The Journal of School Nursing2023, Vol. 39(1) 18-36© The Author(s) 2021Article reuse guidelines:sagepub.com/journals-permissionsDOI: 10.1177/10598405211056646journals.sagepub.com/home/jsn
Concussion or mild traumatic brain injury (mTBI) is a common phenomenon in the United States, with up to 3.6 million sport-related mTBIs diagnosed annually. Return to learn protocols have been developed to facilitate the reintegration of students into school after mTBI, however, the implementation of return to learn protocols varies significantly across geographic regions and school districts. An integrative review of the literature was performed using Whittemore and Knalf’s methodology. A search of published literature was conducted using the PRISMA checklist. Database searches were conducted from March 2,019 to October 2,021 using the terms “mild traumatic brain injury” and “return to learn.” Twenty-eight publications were included. Three themes were derived from this review: lack of policy, poor staff education on concussion symptoms and stakeholder communication breakdown. The development of communication patterns and use of a return to learn protocol could facilitate a gradual return to full academic workload after concussion.
Keywordsconcussion, mild traumatic brain injury, return to learn, school nursing, athletic training, integrative review
A concussion is a type of traumatic brain injury (TBI) defined as a “physiological disruption of brain function resulting from traumatic force transmitted to the head” (McCrory et al., 2017). Concussive mechanisms may include an athletic injury, slip and fall, motor vehicle accident, or any other trauma that involves a blow or jolt to the head. Further, a sport/recreation related concussion (SRRC) is defined as a biomechanical force resulting in a “direct blow to the head, face, neck or elsewhere on the body with an impulsive force transmitted to the head. SRC typically results in the rapid onset of short-lived impairment of neurological function that resolves spontaneously. SRC may result in neuropathological changes, but the acute clinical signs and symptoms largely reflect a functional disturbance rather than a structural injury” (McCrory et al., 2017). In the United States, it is estimated that between 1.1 and 1.9 million sports and recreation related concussions (SRRC) occur annually in children under 18 years of age (Bryan et al., 2016; Gardner & Yaffe, 2015). This subset of the population accounts for roughly 61% of total SRRCs sustained annually leading to a total incidence of SRRC ranging from 980,800 to 2.3 million (Bryan et al., 2016). However, the total number of people affected each year is likely underestimated, as SRRC is often undiagnosed and untreated, especially among youth athletes. In a study conducted by Bryan et al. (2016) it can be estimated that 22.5%-52.7% of SRRCs sustained by persons younger than 18 years of age were not evaluated by any type of healthcare provider.
Previously, the preferred practice for the treatment of SRRC was strict “cognitive rest,” in which the patient is instructed to eliminate stimuli and reduce mentally-taxing activities to facilitate recovery by reducing stresses to the brain (Valovich McLeod & Gioia, 2010). Over the last decade, research has indicated that while cognitive rest is vital for rehabilitation immediately following the injury, cognitive rest can be detrimental if prolonged (McCrory et al., 2017). It is suggested that immediately following the SRRC injury, a period of 24–48 hours of cognitive rest is most beneficial (Harmon et al., 2018; McAvoy et al., 2018; McCrory et al., 2017). These instructions are part of the larger Return to Learn (RTL) protocol, which has been adopted by a number of professional organizations, including the American Academy of Pediatrics, National Association of School Nurses, and National Athletic Trainers’ Association, in parallel to Return to Play (RTP) recommendations (Broglio et al., 2014; Diaz & Wychoff, 2013; Halstead et al., 2013; Irvine et al., 2017). The RTL protocol involves a period of cognitive rest followed by light thinking activities if the individual remains symptomfree (Olympia et al., 2016). McAvoy et al. (2018) stressed the importance of individualized, graded return to cognitive activities in a return to learn program. Return to cognitive activities and responsibilities required for students’ success must be individualized through close monitoring of symptom burden (McAvoy et al., 2018). This essential component of return to learn programs is vital to the success of the student. Accurate symptom monitoring and tracking of SRRC’s in students is complicated due to the numerous pathways of injury recognition and surveillance (McAvoy et al., 2018)). Regular symptom monitoring should proceed as the student re-enters school with appropriate academic supports made to facilitate learning. RTL protocols require the input of teachers and educational specialists due to their expertise in the realm of pedagogy (McAvoy et al., 2018). This knowledge is key in accurately implementing academic supports in the best possible fashion for each impacted student.
Academic supports exist in three distinct levels (McAvoy et al., 2018). The first level is defined as universal supports; this includes any academic adjustment that can be applied to individual students. McAvoy et al. (2018) highlights the importance of an individualized health plan (IHP). The IHP can be promptly instituted for each student exhibiting difficulties in the classroom and are typically put in place following teacher observation. The second level is the targeted level of support and involves level a more formal academic accommodation (McAvoy et al., 2018). Academic accommodation can be defined as “modifications or adjustments to the tasks, environment or to the way things are usually done that enable individuals with disabilities to have an equal opportunity to participate in an academic program or a job” (U.S. Department of Education, 2007). A 504 plan is typically considered if the student exhibits a medical condition that inhibits a major life activity (United States. Department of Health, Education, & Welfare. Office for Civil Rights., 1978) and is often instituted at the second level of academic support (McAvoy et al., 2018). In the setting of SRRC, cognitive impairments following injury can be considered debilitating to major life activities because students may experience tremendous difficulty with concentration and memory (McAvoy et al., 2018). The third level of academic support is the most specialized and individualized form of academic modification. This level of support includes parental notification as well as a formal individualized educational plan (IEP); this is typically not utilized in the setting of SRRC due to the short-term nature of the disabilities experienced following concussion (McAvoy et al., 2018). All three levels of academic support can be applied in the event of a life-altering injury such as an SRRC. Accommodations, modifications, and academic supportsshould be made to ease the transition of students to the classroom or lecture hall following a SRRC.
Despite the dissemination of RTL recommendations over the past decade, there still remains a striking lack of implementation of RTL programs in primary and secondary schools, and particularly across colleges and universities in the United States (Aukerman et al., 2016; Dennis et al., 2018; Valovich McLeod et al., 2017). Three recommended RTL protocols that have been implemented more widely in secondary schools but less so in the college or university setting, including BRAIN 101, REAP project, and Brainsteps (Glang et.al, 2010; McAvoy, 2012; PA Brain Injury Association et al., 2007). Each of the RTL protocols include a gradual return to the academic setting facilitated by an academic accommodation. McAvoy et al. (2018) outlined thirteen essential components to an RTL protocol in the 2020 consensus statement. The thirteen components are grouped into six categories. The six categories include: cognitive rest, concussion management team composition, progress monitoring, ascending levels of academic support, neuropsychological testing, and RTL legislation (McAvoy et al., 2018). Each of these categories are focused on the understanding that RTL should be gradual and individualized to each students’ personal experiences as SRRC experiences and rehabilitation is highly unique.
With the availability of these guidelines, academic institutions could partner with athletic trainers or other qualified healthcare providers to augment wider implementation; however, this is currently not the case. Thus, to identify facilitators and barriers to the implementation of RTL protocols in academic settings for student athletes following a concussive injury, an integrative review was conducted of existing literature focused on perception of key stakeholders. The stakeholders of interest to this review included student athletes, parents, school nurses, athletic trainers, teachers, and school administrators. The review was guided by the following questions:
This integrative review was guided by the updated methodology proposed by Whittemore and Knafl (2005). The methodology involves a five-step process carrying the researcher from the identification of a problem and developing research question(s) through data analysis and presentation. The five steps are as follows: problem identification, literature search, data evaluation, data analysis and presentation/dissemination (Whittemore & Knafl, 2005). The review process as it relates to the implementation of RTL protocols is outlined in Table 1. To increase methodological rigor, Whittemore and Knafl (2005) outline ten specific aspects of the data analysis process. The data analysis process is for identification of themes and reporting results from the review. The ten steps are: noticing patterns; seeing plausibility; clustering; counting; making contrasts and comparisons; discerning common and unusual patterns; subsuming particulars into general (generalization); noting relations between variability; finding intervening factors and building a logical chain of evidence.
To complete the literature search and review, the Preferred Reporting Items for Systematic Reviews (PRISMA) statement (Page et al., 2021) was followed. An electronic database search of the Cumulative Index of Nursing and Allied Health Literature (CINAHL), MEDLINE (PubMed), PsycINFO and ProQuest was conducted from March 3rd, 2019, through October 6th, 2021, for primary research articles focused on perceptions of key stakeholders on implementation of return to learn protocols for student athletes that were published in the English language between 2015–2021. This period was selected because it represents the primary time span in which Return to Learn programs have evolved. Keywords used for the literature search were: “brain concussion or brain injuries, traumatic (MESH terms) or mild traumatic brain injury, or mtbi” AND “return to learn.” All articles were compiled into a table and screened for duplicate entries. Following the removal of duplicates, title and abstract screening of 108 unique articles was conducted in which the following inclusion and exclusion criteria were used to select eligible publications:
Inclusion criteria: focus of the study was on perception of key stakeholders (teachers, school nurses, athletic trainers and school administration) regarding implementation of return to learn protocols for student athletes, qualitative or quantitative research design, peer reviewed, study setting in North America.
Exclusion criteria: the study did not include implementation of return to learn in a school setting, did not include perceptions of stakeholders, review articles.
Additionally, after screening for inclusion and exclusion criteria, a posteriori discrimination was utilized to remove guidelines and educational resources. Figure 1 illustrates the search process in more detail. Following this additional removal, four articles wer added through ancestry search and included in the literature search. In total, 28 unique studies were included for quality appraisal.
The 28 articles included for quality appraisal were assessed using the Mixed Methods Appraisal Tool (MMAT). The version of the MMAT used for this review was the updated 2018 version published by Hong et al. (2018). This updated version draws from both the original MMAT developed in 2006 by Pluye et al. (2009) and the revised 2011 version (Pace et al., 2012). Table 2 depicts the criteria used to review and appraise each article from the literature search. The MMAT was chosen as it has appraisal techniques that allow for the use of qualitative, quantitative, and mixed methods study designs. The MMAT does not place studies in any organized methodological hierarchy but allows for independent review of methods and quality appraisal. An a priori quality appraisal, a score on the MMAT of 75% or higher was used to select publications for the final analysis, meaning that there could be one noted area of weakness in the design or methods of the study that could potentially bias the results. This threshold was selected, however, because of the paucity of research on the subject and the premise of needing to assess the weaknesses in the current body of research. After each individual article was read, screened for eligibility, and assessed for quality, unique aspects and characteristics of each study was compiled into a table for ease of access and readability. This also improved comparisons and theme development. Table 3 depicts the key characteristics of each included study with the quality appraisal results integrated in the last column.
Of the 28 studies included in the review, 10 studies used a qualitative design (grounded theory, phenomenology), 17 used a descriptive quantitative design (cross-sectional surveys), and one study used a mixed methods design. The one study that reported a mixed methods design (Lyons et al., 2017) did not use a specific typology for mixed methods research; instead, it utilized a survey needs assessment with both quantitative and qualitative items. Based on the results, Lyons et al. (2017) developed 4 domains and convened an expert panel to revise the RTL protocols based on the 4 domains. Mixed methods designs are classified as type five using the MMAT and are depicted in Table 3. Two selected studies were dissertations accessed from ProQuest (Acord-Vira et al., 2019; Jordan, 2017). The study by Acord-Vira et al. (2019) used a cross-section survey, while Jordan (2017) used a qualitative design with case study interviews.
The 12 descriptive quantitative designs were exclusively conducted via internet survey administration. Researchers utilized national association boards’ email lists to advertise their studies. Response rates varied from 7.4% to approximately 45% among varying populations. Four of the 17 descriptive quantitative designs (23.5%) utilized a validated instrument. All studies using a validated instrument (Johnson et al., 2018; Weber et al., 2015; Weber et al., 2018; Williams et al., 2015) utilized the Beliefs, Attitudes and Knowledge Following Pediatric Athlete Concussion (BAKPAC) instrument. There are two versions of the BAKPAC, one for school nurses (BAKPAC-SN) and one for athletic trainers (BAKPAC-AT). Williams et al. (2015) utilized the BAKPAC-AT while Weber et al. (2015, 2018) utilized the BAKPAC-SN. Johnson et al. (2018) modified the BAKPAC to focus on aspects specifically pertaining to school counselors (BACPAK-SC). The remaining 10 descriptive studies employed the use of novel survey instruments. Descriptive studies are classified as type four in the MMAT and are shown in Table 3. The 10 included studies that used a qualitative design employed a variety of methodologies, including grounded theory, phenomenology, case study and narrative approaches. Many of the qualitative studies did not provide a detailed description of the methods used to derive themes and general conclusions, which was a major weakness identified.
Facilitators and barriers to the implementation of RTL programs were also elicited from the selected publications. Facilitators and barriers can be viewed from the macro- (policy, institutional infrastructure, support services) and micro-level (care coordination and communication among individuals). Blackwell et al. (2017) found that RTL protocols are not adapted to the developmental stage of the individual with SRRC, and this could represent a barrier to implementation.
Barriers to RTL Protocols. Utilizing the steps to data analysis provided by Whittemore and Knafl (2005), three main barriers were identified using information from the 22 articles included in this review. Outcomes from each article were synthesized together and collectively described three “root barriers” to successful implementation of RTL. As explained previously, there are barriers at the macro and micro levels of implementation. The most notable macro-barrier was the inherent lack of policy concerning the RTL process in schools and infrastructure in which to carry out the process (scheduling and communication records for continuity across the student’s academic journey). This lack of regulatory guidelines and detailed requirements on RTL process implementation resulted in variability in RTL design, adherence and oversight of key objectives, and outcomes monitoring. Thus, although each state does have legislation regarding return to play, the RTL process is often not included in major legislation and policy.
Two main barriers were found to exist at the micro level: education of staff (ranging from lack of knowledge about concussion symptoms to not understanding the accommodations process or how to request services) and communication amongst stakeholders. Gaps were identified through a Delphi study conducted in Washington state by Lyons et al. (2017). Highlights of the RTL summit as described in the article included widespread barriers to providing and receiving academic supports, current lack of school policies, and wide variability in communications patterns (Lyons et al., 2017). These themes were supported through the findings from the 22 included articles.
Lack of Policy Surrounding RTL. Although concussion legislation has been implemented in 48 states (Society for Health and Physical Educators, 2020; https://www.shapeamerica.org/standards/guidelines/Concussion/state-policy.aspx), they are generally broad, directing athletes to refrain from returning to play for at least 24 h. Both Arizona and South Carolina allow students to return to play within 24 h if cleared by a healthcare provider. In interviews with 64 high-school athletic trainers, Davies et al. (2018) reported agreement in responses of three core tenants of concussion management: removal from play, return to play, and concussion education. However, concussion management protocols did not include RTL, even though the athletic trainers agreed it was a critical component to follow. In addition, two cross-sectional surveys among school administrators and nurses found that policies implemented to address concussion were not systematically implemented between states or provinces because the legislation was so broad (non-specific) and relied on each territory to develop their own policy, procedures and infrastructure (Hachem et al., 2016; Hackman et al., 2020). In addition, only eight states currently have specific laws for concussion that include compliance with RTL protocols (Hackman et al., 2020). The general lack of statewide legislation addressing concussion rehabilitation in school-based settings leads to a deficiency inin education for staff and parents, lack of infrastructure and educationally prepared staff to provide program oversight, and expansion of concussion management and RTL for non-athlete students. Massachusetts has set an example by providing legislation regarding the management of RTL following SRRC. In the study conducted by Howland et al. (2020), the institution of guiding laws pushed schools to develop regulations for returning to learn following SRRC. 87% of the athletic directors surveyed were in support of concussion management teams and had favorable outcomes following the formation of the teams (Howland et al., 2020). There does continue to be a lack of definitive guideline for the creation of a concussion management team and RTL programs, but the regulation of these supports increases the likelihood for favorable outcomes in RTL.
Education of Staff on Concussions. Gaps were identified and highlighted in the articles included in this review. Janson et al. (2019) surveyed high school principals in Indiana and found that 40% of principals did not think academic accommodation were necessary for students who have suffered a concussion. This lack of knowledge surrounding the impact of a concussion on attention span and ability to receive information is a deeply rooted phenomenon in school systems in the United States. Hildenbrand et al. (2018) surveyed 404 physical educators through SHAPE America and found that most school districts do not require any education on concussion. This can be detrimental to the health of students suffering from concussion symptoms exacerbated by the educational environment. Sarmiento et al. (2019) conducted an interdisciplinary focus group and found four themes permeated the return to learn process following a concussion. One of the main themes identified was the challenge with identifying concussions and concussion symptoms (Sarmiento et al., 2019). When teachers and school administrators were surveyed to determine overall knowledge of concussion symptom expression, the general understanding of changes related to a concussion was minimal (Romm et al., 2018). Romm et al. (2018) explained that the lack of knowledge surrounding concussion symptoms and difficulties related to learning following a concussion contributed to the lack of resources and support available to struggling students. This concept was again highlighted by Johnson et al. (2018) after surveying school counselors and their perceptions of return to learn following SRRC. Nealry half of the school counselors saw the benefit of instituting formal academic supports (504 plans or IEPs) following SRRC (Johnson et al., 2018) but felt that school counselors needed more education on the specifics of management following SRRC. Return to learn following a concussion was not viewed as an important aspect of care following a concussion in school aged students (Davies et al., 2018; Dreer et al., 2017).
Communication Amongst Stakeholders in the RTL Process. Lack of communication surfaced as one of the main gaps in the proper implementation of an RTL protocol. The breakdown of communication can be attributed to two main points: lack of role definition in the RTL process and lack of clear communication pathways amongst all stakeholders. Lack of clear communication pathways may be exacerbated by the number of individuals involved with the care coordination of a student who has suffered a concussion. Typically, a physician, school nurse, parents, school administrator and teachers are involved as important stakeholders in the return to learn process (Welch Bacon et al., 2018a). Most schools also include an athletic trainer (AT), although there are schools that lack this expertise as a part of existing athletic programs (Bacon et al., 2017; Jones et al., 2019). Due to the number of individuals involved, there are many opportunities to address communication breakdown. Additionally, a lack of role identification and responsibility exists in coordinating a RTL plan following a concussion. Kasamatsu et al. (2016) surveyed 1124 athletic trainers (AT) in the secondary school setting; 74% viewed the AT as the primary individual responsible for return to play but only 35% for academic integration and success as consistent with the RTL process. There was no majority consensus for the “point person” managing the return to academics and this widespread delegation of a “point person” for academic integration shows the communication gap in helping the student achieve a successful RTL. In a cross-sectional survey of 151 school nurses, Wing et al. (2016) concluded that school nurses struggled with communication between interdisciplinary medical teams and school administrators on how to best integrate students following a concussion.
The focus of the articles included in the review primarily centered on barriers to implementation; however, a key facilitator of proper and effective RTL identified throughout the literature was communication. Facilitators of RTL protocols can be implemented at the macro and micro levels as well. At the macro-level, two studies reported on facilitators of policy to mandate concussion monitoring (Hachem et al., 2016; Hackman et al., 2020). Additionally, the existing method for assessment and implementation of academic supports plays to the strengths of school systems to use these welldesigned and understood processes. The supports program serves as a bridge from the macro level of policy to the micro level of school system and the individual. The difficulty in implementing the academic supports for students who have suffered a concussion is the lack of knowledge on the existence of these tools and how to use them (Welch Bacon et al., 2017; Williams et al., 2015; Williamson et al., 2018). Weber et al. (2015) surveyed an interdisciplinary team of school nurses and athletic trainers (AT) in regard to academic supports and found that schools with ATs have increased knowledge of academic supports and were able to provide better access to these programs to students with concussions (Weber et al., 2015). This demonstrates the key to success involving the implementation of RTL protocols, effective communication amongst stakeholders, knowledge of academic supports and symptoms of a concussion. A study conducted in Ontario, Canada showed that overarching policy mandating concussion education and management protocols are important to the success of students following a concussion, although gaps remained as only 77% of schools were following the legislation (Hachem et al., 2016). Additionally, through use of a directed, educational lecture for professionals employed in secondary schools, knowledge of concussion management is significantly improved using a pre-posttest study (Carzoo et al., 2015). In the study by Carzoo et al. (2015), various educators and student support staff were invited to attend a presentation created using information from most recent concussion consensus statements as well as the Center for Disease Control (CDC)’s “HEADS UP” for concussion. Personnel that attended the lecture improved post-test scores by approximately 10% (Carzoo et al., 2015).
Perceptions of RTL Protocols Amongst Various Stakeholders in the RTL Process. Perceptions of student athletes affected by SRRC provided insight on the use of RTL and described the accessibility to needed academic supports when an RTL protocol was used (Acord-Vira et al., 2019). Student athletes were more likely to receive academic supports than students who had suffered a concussion unrelated to school athletics; however, there was a general lack of knowledge surrounding academic supports amongst collegeage students (Acord-Vira et al., 2019). Academic supports are already built into the infrastructure of schools in the United States and can carry over into the college/university setting when services are initiated by the student. Runyon et al. (2020) interviewed 15 athletic trainers on their perceptions of their role in the development of policy surrounding the RTL process following a concussion. Three themes emerged and focused on the individualization of RTL for each student, clear communication, and collaborative practice utilizing academic supports throughout the process (Runyon et al., 2020).
This integrative review synthesized themes from 28 unique articles surrounding the RTL process for individuals suffering from sport or recreation-related concussion. The integrative review captured research performed in several different populations and settings in North America, including most roles involved the RTL process. School principals, teachers, athletic trainers, and school nurses provide expertise in their own scopes of practice and are essential to the success of an RTL guideline or protocol.
The combination of different roles or stakeholders demonstrated a very similar opinion on the implementation of RTL protocols. Surprisingly, the major theme uncovered surrounded a general lack of knowledge amongst stakeholders for RTL guidelines and accommodation services available. Each of the stakeholders in the school setting (administration, teachers, nurses, and athletic trainers) all possess knowledge about concussions and understand the difficulty associated with academic study. Each stakeholder provides a specific set of skills and resources for individuals who have sustained an SRRC. Nonetheless, there was a lack of consistent communication between the groups, and this inhibited the chain of specialized knowledge from being combined and benefitting the affected individual(s). Miscommunication and, ultimately, a lack of role clarity in assisting individuals with SRRC in accessing accommodations, hindered the effectiveness of existing RTL protocols or a gradual reintegration into the academic setting if no specific guidelines were used.
The implementation of RTL protocols is hindered by three major barriers identified in the literature review. Lack of staff education, communication pathway breakdowns, and a lack of guiding policy of an RTL protocol are the biggest detriments to a successful RTL. The use of existing academic supports can modify the implementation at the macro-level through policy changes. The use of academic supports would also improve staff education and awareness of the variability of the RTL process following a concussion. Use of academic supports and they customizability they offer allows for an individualized program for each student with an SRRC. The creation and utilization of a concussion management team comprised of the various stakeholders would reduce communication breakdown through clear roles and responsibilities of stakeholders in RTL for each student. Concussion management teams would also be responsible for the development of concussion education programs for staff in the school setting to improve awareness of concussion symptoms and training on when to intervene to reduce strain of the students during their RTL. Results of the integrative review were used to develop a conceptual framework of the facilitators and barriers to implementation of RTL (Figure 2). This framework can serve as a starting point for future research in the field.
This review highlighted the importance of communication amongst all stakeholders involved with the RTL process. Athletic trainers, school nurses, medical professionals, and instructors each must provide consistent communication with one another to provide an ideal RTL experience for the individual. As all students are definitively unique as far as the symptom experience, tolerance and functioning following an SRRC, frequent and clear communication is imperative to ensure that each member of an RTL “team” is adequately informed and can appropriately understand the individual plan. An RTL protocol can improve this knowledge, but the communication amongst stakeholders is of utmost importance in gradual return to full academic workload. The development of clear communication patterns and educational workshops could benefit each institution in preparing to help individuals RTL following a concussion.
Themes extracted from this integrative review emphasized the need for enhanced communication amongst stakeholders in the RTL process. Identification of concussion symptoms and understanding the unseen impact of someone who has suffered an SRRC are paramount to ensuring an appropriate gradual RTL plan.
The existence of legislation can improve an institution’s awareness of the impact of SRRC, but specific education must be utilized to cement tenets of RTL protocols into daily practice. Improved understanding of concussion symptoms including the current guidelines on returning to learn seems to be the most influential piece in facilitating RTL leading to better patient outcomes. Expanded knowledge is necessary pertaining to each of the common barriers to RTL protocol implementation. This review demonstrated that the lack of communication amongst the various stakeholders combined with limited knowledge of the impact of concussion and guidelines for gradual RTL are the most common barriers studied currently. Much of this has the potential to be improved via the development of an educational workshop discussing specific RTL programs like BRAIN 101, REAP project and Brainsteps (Glang et al., 2010; McAvoy, 2012; PA Brain Injury Association et al., 2007) and symptom exacerbation signs.
It is vital that a clear line of communication among all stakeholders; the patient (student), parents, athletic trainer, school nurse, school counselor, other qualified school sanctioned healthcare providers, instructors, and administrative professionals occurs to ensure a holistic approach to gradual RTL and protocol implementation. Coordination of RTL at the macro- and micro-level will help to promote the best possible outcome for the affected individual.
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.
Joseph Fetta https://orcid.org/0000-0002-7654-2864
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1 School of Nursing, University of Connecticut, Storrs, CT, USA
2 Korey Stringer Institute, University of Connecticut, Storrs, CT, USA
3 National Institute for Nursing Research, Bethesda, MD, USA
Corresponding Author:Joseph Fetta, MS, RN, CNRN, University of Connecticut School of Nursing, 231 Glenbrook Rd., Unit 4026, University of Connecticut, Storrs, CT 06269-4026, USA.Email: joseph.fetta@uconn.edu
