Sport, healthcare and educational organisations’ perceptions of a framework for managing concussion in New Zealand schools: a qualitative study

Participants felt priorities varied between sectors, influenced by organisational purpose, resourcing, knowledge, and desired student outcome. Healthcare providers (HCPs) suggested sports coaches and organisations often focussed on students’ medical clearance for return-to-sports, not always appreciating the impact of premature return on the student’s wellbeing, learning, and long-term recovery. Different priorities and implementation requirements were reported across different sports, complicating concussion management. Sports organisation participants appeared wary of player and parents’ frustrations about missing sporting opportunities due to stand-down periods, especially if they ‘only had a mild concussion’.

I think the different opinions that can come in and the different pressures that students can feel, both in the sporting contexts and in the school contexts. How can they play rugby when they can’t come to school and concentrate for a period … (Interview 11 – Education sector)

Schools were often resistant to change due to limited financial and human resourcing and ever-increasing responsibilities. Finding additional resourcing for yet ‘another’ new process could be challenging and act as a barrier to implementation.

I suppose I’m cautious about it, because, anecdotally we hear infinitum how stressed the schools are and how much pressure they’re under … (Focus group 10 – Sport sector)

Participants reported lack of practical guidelines for concussion management for schools, with HCPs often liaising between schools, sports teams, and parents. Varied sports-specific concussion guidelines confused implementation.

In terms of the overall concussion guidelines, there hasn’t been as much implementation across sport, and that kind of goes back to my earlier points around us needing to get a more consistent and agreed approach, and then I think it’s easier for all sports organisations to pick it up. (Interview 2 – Health sector)

Participants reported varied concussion knowledge in school, sport, and healthcare sectors

Often there’s not a lot of uptake from schools, because I think it’s not that there’s necessarily a resistance to help or anything. I don’t think that’s the issue. I think it’s a bit of a scary bogey condition that teachers feel a little bit not able to really understand or support well. (Interview 3 – Health sector)

They considered concussion knowledge to be context-dependant and role-specific: coaches needed to recognise a potential concussion during sport, whereas teachers needed insights for individualised return-to-learn processes. Participants suggested that enhanced knowledge could facilitate buy-in and collaboration between stakeholders.

Participants identified increasing public awareness about potential long-term concussion consequences. They believed that current media attention could be leveraged to raise awareness about concussion in schools.

Participants reported witnessing persistent uncertainty in identifying concussions. Inconsistent player removal from sport by coaches despite of injury added to the discourse of fear and uncertainty. Under-reporting potential concussions was reinforced by some coaches wanting their players to remain available for selection, parents who wanted their children to excel in sports, and players not wanting to let their team down. Some participants noted that under-reporting was amplified by the Kiwi attitude of ‘she’ll be right’ and not wanting to ‘make a fuss’.

We know that quite a lot of them under-report because they are keen to get back playing with their friends in the playground, or they’ve got an exam to study for, or they’ve got a sports match to play. (Focus group 2 – Sport sector)

Participants considered the framework to be clear and understandable, acknowledging the limited time and resourcing of teachers. The structured processes could facilitate identifying a potential concussion, removal of such student from the sports field, and encourage accessing health care.

Personally, I saw a lot of value in it. Because there’s no system currently. And I think everyone’s crying out for something around concussion and how it’s managed. And it looks without trying to downplay the work you’ve done, it looks really relatively simple, which is fantastic. So the process looks easy for somebody to be able to pick it up, and then pass it on to the next person to make sure all of those things are happening in the background. (Focus group 3 – Sport sector)

FRANCS might create shared accountability and responsibility across stakeholders for students’ wellbeing and return-to-learn and return-to-sports processes. The resources embedded in FRANCS were considered useful concussion management guides, enhancing confidence and potentially decreasing uncertainty and fear about the process.

A perceived barrier to current processes was parents’ burden to drive the post-concussion process, often lacking knowledge to do this confidently. A streamlined reporting and referral system within the school and with HCPs may provide a more holistic, supported recovery experience for the student and their whānau (extended family). Participants appreciated that FRANCS had been developed locally, piloted, and adapted for the NZ school system.

Lack of consistent immediate management and communication between different stakeholders (school, sport club, and home) was considered a barrier. Participants suggested that a central school-based communication point would minimise risk of students ‘falling through the cracks’, including those that incurred a concussion external to the school.

We’ve had a few cases where it would have been really helpful to have that pressure taken off the parents and have a designated person who was able to facilitate those things. And particularly if a student is enrolled in a multi-disciplinary concussion service, often there’ll be clinicians involved that need to liaise with the school, and we found that can be quite challenging, our occupational therapists don’t know who to get hold of [in the schools], or things just sort of disappear into the void. So I really liked the idea of having a touch point in each school, and then it’s really consistent, regardless of what school that kid goes to. (Focus group 1 – Health sector)

The relationships between schools, sports coaches, HCPs, and parents were considered pivotal for the framework’s success. Further collaborations were recommended to adapt FRANCS to individual schools’ resources, diversity, and culture. Greater understanding of how concussion impacted Māori and Pasifika communities and how these communities accessed and engaged with health care is required.

Like with all kinds of co-designs, especially if we’re looking towards Māori and Pasifika, is going and saying, what do you need? Because I think we’re pretty good at being like, here we go. This is the right way to do it. … We’ve translated it for you … And it may be about, you know, you have to sit down and talk about concussion as a community. (Focus group 8 – Health sector)

FRANCS’ educational resources were considered useful to improve concussion awareness among the community, which could enhance confidence to report suspected concussions, support students’ recovery, and seek timely help from HCPs.

It is good awareness for the students themselves, because maybe the students themselves realise that they’re not quite right, and they need help. Often the teachers and the parents may not actually realise that, especially with students going through particularly adolescence … and remember symptoms on things like … is it an adolescent growing happening, or is this something different in my body? And it’s giving the students the knowledge to say, hey, there is actually something else going on. And I think the more education we can get at those crucial points. Like the students are a different stakeholder group, they may take responsibility themselves. (Focus group 9 – Health sector)

Quality concussion-related education and resources would need to be adaptable for different contexts and roles for schools, HCPs, parents, sporting organisations, or other community members. Uncertainty was raised around who should be responsible for delivering and resourcing concussion education and where to find relevant resources.

Participants believed that not all HCPs had the knowledge required for concussion diagnosis, rehabilitation, and symptom management, posing a risk for students being prematurely cleared for return to activities.

That’s a knowledge gap within [medical] general practice, which really does worry me, because I think they green-light people who aren’t ready for a lot of things, where they still need that measure of support. They still need to be kept out of sport, limited hours, whatever it may be, that symptom management requires the GP to put some boundaries around those things, and they don’t. And so it is a worry. (Interview 6 – Health sector)

Multi-disciplinary concussion clinics were limited to specific sports or geographical regions. Concussion services funded by Accident Compensation Corporation (ACC, NZ’s national no-fault accident scheme) for those with persistent symptoms needed expansion across the country.

Participants identified gaps and suggested specific modifications to FRANCS. A consistently voiced concern was around the role and required skillset of the ‘concussion manager’, the central communication point suggested in FRANCS for receiving concussion reports at the schools, ‘navigating’ the student rather than making healthcare decisions. The concussion manager (or officer) might be an administrator or teacher instead of a school nurse or other HCP. Participants thus suggested that the role would have to be carefully defined to remain within the scope of the staff member.

GPs were the only HCPs who could diagnose concussion in NZ. Participants considered restricted diagnosis and clearance to be barriers, given GP accessibility (either no availability or time/financial constraints) in various regions. Participants noted that students with sports-related concussions were often assessed by a physiotherapist or occupational therapist prior to accessing GPs. Alternatively, some students could not access a GP and were managed by the physiotherapist only.

The reality is, [the physiotherapists] are not making the diagnosis but they are actively involved in management and if we look at some of the research in sport, physiotherapists and concussion … physios are already doing this. So why don’t we record what’s actually happening in the field? … Accessing the GP’s is difficult, whereas our physiotherapy colleagues and occupational therapist colleagues are doing this, they’re telling people, we don’t think there’s a major issue here based on what I see, then you can turn to narrow the scope. That’s what’s happening in the community as we speak. (Focus group 6 – Health sector)

Participants indicated the framework was unclear about monitoring the student’s recovery: how and by whom symptoms would be assessed, and who was responsible for managing rest, recovery, and follow-up with the student within the school. Clarity was also needed for reporting concussion processes that occurred external to the schools.

Collaboration between local, regional, and national stakeholders was needed to raise awareness of FRANCS, support schools to tailor FRANCS to their contexts, and develop long-term policies for concussion support for all schools. Participants suggested that wider implementation of FRANCS would need collaborations between ACC, the Ministry of Education, and the Ministry of Health.

I have had several meetings, trying to get broad injury prevention strategies into schools, and the observation is that it’s really important to get the interdepartmental agreement in order to actually make them work. ACC was very engaged. But [the Ministry of] Health … were totally unengaged. … I don’t believe this will ever be successful at a national level, unless you can get the Ministry of Education to be involved. (Interview 7 – Health sector)

Suitably trained HCPs, concussion clinics, ACC concussion services, and local concussion researchers could support implementation.

Most participants felt external support may be required for concussion education and resourcing. Schools may face human and financial resource limitations. Suggested support included having people available to guide initial implementation and part-funding the concussion officer’s position. Support might be needed from ACC and the Ministry of Education.

Lack of awareness of concussion management was a common barrier. Participants from all sectors recounted stories of individuals who had not appreciated the seriousness of concussion. The busy lives and copious amount of new information offered daily via media and the schools could not always be absorbed. Real-life stories of concussion experiences by students and their whānau should be included in resources, as well as stories of successful implementation of FRANCS in schools. Face-to-face conversations and interactions were important, preferably within the respective school communities and their HCPs. A multi-modal approach to disseminating information was recommended, via social media, radio, television, roadshows, research journals, conferences, and a centralised website.

There are quite different demographics you need to target. So looking at what are the other ways that we can be targeting? Things like social media, bite size TikToks, around you know, things like that, that kind of thing. You may be saying that same message different ways. (Focus group 8 – Health sector)

Participants suggested that schools could use existing administration resources to minimise the workload impact of FRANCS. School administrators who understood their internal systems could set up school-specific concussion reporting systems. Concussion reporting should also be included as part of existing injury/incident reporting requirements. Participants recommended using existing forms of information dissemination, such as professional development providers and embedding information in coaching handbooks and school newsletters.