Making return-to-play decisions in competitive sport: challenges, coping, and preparation among athletic trainers

Abstract

Athletic trainers are challenged by the task of making ethical return-to-play (RTP) decisions in a sport culture that normalizes pain and playing through injury. The purposes of this study were to examine within an athletic training sample a) the accuracy, applicability and comprehensiveness of Creighton et al.'s (2010) decision-based RTP model, b) to what extent and under what circumstances decision-modifier variables influence RTP decisions, and c) athletic trainers' strategies and perceptions of their professional preparation for dealing with decision-modifier variables in RTP decisions. Twelve certified athletic trainers of various ages (M = 34.67 yrs, SD = 6.12 yrs) and with varied professional experience (M = 12.08 yrs, SD = 6.08 yrs) participated in semi-structured interviews regarding their experiences making RTP decisions. Template analysis (King, 1998) and thematic coding (Braun & Clarke, 2006) were used to analyze the data. The 3-step decision-making process was supported; however, modifications were necessary. Medical factors considered in step one included signs and symptoms, functional testing, physical healing, psychological state and personal medical history. In step two, all of Creighton et al.'s (2010) sport risk modifiers were retained and potential seriousness, environmental conditions, expertise of physicians and psychological state were added. Decision modifier variables in step 3 of the model were expanded. External modifier variables included situational pressures, such as game and player importance, time issues, and competitive level; external people, such as athletes, parents, coaches, agents, non-team physicians, administration, management, media other athletic trainers, and officials; and sources of financial conflict of interest, such as bonuses, incentives or the athletes' financial state. Internal decision modifier variables included anxieties over job security, litigation, or professional reputation, and personal factors, such as age and experience, emotional attachment, personal biases, and gender. An external by internal interaction effect increased the potential for RTP decision modification. Strategies suggested for coping with potential decision modifier variables included establishing objective, evidence-based protocols, educating and establishing trusting relationships with stakeholders, creating a positive work environment, and fostering confidence in decision-making skills. Shortcomings in current professional preparation are outlined, and a framework for improving athletic training education efforts is provided.