Athletic directors at the thirty percent of U.S. high schools lacking access to athletic trainers identify lack of AD hiring authority, budgetary constraints and non-budget factors, including rural location, misconceptions about an AT's role, and community interference, as barriers to hiring athletic trainers, a new study published in the Journal of Athletic Training

Researchers at the Korey Stringer Institute conducted 20-minute interviews of 20 athletic directors at public high schools without athletic training access, randomly selected by geographic region, to find out why their school did not employ even a part-time AT. Three major themes emerged from the data: lack of power, budget concerns, and non-budget concerns: 

Lack of Power:

Public school ADs perceived they lacked the power to make hiring and budget decisions and that there was little to no chance of persuading schools or departments to allow them to do so, despite prior efforts. Responses included "zero chance" and "no way." Reasons included priority of teacher hires and the challenge of shifting monies from other departments and budget cuts. The ADs said that a lack of support from supervisors in the school hierarchy existed and they did not believe it could be overcome.

Budget Concerns:

The funds allocated to a specific department or projects within a school can be a leading factor in the services and programs that a school can provide for its student athletes. All but one AD in the study attributed not employing an AT to a lack of funding. Eighteen of 20 discussed budget concerns as a major barrier to hiring. "It was financial, period, financial" said one AD. Another said "we would love to but ... this is just not going to happen." A third said "the school just runs a sports program under what's called the bare minimum amount of money we can come up with." Limited resources and budgetary concerns were primary factors in prohibiting hires.

• Rural Area/Location: Resources in these areas can be substantially limited and location can be problematic; schools may be several miles from cities. Many rural ADs rely on the local emergency medical system (EMS), physician assistants or traveling physicians in the absence of hiring an AT. "We do have one small school that is about 110 miles away and they have a volunteer athletic trainer. It's just that I don't know how we'd get someone to come out here," said one AD.
• Misconceptions About the Role of the Athletic Trainer: Although most ADs understood the role of the AT, others thought the coaches had sufficient knowledge and training to address the medical needs of the athletes without an AT. All 20 participants stated that their coaches received training in first aid, CPR and concussion recognition and were expected to apply this knowledge during practices and games. This misconception extended to the belief that other health care providers, including emergency medical technicians (EMT) or physical therapists, could be appropriate substitutes for ATs.

High school interscholastic leagues often mandate medical personnel only for football games. High schools that do not employ ATs may rely on their coaching staffs or others to act in emergency situations. Seventeen ADs reported that they had football teams and did not employ ATs. One AD said that because there was a hospital nearby, they didn't have an AT on staff and that the hospital might bring someone by the field from time to time. "If minor injuries occur, you know, we handle that on-site ourselves," said another. "Well, the hospital obviously has a person ... I don't know if it's like a pure AT and it is probably more of a physical therapist type," adds a third.

Preventable injuries and deaths 

"Most deaths that occur in sport are preventable and result from a failure to have proper prevention strategies in place, immediately recognize the condition, and/or implement appropriate care," said co-author Douglas J. Casa, PhD, ATC, FNATA, chief executive officer of KSI and director of Graduate Athletic Training Education, Department of Kinesiology, at the University of Connecticut. "Prompt management of these injuries is critical to the patient's positive outcome and should be carried out by trained health care personnel, such as the athletic trainer, to minimize risk."

As reported in the study, among the recommendations of the Inter-Association Task Force for Preventing Sudden Death in Secondary School Athletics Programs issued in 2013 was one that urged all high schools to have an AT on staff to take care of emergency situations and provide care for student athletes. Some schools rely on coaches, ADs or bystanders who are not trained in discerning the similar signs and symptoms of potentially fatal conditions.

Recommendations

While continued research is needed, the authors hope that identifying these barriers will lead to the development of strategies to overcome them.

They recommend that:

• Athletic directors continue to advocate for the hiring of athletic trainers despite budget concerns and educate parents, school boards and superintendents about the benefits that an athletic trainer can bring to the student athlete's well-being and medical care.  
• State legislatures be encouraged to pass more structured guidelines for athletic health care that follow the recommendations of NATA and other organizations about appropriate medical care in secondary schools, following the lead of Hawaii, the only state in the country which requires high schools to employ ATs.
• States that have model programs and the positive effects of community support - especially through the collective voice and power of parents - be promoted.
• Efforts be made to address the misconception that basic first aid/CPR/concussion recognition training for coaches is an acceptable substitution for athletic training services.
• Programs become creative with budgets, such as by sponsoring pilot programs with support and/or grants from local hospitals and clinics; hiring graduate assistant athletic trainers to provide care in rural areas or appeal to newly credentialed athletic trainers who are excited about their careers who may be a good fit for those environments; and consider community outreach programs with clinics, hospitals and universities as a way to fund or acquire athletic trainer services.

"It is our goal that these findings are catalyst for change," says lead author, Stephanie Mazerolle. "We hope that all high school student athletes will someday have full-time athletic trainers and receive the gold standard of care they deserve."

Sources:

National Athletic Trainers' Association

Mazerolle SM, Raso SR, Pagnotta KD, Stearns RL, Casas DJ. Athletic Directors' Barriers to Hiring Athletic Trainers in HIgh Schools, J Athl Tr. 2015;50(10):1059-1068. (accessed December 9, 2010 at http://natajournals.org/doi/pdf/10.4085/1062-6050-50.10.1.)

Posted December 9, 2016