evidence-based practices in concussion management (CM) have been codified into legislation. However, legislation is varied, and implementation is narrowly evaluated. School nurses hold a unique position to assess the implementation of health policies. The implementation of concussion management policies across Massachusetts high schools was evaluated by the school nurse. A cross-sectional survey was sent to school nurses (N = 304), and responses (n = 201; 68.1% response rate) were tallied whereby higher scores indicated more practices being implemented. One open-text question was included to encourage nurses to provide context regarding implementation in their school. Descriptive statistics and thematic analysis were used to assess current implementation and nursing perspectives. Findings indicate that the degree of implementation varies, and some nurses reported difficulty with mobilizing clinical uptake of concussion management practices in their schools. Further implementation research is needed, and school nurses are an important stakeholder to include when assessing the clinical uptake of concussion management policies in schools.
Keywordsconcussion policy, implementation science, pediatric concussion, youth sport, school nurses
Each year, an estimated 1.5–3.0 million concussions in youth under the age of 19 are reported (Bryan et al., 2016). In a study of youth student–athletes (grades 8–12) in the United States, approximately 20% reported experiencing a concussion in their lifetime, a rate twice that of non-athlete youth peers (Veliz et al., 2017). Concussions can result in both short-term symptomatology and long-term sequelae that can impact functioning across several life domains including decrements in sport performance, peer relationships, sleep changes, increased mental health challenges, and decreased academic engagement (Ellis et al., 2015; Iadevaia et al., 2015; McCrea et al., 2013; McCrory et al., 2017; Purcell et al., 2016; Russell et al., 2016; Stazyk et al., 2017). Moreover, concussion symptoms are diverse, and idiosyncratic, may be impacted by pre-morbid conditions, and can be difficult to alleviate (Dillard et al., 2017). Substantial research efforts have been devoted to concussion prevention and identification of injury (Caron et al., 2015; Caron et al., 2018; Hunt et al., 2016), symptom management and treatment (Leddy et al., 2018; McLeod et al., 2017), and to the development of processes for optimally returning young people back to functioning (DeMatteo, Stazyk, Giglia et al., 2015; DeMatteo, Stazyk, Singh et al., 2015; Gioia, 2016; Kirelik & McAvoy, 2016).
Some of the established best practices in concussion management have now been codified into state law, with all 50 states and the District of Columbia having established some form of concussion management legislation (Thompson et al., 2016). However, these laws differ across states and their implementation is not well understood. Early research on the implementation of concussion management indicates high levels of variability both across and within states (Glang et al., 2008; Halstead et al., 2016; Heyer et al., 2015; Lyons et al., 2017; Simon & Mitchell, 2016; Thompson et al., 2016). The potential challenge of translating policy and research to practice has been emphasized in recent years as an important area of study, as implementation research indicates uptake of best practices and clinical advancements is severely lacking (Bauer & Kirchner, 2020). Within the state of Massachusetts specifically, concussion management mandates for student–athletes have existed for public and private schools that are part of the Massachusetts Interscholastic Athletic Association (MIAA) since 2010. This initial legislation authorized the Massachusetts Department of Public Health to improve concussion management for student–athletes. The law was followed by the promulgation of regulations in 2011 detailing specific requirements for schools. Despite these progressive and iterative efforts to improve concussion management in Massachusetts high schools, the translation of these regulations into practice remains largely unassessed.
Implementation science emerged out of the need to improve the uptake of clinical advancements, extending beyond efficacy and effectiveness trials (Bauer & Kirchner, 2020). Within a formal implementation study, researchers evaluate the contextual barriers and potential facilitators to clinical uptake and evaluation can be conducted at the individual patient and provider level as well as up through the organizational and policy level. Examining implementation is essential for closing the theory-to-practice gap yet is largely absent within youth concussion management. Moreover, within schools, variability and systematic disparities in implementation have been observed previously in other school-based policies at the state, district, school, and even student levels (Shifrer et al., 2011; Skiba et al., 2014; Skiba et al., 2011; Skiba et al., 2005; Sullivan & Bal, 2013; Sullivan et al., 2013) further prompting evaluation of the implementation of concussion management practices. This study was the first to assess the implementation of concussion management practices in Massachusetts high schools. Massachusetts was specifically selected for the current study given established academic-public health department partnerships alongside the well-established and specific concussion management policies, thus creating an optimal environment to examine the translation of established policy into practice.
The current study evaluated implementation from the perspective of a single stakeholder, present in each high school in Massachusetts—the school nurse. The school nurse was selected for the current study given their position at the intersection between healthcare, sport, and academics as well as their role as an advocate for student health and safety. In previous research by our group (Campbell et al., 2020; Hackman et al., 2020; Howland et al., 2018), collaboration with school nurses has offered unfettered, on the ground, perspectives of the day-to-day practices in schools, and the partnership has been critical to evaluating the translation of public health policy to school practices. Within public health policy in Massachusetts specifically, nurses provide the most direct link between the state’s Department of Public Health and school practices. School nurses are an extremely valuable stakeholder within Massachusetts high schools to improve clinical uptake through the identification of barriers and facilitators to implementation.
The purpose of this study was to describe the implementation of concussion management practices in Massachusetts high schools from the perspective of the school nurse. Survey responses alongside qualitative nurse responses will be presented, which offer nursing perspectives on the clinical uptake efforts in their school.
To carry out these aims, a cross-sectional survey study design was employed. Data were collected from school nurses via self-report surveys. School nurses are mandated in all Massachusetts high schools.
Surveys were sent to a single school nurse employed in each eligible high school in Massachusetts. School nurses were included if they were employed at least part-time at a public school that had a student population > 100 students. This sample frame was selected because private schools and special purpose public schools with less than 100 students often operate differently (e.g., different legislative requirements, no extracurricular sport) than other public schools and are likely to have dissimilar barriers to policy implementation.
Following IRB approval from the University of Massachusetts Boston (IRB Protocol Number: 2019146) and the Boston University Medical Campus (IRB Protocol Number: H-38653), eligible schools were identified using the Massachusetts Department of Early and Secondary Education’s website (https://profiles.doe.mass. edu/). There were 344 public high schools with > 100 students. The Boston Public School District was not included (n = 33) due to regulatory barriers and delayed approvals, which were impacted by the COVID-19 pandemic (i.e., unanticipated Institutional and Scientific Review Board requirements specific to the Boston public schools and in addition to the full project’s IRB),andn=6identified schools were no longer in operation at the time of data collection. Therefore, N = 304 public high schools were included in the contact list (see Figure 1). The nurse in each school was identified through collaboration with regional school nurse consultants, who support the nurses in their region and are a liaison between the nurses and the Massachusetts Department of Public Health The state of Massachusetts has six distinct regions (West, Southeast, MetroWest, Boston, Central, Northeast). Through collaboration with all 6 regional school nurse consultants, a nurse stakeholder was identified in each school. When nurse leaders did not have direct contact information for a school nurse, schools were contacted individually to request the email address of their primary school nurse.
In January 2020, surveys were then sent to the 304 identified school nurses via email. The emails were forwarded to each nurse individually by their regional nurse consultant. The email included the full consent document and overview of the study, as well as a link to the Qualtrics survey. Consent to participate was obtained through selfselection into the study through clicking the link at the end of the email. Three additional email notices were sent as follow-up reminders to complete the survey in February and March 2020. Nurses were asked to ignore subsequent emails if they had completed the survey previously and duplicate surveys were removed from the sample. Initial emails were sent in January 2020 and data collection ended in April 2020.
Nurse demographic questionnaire. A brief screening questionnaire was included at the start of the survey to verify that the nurse worked in a public school and that the school had an extracurricular sports program. Additional questions assessed the type of school in which they were employed (charter vs traditional public), their school’s involvement in the Massachusetts Interscholastic Athletic Association (MIAA), employment practices in the school (number of full-time nurses and athletic trainers), and the years of experience the nurse had in their current school.
Concussion management implementation survey. In collaboration with colleagues at the Boston Medical Center Injury Prevention Center, the lead author developed a survey that assessed school concussion practice implementation. Concussion management practices included three distinct categories: (1) neurocognitive baseline testing, (2) mandated practices from Massachusetts youth concussion legislation, and (3) interdisciplinary care practices. The first category (i.e., baseline neurocognitive testing) was comprised of four questions that asked nurses about neuropsychological baseline testing in their school. Questions were asked about the mechanism of testing (onsite or online) and which students were tested (all students, students engaged in extracurricular sports). Category 2 (i.e., mandated practices) questions prompted the nurses with the stem “please indicate to the best of your knowledge which of the following practices were consistently (> 90% of the time) implemented in your school for students who incurred head injuries while involved in extracurricular, interscholastic sports including cheerleading and marching band.” Practices included the explicitly required school policy components listed in the Massachusetts regulations (105 CMR 2001.000: Head Injuries and Concussions in Extracurricular Athletic Activities, 2014) promulgated by the Massachusetts Department of Public Health pursuant to the Massachusetts law (M.G.L. c. 111, § 222). Section two of the survey consisted of 25 items that represent the mandated components in Massachusetts. Nurses were asked to respond “yes,” “no,” or “unsure” to each practice. The final category (i.e., use of an interdisciplinary team) started with a single question—“during the 2018/2019 academic year, did your school have a collaborative forum that included multiple school stakeholders, and which facilitated collaboration and communication for managing injury prevention, identification, and return-to-activity?” (i.e., employment of a concussion team). If nurses responded “yes” they were asked to identify which stakeholders were involved in a team and asked to provide a rating between 1 and 10 that represented the level of coordination between the team members (1 = no coordination, 10 = complete integration and collaboration).
Describe Current Concussion Management Practices. To begin data analysis, tallied scores were created for each category resulting in a baseline testing score (max score 8; range 0–8), mandated practice score (max score 25; range 0–25), and collaboration score (max score 22; range 0–22). Prior to tallying scores, negatively worded questions were reverse scored so that a higher score represented more practices being implemented on a consistent basis. Descriptive statistics were used to measure the current implementation of concussion management practices. Specifically, the distribution of responses across mandated practices was evaluated for patterns of consistent or inconsistent implementation in schools. For each analysis, the maximum number of responses was used where construct-level data were present. Missing data were treated with mean item imputation as < 5% of data were missing (1.2%) and were thus assumed to be missing completely at random (Newman, 2014).
Evaluate Barriers and Facilitators to Implementation. To analyze the final survey question (i.e., “Is there anything else you would like to tell us about your school’s management of head injuries in students?”), a qualitative content analysis of open-text responses was conducted by the first author. Content analysis is a specific qualitative methodology that focuses on language and communication from participants for the purposes of classifying qualitative responses into meaningful categories (Hsieh & Shannon, 2005). Using an implementation science frame and through inductive analysis, themes were identified that represented the barriers and facilitators nurses experienced with policy implementation and concussion management in their schools. To identify initial codes, nurse responses to the final question were first to read and re-read and basic themes were noted for each individual response. Similar individual codes were subsequently clustered to create larger organizing themes, that represented identified barriers and facilitators shared across schools.
Of the 304 nurses who were contacted to participate in this study, 200 provided eligible survey responses, and 34 responses were removed due to missing data. As such, N = 166 schools were included in the current analyses. Nurses from all six regions of the state were represented by respondents, however, there was an underrepresentation within the Boston region because the Boston Public School District did not participate in the study. Table 1 contains the demographic data of the 166 school nurses who responded to the survey. Of the 166 eligible nurse responses, the majority (89.6%) were not working in a charter school, all had formalized extracurricular sports and almost all (91.5%) were a part of the Massachusetts Interscholastic Athletic Association (MIAA). On average, school nurses reported approximately 1.5 full-time nurses in their school and .6 full-time athletic trainers. Respondents most frequently reported between 1 and 5 years of nursing experience (40.6%), followed by greater than 10 years of experience (29.7%).
Overall, school nurses report that they and other stakeholders in their school implemented most of the mandated concussion management practices > 90% of the time, however, there was also considerable variability in nurse responses (see Figure 2). The mean implementation score across all nurses was 18.7 out of a maximum possible score of 25, indicating a mean adherence rate of 74.8% for mandated practices. The range in a number of practices implemented, however, varied considerably from 0 to 25, and 30.7% of nurses reported their school implementing less than the average number of mandated practices (≤ 17) on a regular basis. Most school nurses (88%) reported that their school implemented between 13 and 23 of the 25 practices, with only two school nurses reporting implementation of all 25 practices on a regular basis. Of note, the two nurses who reported 100% adoption of the mandated practices worked in schools with two full-time nurses and two full-time athletic trainers, representing an above average number of school nurses (M = 1.54 ± 0.76) and athletic trainers (M = 0.64 ± 0.51) employed. In examining frequencies to individual policy practices, the most implemented practice was the annual exam, reported by 161 of the 166 respondents (97%). Nurses also commonly reported that their school used a medical clearance protocol (159/166, 96%), removed student–athletes from play following a suspected concussion (157/166, 95%), and developed return-to-play plans (156/ 166, 94%). The least commonly reported practices surrounded training of non-health staff including teachers (10/ 166, 6%) and counselors (15/166, 9%). Additionally, less than half of the nurses reported that their school had developed a plan for communicating information to parents who do not speak English as their primary language (73/166; 44%). Figure 3 displays the frequency of yes responses for each policy.
Overall, for practices not mandated by Massachusetts regulations, nurses reported lower levels of adoption by their schools. Many nurses did, however, report implementing neuropsychological baseline testing (see Figure 4). Specifically, 68.9% (113/164) reported providing neuropsychological baseline testing (in-person or online) to all or some of their student–athletes, with 17.1% of nurses reporting that they offer both online and in-person testing to all student–athletes. In contrast, 31.1% (58/164) of nurses reported that they are either unsure or not conducting any neuropsychological baseline testing of any kind with their student–athletes, with 13.4% of those nurses reporting that they are unsure of the baseline testing practices in their school.
Fifty percent of the nurses confirmed having a collaborative forum or integrated concussion team, (see Figure 5) however the number of stakeholders involved in the team and the reported extent of their collaboration (i.e., intentional coordination and communication) was varied. Of those who provided a team collaboration score of 77/83, the mean rating was 7.58/ 10, with 18/77 (23.4%) rating their team at a 10/10 collaboration, and 13/77 (16.9%) reporting their integration as ≤ 5/10, with a score of 10 representing a high level of coordination and communication between team members and a score less than five indicating little communication and coordination. The stakeholders most frequently included in concussion management teams were nurses (77/80, 96.3%), athletic directors (71/80, 88.8%), athletic trainers (66/80, 82.5%), and student– athletes (62/80, 77.5%). The least commonly included stakeholders were school counselors (51/80, 63.8%), principals (44/80, 55%), teachers (49/80, 61.3%), physicians (39/80, 48.8%), and neuropsychologists (3/80, 3.75%).
Of the 166 nurses who completed the survey, n = 45 nurses voluntarily provided an optional additional narrative context with regard to the implementation of concussion management practices in their school. Results of the content analysis revealed several facilitators and barriers to implementing concussion management practices consistently in schools (see Figure 6) which highlighted the unique experiences of school nurses in their efforts to carry out this specific health policy. Although experiences varied across nurses, with some nurses reporting more facilitators and others more barriers, general organizing themes did emerge resulting in four common facilitators to implementation and five common barriers to implementation.
In discussing facilitators to implementation, many nurses expressed the usefulness of utilizing existing school infrastructure. Specifically mentioned were existing programs in place to support adolescents’ integration back into school after illnesses. Nurses also highlighted the importance of dedicating resources to the school to support policy implementation at both the administrative and governmental levels. Identified resources included time for the nurses and other staff to communicate with one another, training to learn about new policies and understand concussion better, and technology to support information sharing across school stakeholders. Additionally, nurses noted the importance of establishing a dedicated concussion team and therein highlighted factors related to team functioning such as role clarity among team members, communication, information sharing, leadership, and the importance of athlete and parent inclusion into the team. Finally, nurses discussed that implementation was more effective when guidelines and protocols were clearly delineated and agreed upon by relevant staff prior to school initiation so that all stakeholders were aware of the steps to take in response to a student–athlete concussion.
Several barriers to implementation also emerged from the open-text response data, which negatively impacted nurses’ ability to implement concussion management practices consistently in their schools. Nurses expressed difficulty collaborating with outside physicians and stakeholders (e.g., EMTs), and stated that it was often time-consuming or even seemed not possible to connect and communicate with providers who were not embedded in the school. Nurses also stated that they experienced staffing barriers such as high turnover of school staff and inadequate staffing (e.g., not having a dedicated athletic trainer). Variability and uncertainty in written protocols was commonly identified as a barrier to effective implementation. That is, nurses often described relying on outside physicians to write the return-to-activity plan for their patient (i.e., student– athlete), which would then result in high variability in plans across student–athletes as well as unclear direction for the school staff responsible for carrying out the written recommendations. Some nurses also cited limited resources as a barrier to effective policy implementation, including feeling a lack of power in their ability to make changes in their school, a lack of administrative support for policy implementation, a large school size, and limited finances to support the training of staff and collaboration efforts. Across many of the challenges, a common theme emerged which alluded to the siloed nature of healthcare, academic, and sport spheres which resulted in an increased burden on nurses to bridge the silos to optimize care for the student– athlete.
The purpose of this study was to evaluate the implementation of mandated and non-mandated concussion management practices across Massachusetts public high schools during the 2018−2019 academic year. The evaluation was conducted through the perspective of a ubiquitous stakeholder in Massachusetts high schools—the school nurse. Overall, school nurses reported high rates of implementation, particularly among practices mandated by state regulations. On average, nurses reported that 74.8% of the mandated practices were implemented in their schools on a consistent basis. Current study implementation rates were higher than previously observed in a study in Washington state wherein stakeholders (i.e., nurses, teachers, administrators, parents) expressed feeling unsure of how to carry out their state’s return to learn guideline given a lack of clear directives (Lyons et al., 2017). The clear directives offered by the 2011 regulations in Massachusetts may therefore be an important determinant of the comparably high implementation rates observed in the current study. Although still debated in the literature (Baugh et al., 2014; Buckley et al., 2017), the results of this study do lend support to the potential positive impact of legislating established best practices (Flaherty et al., 2016; Hackman et al., 2020; Howland et al., 2018; Howland et al., 2021). That is, there was a notable difference in the implementation rates between practices mandated in the state and practices discussed in the evidence base and academic consensus statements (McCrory et al., 2017) but not included in the legislation.
Even though current calls for integrated approaches to student–athlete care are published in the literature (Collins et al., 2016; Hayden et al., 2017), these recommendations have not been adopted into legislation resulting in only 50% of nurses reporting the use of a concussion team for managing student–athletes after a concussion. Implementation of baseline testing, however, occurred 68.9% of the time and while this rate is lower than the mandated practices in Massachusetts, it is still higher than previously observed rates (Lyons et al., 2017), indicating that additional outside factors may also impact non-legislated implementation practices.
To this end, in the current study, themes from nurse opentext responses did highlight several facilitators and barriers to implementation that may impact both mandated and nonmandated practices. The results of the open-text content analysis revealed that resources can either facilitate or hinder their ability to carry out concussion management. Policy implementation in other spheres of academia (school discipline, special education) highlights school economic status as a risk factor for suboptimal policy implementation (Skiba et al., 2014, 2005; Sullivan & Bal, 2013; Sullivan et al., 2013).
The specific context of Massachusetts is important in interpreting the findings, that is the mandated components evaluated in this study had been codified into the Massachusetts regulations for over a decade. Researchers have previously pointed toward time being an important factor in understanding the implementation of policies. Specifically, Yang et al. described implementation as bell-curved in nature where early adoption results in high implementation rates early in the life of a policy, followed by an implementation peak and slow decline over time (Yang et al., 2017). Given the crosssectional nature of this study, it is not possible to determine where along the bell-curve concussion policies in Massachusetts are, and so this may warrant future attention using a longitudinal design. Additionally, it is notable that in the state of Massachusetts, nurses are mandated in every high school (Massachusetts Department of Public Health, 1998). Given nurse responses regarding their role in leading and implementing concussion management practices, school nurse mandates may be an important facilitating factor in the translation of policy to practice in schools. Future research should examine implementation rates in states without mandated nurses to measure the impact of employing full-time nurses in each school building. Another facilitating factor unique to the state of Massachusetts is the employment of regional nurse consultants who are charged with supporting the translation of public health policy to daily school practices and may have played an important role in schools’ successful adoption of mandated practices.
Finally, some of the primary gaps in implementation reported by nurses appear to be related to communication and collaboration between stakeholders, including communication between academic and sport staff, healthcare and school staff, and school and families. The need for integrated teams to support student–athletes in schools and breakdown barriers between academics and sports has been called for in previous research (Hayden et al., 2017) and is highlighted again in this study. Breakdowns in communication or lack of coordination have been shown to exacerbate challenges and individual burdens associated with managing healthcare concerns (Rosen et al., 2018) and may increase vulnerabilities for student–athletes who are unable to navigate the multiple systems involved in their care. For example, many nurses responded unsure to survey items, and although an unsure response does not necessarily indicate that a practice is not occurring in their school, it does suggest that if the management practice is occurring, it is outside of the awareness of the school nurse, highlighting a disconnect between the academic, health, and athletic spheres. Future studies that explicitly examine communication and coordination among school professionals may offer important opportunities for ameliorating the burden placed on student–athletes or nurses alone to manage the return-to-sport and return-to-play processes.
This study offers important and novel information regarding the current implementation of concussion management practices in Massachusetts and emphasizes the importance of working with on-the-ground school nurses to evaluate implementation. However, there are limitations to this study. First, although all six regions of Massachusetts are represented in the current sample, the Boston region is under-represented as the Boston Public School system did not participate due to administrative barriers. Future research should be conducted to assess whether implementation within a system and school structure as robust as the Boston Public Schools might differ from the school systems presented in the current study. Another limitation of this study was the self-report nature of the survey which may have resulted in overly positive ratings of implementation due to the social desirability effect and or fear of repercussion. This study was particularly vulnerable to this concern as nurses were asked to provide the name of their school at the end of the survey. One potential area for future research that may support a more objective assessment of implementation would be to use a case study design to allow for naturalistic observation as well as multistakeholder assessment, including student–athlete and family perspectives on policy implementation. Finally, as discussed above, the state of Massachusetts is an early and progressive adopter of state legislation surrounding concussion management and therefore findings may not generalize to other states across the country that have taken different legislative approaches to the management of youth concussion (Thompson et al., 2016). Future research should replicate this study in other states or geographical regions to better concussion management practice implementation practices across the country.
The findings of this study also prompt future inquiry. The variability in implementation in the current study prompts further implementation research in concussion management to evaluate the barriers and facilitators to clinical and practice uptake at the individual, school, district, and state levels. Given that qualitative responses from nurses alluded to the role of resources as both barriers and facilitators to their ability to implement policies, evaluating the implementation through a disparities or disproportionality lens may be warranted to assess whether variability is random or systematic and related to systemic oppression (Herbers et al., 2012; Skiba et al., 2014, 2011, 2005). Future studies should adopt an implementation science lens (Bauer & Kirchner, 2020) to examine implementation practices over time, leveraging longitudinal designs to evaluate how codifying best practices into policy changes implementation behaviors over time.
Given the documented disparities in implementation across schools, future qualitative work will be useful for further illuminating the specific barriers and catalysts to implementation across schools with varied implementation. Through a qualitative lens, it is feasible to identify common barriers to effective implementation and mechanisms in place that supports implementation, both of which can be used to inform implementation in other public high schools. This study did not evaluate the impact of the disparate application of the policy on the outcomes and experiences of student–athletes, a critical area for further inquiry.
The results of the study also have implications at the policy and practice levels. To begin, the results of this study do support the utility of codifying best practices, and the need to outline clear directives and expectations when establishing health policy. There was a clear need for specificity regarding what should be done on the ground to help facilitate the implementation of established policies. Nurses reported that at times, the concussion policy language was vague and thus left specific practices to interpretation which may provide the flexibility needed to adapt to unique school contexts but may also leave nurses without actionable steps to take to facilitate adherence to policies.
The current study was the first to evaluate the implementation of concussion management practices in Massachusetts through the lens of the school nurse. Results indicate that the codification of best practices supports implementation. However, variability in implementation persists, highlighting the need for implementation science within this sphere. Collaboration and partnerships were important drivers of this research and collaborating with school nurses was critical to supporting this work and facilitating partnerships between medical, health policy, and school spheres.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Courtney W. Hess, PhD https://orcid.org/0000-0001-5207-7411
Julia K. Campbell, MPH https://orcid.org/0000-0002-2674-1830
Bauer, M. S., & Kirchner, J. (2020). Implementation science: What is it and why should I care? Psychiatry Research, 283, 112376. https://doi.org/10.1016/j.psychres.2019.04.025
Baugh, C. M., Kroshus, E., Daneshvar, D. H., Filali, N. A., Hiscox, M. J., & Glantz, L. H. (2014). Concussion management in United States college sports: Compliance with National Collegiate Athletic Association Concussion Policy and areas for improvement. The American Journal of Sports Medicine, 43(1), 47–56. https://doi.org/10.1177/0363546514553090
Bryan, M. A., Rowhani-Rahbar, A., Comstock, R. D., & Rivara, F. (2016). Sports- and recreation-related concussions in US youth. Pediatrics, 138(1), e20154635. https://doi.org/10.1542/peds.2015-4635
Buckley, T. A., Baugh, C. M., Meehan, W. P.III, & DiFabio, M. S. (2017). Concussion management plan compliance: a study of NCAA Power 5 conference schools. Orthopaedic Journal of Sports Medicine, 5(4), 2325967117702606. https://doi.org/10.1177/2325967117702
Campbell, J., Howland, J., Hess, C., Nelson, K., Stern, R. A., Torres, A., & Olshaker, J. (2020). Disparities in baseline neurocognitive testing for student concussion management in Massachusetts high schools. BMJ Open Sport & Exercise Medicine, 6(1), e000752. https://doi.org/10.1136/bmjsem-2020-000752
Caron, J. G., Bloom, G. A., Falcão, W. R., & Sweet, S. N. (2015). An examination of concussion education programmes: A scoping review methodology. Injury Prevention, 21(5), 301–308. https://doi.org/10.1136/injuryprev-2014-041479
Caron, J. G., Rathwell, S., Delaney, J. S., Johnston, K. M., Ptito, A., & Bloom, G. A. (2018). Development, implementation and assessment of a concussion education programme for high school student–athletes. Journal of Sports Sciences, 36(1), 48–55. https://doi.org/10.1080/02640414.2017.1280180
Collins, M. W., Kontos, A. P., Okonkwo, D. O., Almquist, J., Bailes, J., Barisa, M., Bazarian, J., Bloom, O. J., Brody, D. L., Cantu, R., Cardenas, J., Clugston, J., Cohen, R., Echemendia, R., Elbin, R. J., Ellenbogen, R., Fonseca, J., Gioia, G., & Guskiewicz, K., … Zafonte, R. (2016). Statements of agreement from the Targeted Evaluation and Active Management (TEAM) approaches to treating concussion meeting held in Pittsburgh, October 15-16, 2015. Neurosurgery, 79(6), 912–929. https://doi.org/10.1227/neu.0000000000001447
DeMatteo, C., Stazyk, K., Giglia, L., Mahoney, W., Singh, S. K., Hollenberg, R., Harper, J. A., Missiuna, C., Law, M., & McCauley, D. (2015). A balanced protocol for return to school for children and youth following concussive injury. Clinical Pediatrics, 54(8), 783–792. https://doi.org/10.1177/00099228145673
DeMatteo, C., Stazyk, K., Singh, S. K., Giglia, L., Hollenberg, R., Malcolmson, C. H., Mahoney, W., Harper, J. A., Missiuna, C., & Law, M. (2015). Development of a conservative protocol to return children and youth to activity following concussive injury. Clinical Pediatrics, 54(2), 152–163. https://doi.org/10.1177/0009922814558256
Dillard, C., Ditchman, N., Nersessova, K., Foster, N., Wehman, P., West, M., Riedlinger, B., Monasterio, E., Shaw, B., & Neblett, J. (2017). Post-concussion symptoms in mild traumatic brain injury: Findings from a paediatric outpatient clinic. Disability and Rehabilitation, 39(6), 544–550. https://doi.org/10.3109/09638288.2016.1152602
Ellis, M. J., Ritchie, L. J., Koltek, M., Hosain, S., Cordingley, D., Chu, S., Selci, E., Leiter, J., & Russell, K. (2015). Psychiatric outcomes after pediatric sports-related concussion. Journal of Neurosurgery: Pediatrics, 16(6), 709–718. https://doi.org/10.3171/2015.5.PEDS15220
Flaherty, M. R., Raybould, T., Jamal-Allial, A., Kaafarani, H. M., Lee, J., Gervasini, A., Ginsburg, R., Mandell, M., Donelan, K., & Masiakos, P. T. (2016). Impact of a state law on physician practice in sports-related concussions. The Journal of Pediatrics, 178, 268–274. https://doi.org/10.1016/j.jpeds.2016.08.025
Gioia, G. A. (2016). Medical-school partnership in guiding return to school following mild traumatic brain injury in youth. Journal of Child Neurology, 31(1), 93–108. https://doi.org/10.1177/0883073814555604
Glang, A., Todis, B., Thomas, C. W., Hood, D., Bedell, G., & Cockrell, J. (2008). Return to school following childhood TBI: Who gets services? NeuroRehabilitation, 23(6), 477–486. https://doi.org/10.3233/NRE-2008-23604
Hackman, H., Howland, J., Taylor, A., Brown, L., Gapinski, M. A., Olshaker, J., & Stern, R. A. (2020). Application of components of the Massachusetts’ sports concussion regulations to all students with concussion: A survey of school nurses. The Journal of School Nursing, 36(4), 265–271. https://doi.org/10.1177/1059840518818709
Halstead, M. E., McAvoy, K., & Brown, B. E. (2016). Expanding concussion laws not necessary for return to learning after concussion. Pediatrics, 138(6), e20163194. https://doi.org/10.1542/peds.2016-3194
Hayden, L., Hess, C., Broadhead, S., & Gould, K. (2017). A schoolbased multidisciplinary response to student–athletes’ mild traumatic brain injury. Journal of Multidisciplinary Research, 9(3), 17–31.
Herbers, J. E., Cutuli, J., Supkoff, L. M., Heistad, D., Chan, C.-K., Hinz, E., & Masten, A. S. (2012). Early reading skills and academic achievement trajectories of students facing poverty, homelessness, and high residential mobility. Educational Researcher, 41(9), 366–374. https://doi.org/10.3102/0013189X12445320
Heyer, G. L., Weber, K. D., Rose, S. C., Perkins, S. Q., & Schmittauer, C. E. (2015). High school principals’ resources, knowledge, and practices regarding the returning student with concussion. The Journal of Pediatrics, 166(3), 594–599.e597. https://doi.org/10.1016/j.jpeds.2014.09.038
Howland, J., Hackman, H., Taylor, A., Brown, L., Gapinski, M. A., Mills, J. K., & Thornton, K. (2018). Evaluation of implementation of Massachusetts sports concussion regulations: Results of focus groups with school nurses and athletic trainers. The Journal of School Nursing, 34(5), 344–349. https://doi.org/10.1177/1059840517702697
Howland, J., Hackman, H., Torres, A., Campbell, J., & Olshaker, J. (2021). It is time to rewrite state youth sports concussion laws. BMJ Open Sport & Exercise Medicine, 7(1), e000959. https://doi.org/10.1136/bmjsem-2020-000959
Hsieh, H.-F., & Shannon, S. E. (2005). Three approaches to qualitative content analysis. Qualitative Health Research, 15(9), 1277–1288. https://doi.org/10.1177/1049732305276687
Hunt, A. W., De Feo, L., Macintyre, J., Greenspoon, D., Dick, T., Mah, K., Paniccia, M., Provvidenza, C., & Reed, N. (2016). Development and feasibility of an evidence-informed selfmanagement education program in pediatric concussion rehabilitation. BMC Health Services Research, 16(1), 1–8. https://doi.org/10.1186/s12913-016-1664-3
Iadevaia, C., Roiger, T., & Zwart, M. B. (2015). Qualitative examination of adolescent health-related quality of life at 1 year postconcussion. Journal of Athletic Training, 50(11), 1182–1189. https://doi.org/10.4085/1062-6050-50.11.02
Kirelik, S. B., & McAvoy, K. (2016). Acute concussion management with remove-reduce/educate/adjust-accommodate/pace (REAP). The Journal of Emergency Medicine, 50(2), 320– 324. https://doi.org/10.1016/j.jemermed.2015.02.054
Leddy,J.J.,Haider,M.N.,Ellis,M.,&Willer,B.S.(2018). Exercise is medicine for concussion. Current Sports Medicine Reports, 17(8), 262. https://doi.org/10.1249/JSR.0000000000000505
Lyons, V. H., Moore, M., Guiney, R., Ayyagari, R. C., Thompson, L., Rivara, F. P., Fleming, R., Crawley, D., Harper, D., & Vavilala, M. S. (2017). Strategies to address unmet needs and facilitate return to learn guideline adoption following concussion. Journal of School Health, 87(6), 416–426. https://doi.org/10.1111/josh.12510
Massachusetts Department of Public Health. (1998). Options for developing school health services in Massachusetts.
McCrea, M., Guskiewicz, K., Randolph, C., Barr, W. B., Hammeke, T. A., Marshall, S. W., Powell, M. R., Ahn, K. W., Wang, Y., & Kelly, J. P. (2013). Incidence, clinical course, and predictors of prolonged recovery time following sport-related concussion in high school and college athletes. Journal of the International Neuropsychological Society, 19(1), 22–33. https://doi.org/10.1017/S1355617712000872
McCrory, P., Meeuwisse, W., Dvorak, J., Aubry, M., Bailes, J., Broglio, S., Cantu, R. C., Cassidy, D., Echemendia, R. J., & Castellani, R. J. (2017). Consensus statement on concussion in sport—The 5th international conference on concussion in sport held in Berlin, in October 2016. British Journal of Sports Medicine, 51(11), 838–847. https://doi.org/10.1136/bjsports-2017-097699
McLeod, T. C. V., Lewis, J. H., Whelihan, K., & Bacon, C. E. W. (2017). Rest and return to activity after sport-related concussion: A systematic review of the literature. Journal of Athletic Training, 52(3), 262–287. https://doi.org/10.4085/1052-6050-51.6.06
Newman, D. A. (2014). Missing data: Five practical guidelines. Organizational Research Methods, 17(4), 372–411. https://doi.org/10.1177/1094428114548590
Purcell, L., Harvey, J., & Seabrook, J. A. (2016). Patterns of recovery following sport-related concussion in children and adolescents. Clinical Pediatrics, 55(5), 452–458. https://doi.org/10.1177/0009922815589915
Rosen, M. A., DiazGranados, D., Dietz, A. S., Benishek, L. E., Thompson, D., Pronovost, P. J., & Weaver, S. J. (2018). Teamwork in healthcare: Key discoveries enabling safer, highquality care. American Psychologist, 73(4), 433. https://doi.org/10.1037/amp0000298
Russell, K., Hutchison, M. G., Selci, E., Leiter, J., Chateau, D., & Ellis, M. J. (2016). Academic outcomes in high-school students after a concussion: A retrospective population-based analysis. PLoS One, 11(10), e0165116. https://doi.org/10.1371/journal.pone.0165116
Shifrer, D., Muller, C., & Callahan, R. (2011). Disproportionality and learning disabilities: Parsing apart race, socioeconomic status, and language. Journal of Learning Disabilities, 44(3), 246–257. https://doi.org/10.1177/0022219410374236
Simon, L. M., & Mitchell, C. N. (2016). Youth concussion laws across the nation: Implications for the traveling team physician. Current Sports Medicine Reports, 15(3)), 161–167. https://doi.org/10.1249/JSR.0000000000000268
Skiba, R. J., Chung, C.-G., Trachok, M., Baker, T. L., Sheya, A., & Hughes, R. L. (2014). Parsing disciplinary disproportionality: Contributions of infraction, student, and school characteristics to out-of-school suspension and expulsion. American Educational Research Journal, 51(4), 640–670. https://doi.org/10.3102/0002831214541670
Skiba, R. J., Horner, R. H., Chung, C.-G., Rausch, M. K., May, S. L., & Tobin, T. (2011). Race is not neutral: A national investigation of African American and Latino disproportionality in school discipline. School Psychology Review, 40(1), 85–107. https://doi.org/10.1080/02796015.2011.12087730
Skiba, R. J., Poloni-Staudinger, L., Simmons, A. B., Renae Feggins-Azziz, L., & Chung, C.-G. (2005). Unproven links: Can poverty explain ethnic disproportionality in special education? The Journal of Special Education, 39(3), 130–144. https://doi.org/10.1177/00224669050390030101
Stazyk, K., DeMatteo, C., Moll, S., & Missiuna, C. (2017). Depression in youth recovering from concussion: Correlates and predictors. Brain Injury, 31(5), 631–638. https://doi.org/10.1080/02699052.2017.1283533
Sullivan, A. L., & Bal, A. (2013). Disproportionality in special education: Effects of individual and school variables on disability risk. Exceptional Children, 79(4), 475–494. https://doi.org/10.1177/001440291307900406
Sullivan, A. L., Klingbeil, D. A., & Van Norman, E. R. (2013). Beyond behavior: Multilevel analysis of the influence of sociodemographics and school characteristics on students’ risk of suspension. School Psychology Review, 42(1), 99–114. https://doi.org/10.1080/02796015.2013.12087493
Thompson, L. L., Lyons, V. H., McCart, M., Herring, S. A., Rivara, F. P., & Vavilala, M. S. (2016). Variations in state laws governing school reintegration following concussion. Pediatrics, 138(6), e20162151. https://doi.org/10.1542/peds.2016-2151
Veliz, P., McCabe, S. E., Eckner, J. T., & Schulenberg, J. E. (2017). Prevalence of concussion among US adolescents and correlated factors. JAMA, 318(12), 1180–1182. https://doi.org/10.1001/jama.2017.9087
Yang, J., Comstock, R. D., Yi, H., Harvey, H. H., & Xun, P. (2017). New and recurrent concussions in high-school athletes before and after traumatic brain injury laws, 2005–2016. American Journal of Public Health, 107(12), 1916–1922. https://doi.org/10.2105/AJPH.2017.304056
Courtney W. Hess, PhD, is a postdoctoral fellow in the Anesthesiology, Perioperative, & Pain Medicine Department at Stanford University School of Medicine, California, USA.
Jonathan Howland, PhD, MPH, MPAis a professor emeritus in the Emergency Medicine Department at Boston University School of Medicine, Boston, Massachusetts, USA.
Holly Hackman, MD, MPH, is a public health physician and an epidemiologist in the Emergency Medicine Department at Boston University School of Medicine, Boston, Massachusetts, USA.
Julia K. Campbell, MPH, is a doctoral student at the University of North Carolina at Chapel Hill.
Steven Vannoy, PhD, is an associate professor in Counseling & School Psychology at the University of Massachusetts Boston, Boston, Massachusetts, USA.
Laura Hayden, EdD, is an associate professor in Counseling & School Psychology at the University of Massachusetts Boston, Boston, Massachusetts, USA.
1 Counseling & School Psychology, University of Massachusetts Boston, Boston, MA, USA
2 Emergency Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
3 Boston Medical Center, Boston, MA, USA
4 Health Behavior, University of North Carolina Chapel Hill, Chapel Hill, NC, USA
Corresponding Author:Courtney W. Hess, PhD, Stanford University School of Medicine, Department of Anesthesiology, Perioperative, and Pain Medicine, 1070 Arastradero Road, Palo Alto, CA 94304, USA.Email: cwhess@stanford.edu
