Assessing concussion knowledge and awareness in faculty and staff in a collegiate setting

Introduction

Return to play protocols and best practices developed for the medical management of concussions are well documented in the literature.^1,2 Recovery from a concussion is an individualized process that requires assessment of symptoms related to physical activity and those that develop with cognitive exertion.^3–5 National programs, such as BrainSTEPS, have been developed to initiate team (e.g. teachers, parents, students and health professionals) management of students in primary and secondary schools who have had a mild traumatic brain injury (mTBI). All stakeholders work together to gradually return students to the classroom. This model for return to learn has been recommended for students or individuals who have suffered from concussions. ¹ According to the National Collegiate Athletic Association (NCAA) Sports Medicine Handbook ² it is recommended that colleges and universities implement an academic return to learn plan for student-athletes who sustain a concussion. It is unclear if this practice extends to all students attending the colleges and universities which speaks to the need for return to learn programs for non-athlete students as well.

Symptoms of concussion may negatively impact college students’ academic performance and potential success in the classroom. Return to learn protocols are a means to support students who experience concussion symptoms that are exacerbated by cognitive requirements. There are components to these protocols that are integral to the support of concussion recovery for students. ⁶ First, the protocols ensure that evidence-based methods are being used to manage concussion interventions both medically and academically. Hall et al. suggest a gradual approach to physical activity and cognitive activity. ⁶ The authors acknowledge that return to play protocols are consistently practiced by the team management for college athletes, but return to learn protocols tend to be implemented more on an individual basis with the academic instructors needing to have an understanding of the cognitive implications involved in concussion management. Return to learn protocols included in concussion management policies at the institutional level support optimal recovery from concussion. While cognitive symptoms related to concussion in college athletes typically resolve after seven days, ⁷ other research suggests that college students’ recovery from concussion takes longer than average. ⁸ Presenting recent findings at the 2017 Association of Academic Physiatrists Annual Meeting in Las Vegas, NV, lead investigator Jayabalam et al. ⁸ reviewed 128 medical charts from undergraduate and graduate college students diagnosed with concussion and concluded an average recovery of 11.5 days for varsity athletes, 19 days for club sport athletes, and 23 days for recreational athletes, while graduate students recovered an average of 31 days compared to undergraduate average recovery of 16 days. Recovery was considered cessation of symptoms of concussion. This study demonstrated that student-athletes fell within the normal range for concussion recovery time, likely because of the team-based medical management and academic monitoring they receive from a concussion management team. However, non-athlete college students who acquired a concussion without academic accommodations may have suffered prolonged symptoms and sustained academic challenges to learning. ⁸

Return to learn protocols require that all parties involved in the education of the student to have knowledge of concussion and management related to their area of focus. It is important that educators have an understanding of the sequelae of symptoms to implement the most effective accommodations to support healing. Academic dysfunction is commonly reported following a concussion diagnosis ⁹ with physical and cognitive symptoms exacerbated in the classroom. ¹⁰ Kasamatsu et al. ¹¹ reported that following concussion education teachers are more likely to recognize concussion symptomology and make academic adjustments in adolescents. A return to learn protocol provides details related to learning accommodations that are incorporated by teachers to support recovery. While symptoms of concussion are linked to academic dysfunction in students who attend primary school, secondary school, and college,^9,12 there is little in the literature specific to the academic accommodations process for the college student. Greater details are available related to the implementation process for academic accommodations in the primary and secondary school setting, and the school nurse and school counselor are generally responsible for developing learning plans to establish the necessary learning accommodations. ¹³ At the college level, faculty and support staff members are part of the return to learn protocol management team and communicate regularly with the athletic department when working with a concussed student-athlete. However, they often rely on communication with the non-athlete student diagnosed with concussion regarding their academic needs. In both concussed students, it is vital that the faculty or support staff members have an understanding of concussion symptomology to implement effective academic accommodations. A survey conducted by Kasamatsu et al. ¹² indicated that primary and secondary school teachers believe that symptoms of a concussion can have an effect on a student’s performance and they should have a role in developing academic accommodations for those students. Most believed that an academic team approach was necessary to manage the academic protocol for a student with a concussion. ¹²

Finally, a protocol ensures that each student will have consistent treatment throughout the healing process. Due to the integral role educators play in the support of academic accommodations for students, clear academic protocols in support of objective measurements that provide management strategies for returning to school after a concussive injury are needed for all students to support their recovery. ⁹ Iverson and Gioia ¹⁴ identify that school personnel are looking for health care professionals to provide targeted goals to identify progression within an intervention plan. Furthermore, there is limited research dedicated to returning to school after injury for clinicians to use as a guide for intervention services. ¹⁵ When considering the educational structure for a college student, there is less time focused on the student being in the classroom and more emphasis on independent work and academic accommodations may be overlooked as a key intervention. ⁶ However, the interventions from the academic and health management team share a symbiotic relationship to the outcomes for any student with a concussion. This collaboration between groups creates an important relationship to ensure the successful management of the concussed student or student-athlete.

Academic accommodations are a necessary component to promote effective and thorough recovery from concussion. With no current literature available to assess college faculty and academic support staff knowledge of concussion, it is difficult to identify potential progress related to concussion recovery in the college population. Furthermore, faculty and staff may have a varying degree of awareness and knowledge of concussions due to the nature of their work in the university setting. Faculty and staff in the health sciences and athletics departments regularly encounter and address biological processes and are likely to have more consistent exposure to information related to concussions and concussion symptoms than individuals from departments with responsibilities that are unrelated to human biological processes. The purpose of this original research project is to assess college faculty and academic support staff members’ awareness and knowledge regarding concussions and student learning. Assessing faculty’s knowledge in concussions coupled with transforming their awareness of how concussions effect student learning will assist in a better understanding of how to adapt learning tasks to assist a student with a concussion.

Methods

Participants

Faculty, athletic coaches, athletic administration, academic support staff, and executive administration employees in an urban, private, NCAA Division II university were recruited for this study. Participants were excluded from the survey if they were listed as faculty adjuncts and any other staff that did not have direct interaction with student-athletes (e.g. physical plant staff). Adjunct faculty were excluded because of their inconsistent contact with students and the part-time nature of their employment. Institutional review board approval was granted for this study.

Electronic survey software (Qualtrics, Provo, UT) was used for all data collection. Participants were emailed an individual link with an invitation to participate in the study and complete the survey. The survey instrument was sent to participants that met the inclusion criteria. The participants were recruited based on the following inclusion criteria: full-time faculty, full-time academic support staff members (those individuals directly related to the academic advising center, etc.), upper level administration (including the health center director and student disability office), and staff in the athletic department. Participants were not recruited for the study if their primary job description and duties fell outside one of the categories listed above. Each participant reviewed the informed consent and electronically accepted to participate in the study prior to taking the survey. Data were collected for a total of two weeks. Reminder emails were sent out to participants after the survey had been open for 7 days and another reminder was sent out after 11 days to participants that had not completed the survey. Participants were able to take the survey on computer or mobile devices. Participants were able to withdraw from the study at any time without repercussions. Overall, 123 participants out of 353 who received the survey responded, which is a 34.8% response rate (Table 1). The largest demographic categories of participants in the current study were primarily over age 51 (40%), female (57%), and had been with the University between 0 and 5 years (42%). A majority of the sample had teaching responsibilities with the University (75%), participated in organized sports (82%), and had never sustained a concussion (80%). Finally, while 73% of respondents report having encountered students who have been diagnosed with concussion, only 48% report providing accommodations with students who had a previous concussion. Notably, a majority of respondents reported not being aware of University concussion protocols (72%). The current concussion protocols include both return-to-play and return-to-learn guidelines that are consistent with the NCAA ² and the National Athletic Trainers’ Association (NATA) ³ best practices. The NCAA mandates each member institution to have these protocols in place.

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Table 1.

Demographic characteristics of participating faculty and staff.

Characteristics	Proportion of participants
Gender a  (%)
Male	42.3
Female	56.9
Age group (%)
20–30	13.9
31–40	22.7
41–50	23.6
Over 51	39.8
Institutional department (%)
Athletics	12.2
Health Sciences	30.1
Humanities	21.1
Business	12.2
Support	10.6
Other	13.8
Year service (%)
0 to 5 years	42.3
6 to 10 years	20.3
11 to 15 years	16.3
15+ years	21.1

^aOne participant chose not to identify their gender.

Instrumentation

The instrument used for this study was originally developed by previous researchers from the British Columbia Injury Research & Prevention Unit and was modified with permission. ¹⁶ The original survey included questions in two main subcategories: attitude and knowledge. The survey was modified to include questions divided into demographic, awareness, and knowledge subcategories. Because the original survey included questions related to parents, players, and coaches, the modified survey reworded survey questions to apply to faculty, athletic administration, and academic support staff. The new instrument was named the Faculty & Staff Concussion Awareness and Knowledge Survey (FS-CAKS). The FS-CAKS consists of 10 demographic questions to address age, gender identification, university department, teaching responsibility, years of service to the institution, participation in organized athletic history, concussion history, encounters with students with concussions, experience with academic accommodations, and awareness of concussion protocols at the institution. The FS-CAKS also assessed participants’ perceived awareness of the impact of concussions on students’ ability to return to learn as well as their knowledge of concussion symptomology. The awareness subcategory of the FS-CAKS survey consisted of Likert-Scaled items with ratings of strongly agree to strongly disagree which was a modification from the original survey. The knowledge subcategory required participants to answer knowledge-based questions that included the following types of questions: select all that apply, true/false, yes/no, or multiple choice answers. Final knowledge scores were calculated by totaling the number of correct responses participants provided for each question (Appendix 1).

The FS-CAKS was then validated by experts for content and face validity, including two academic faculty; licensed as athletic trainers (ATs) specializing in concussion research, two licensed ATs involved with over 20 years of experience, a neuropsychologist, a physical therapist specializing in neurological disorders, an epidemiology specialist, an mTBI researcher, a physician, and an audiologist. The expert panel received the survey instrument and was asked to rate how well the questions were related to the study purpose and to review the content for applicability and clarity (Table 2).

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Table 2.

Expert panel instrument rating scale.

1 = no relationship to the purpose – question not needed

2 = there may be a relationship to the purpose – the researchers should investigate if the wording should remain

3 = the question is good but should be reworded (please provide an example)

4 = strong relationship to the purpose – question should remain in the survey

The expert panel was also asked to provide any comments at the conclusion of the survey to aid with survey clarity and content to increase the content validity of the instrument. After the responses were received, a master survey with each expert’s ratings was compiled and the researchers reviewed all the items. If there is any instrument question with which the majority of the experts were in agreement, then the question was retained as a part of the survey. If the majority of the experts agreed that the question did not fit with the purpose of the study, then the question was removed from the instrument. If there was not a majority decision based on expert review, then the researchers would discuss revision of the question. Nine questions were removed from the study based on content validation. All other questions were kept and/or revised to provide clarity to the participants. The expert panel was also asked to provide opinion regarding the appropriateness of the subcategories of the instrument. There were five questions that were moved between subcategories for clarity.

Results

Descriptive statistics

Frequency statistics were compiled for age, gender identification, institutional department, teaching responsibility, years of service to the institution, participation in organized athletics, concussion history, encounters with students with concussions, experience accommodating students with concussions, and awareness of concussion protocols (Tables 1 and 3).

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Table 3.

Experiences with athletics and concussion of participating faculty and staff.

Characteristics	Proportion of participants
Participation in organized athletics (%)
No	17.9
Yes	82.1
Sustained a concussion (%)
No	65.0
Yes undiagnosed	18.7
Yes diagnosed	16.3
Encounter students with concussions (%)
No	26.8
Yes	73.2
Provide services to concussed students (%)
No	52.0
Yes	48.0
Awareness of concussion protocols (%)
No	71.5
Yes	28.5

Note: Percentages represent proportion of the respondents (n = 123).

Participants reported a relatively high level of awareness for concussion symptoms (range: 2.58–5.00, M = 4.16, sd = .43) and on average demonstrated knowledge of concussion treatments (range: 0.00–13.00, M = 10.37, sd = 2.17). The correlation between faculties’ awareness of concussion symptoms and their knowledge of treatment was not significant.

Awareness of concussion symptoms

A one-way between subjects ANOVA was conducted testing differences in the level of awareness of concussion symptoms between faculty and staff of different institutional departments (i.e., Athletics, Health Sciences, Humanities, Business, Support Staff, Other). Analyses revealed a significant effect of college on individuals’ level of awareness (F (5, 117) = 9.74, p < .001). Post hoc tests revealed that faculty and staff from the business school demonstrated significantly lower levels of awareness when compared to all other academic colleges (see Figure 1; Tukey’s HSD: Support Staff Q(117) = −.706, p = .001; Athletics Department Q(117) = −.767, p = .001; Health Sciences Q(117) = −.692, p = .001; Humanities Q(117) = −.479, p = .002; Other Q(117) = −.381, p = .005). Further analyses revealed that females demonstrated significantly more awareness of concussion symptoms than males (see Figure 2; F (1, 121) = 4.394 p = .04), while those who had prior experience providing accommodations to students demonstrated more awareness of concussion symptoms when compared with those who no experience providing accommodations of students with concussions in the past (see Figure 3; F (1, 121) = 10.488 p = .002).

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Figure 1.

University department predicting awareness of concussion symptoms.

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Figure 2.

Gender differences in awareness of concussion symptoms.

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Figure 3.

Association between history of providing accommodations and awareness of concussion symptoms.

Participants’ awareness was not significantly associated with their personal experience of concussion, past participation in athletics, experience or age (all ps > .05).

Knowledge of concussion treatment

The second series of ANOVAs examining differences between groups of participants on their knowledge of proper concussion treatment revealed only one significant difference. One-way between subjects ANOVA revealed that university college significantly impacted participants’ knowledge of proper concussion treatments (F (5, 117) = 3.67, p < .004; Figure 4). Post hoc tests revealed that faculty and staff from the business school demonstrated lower levels of knowledge than participants from the School of Health Sciences (Tukey’s HSD: Q(117) = 2.401, p = .003) and Other (Tukey’s HSD: Q(117) = 2.325, p = .023).

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Figure 4.

University department predicting knowledge of concussion treatment.

Participants’ past provision of accommodations for students who had experienced concussion was also found to be associated with their knowledge of concussion treatment (F (1, 121) = 4.046, p = .047). Individuals who had provided accommodations were better able to identify proper treatment for concussions than those who had not provided accommodations in the past (Figure 5). Age, gender, participation in organized athletics, concussion history, encounters with students with concussions, and awareness of university concussion protocols were not significantly associated with participants’ knowledge of proper concussion treatment (all ps > .05).

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Figure 5.

Associations between history of providing accommodations and knowledge of concussion treatment.

Discussion

The purpose of this study was to assess faculty and academic support staff awareness and knowledge regarding concussions and student learning. The results of this study found several areas that faculty and staff across the university were lacking in knowledge and/or awareness related to concussions and student learning. Specifically, gender, academic department, and previous experience providing academic accommodations helped to project faculty and staff’s level of knowledge and awareness of concussions.

In our research, women had slightly higher awareness of concussion symptomology compared to men from the response rates on the given survey. Current literature supports differences between genders on general concussion awareness. ¹⁷ Carzoo et al. ¹⁷ found that female secondary school educators’ improved their knowledge of academic concussion management following a 30-min didactic presentation to a greater extent when compared to their male counterparts. Much like the current study, questionnaires were administered to assess concussion knowledge and management in an academic environment. There is also evidence of gender differences regarding concussion symptomology and how it relates to mental health. Topolovec-Vranic et al. ¹⁶ identified that out of 6937 respondents of all ages and roles that ranged from athletes, parents, coaches, teachers and medical personnel, 55% of females reported accurate identification of concussion symptoms related to mental health while males scored 50.9% (p < .05).

Faculty are poised to be in a position to identify early signs of frustration and anxiety because of the regularity in which they see the students during the academic year. Based on faculty’s unique relationship with the students in the classroom, it is important for a university to consider a university-wide holistic approach to concussion management to support both the students and student-athletes who experience this pathology. ¹⁸ A holistic approach to concussion management could utilize on-campus team physicians, ATs, mental health providers, and community-based healthcare providers to create a concussion management plan.

Our survey also reviewed the difference of awareness and knowledge of concussion between various colleges. The College of Business & Engineering faculty and staff scored significantly lower than the College of Health Sciences and Professions (CHSP) faculty and staff and other employees of the university that self-described as not working in a specific department, regarding awareness of concussions. However, while there has not been a study that investigates concussion awareness of individual academic departments, the health programs are housed in the CHSP and one would expect that their medical training would improve their awareness scores. Topolovec-Vranic et al. ¹⁶ suggested that appropriate education and training in recognizing concussion symptoms was essential to increase people’s awareness and knowledge, regardless of their age or background. Similar to the previous research, ¹⁴ knowledge and awareness for educators is essential, but proper collaboration between academic administration and university health services is essential.

Our findings highlight that faculty and staff in colleges other than the CHSP lack knowledge and awareness of concussion symptomology, so collaboration in the management of concussions for students is essential for successful outcomes. In fact, Topolovec-Vranic et al. ¹⁶ determined that lower levels of knowledge related to concussion symptomology correlated with higher severity of post-concussion symptom reports. However, including education about concussions early on correlated with a reduction in symptom severity. Educator’s awareness and knowledge of concussion management can assist in minimizing post-concussion symptoms and prevent prolonged recovery.

Educators with previous participation in providing accommodations for students with concussions were able to identify a decline in academic performance and recommend academic accommodation more often. ¹⁸ While athletes are closely monitored after concussions and they are instituted in a return to play protocol with supervision from ATs and a physician, the same approach needs to be taken for non-athletes through instituting a return to learn protocol with a management team available.

Sady et al. ⁴ investigated the effects that learning protocols and comprehensive team management had on the outcomes for a concussed student. Their paper suggests school-based education and management of concussion programs include established policies and procedures, education, and training for school personnel and consistent implementation of a plan to address student needs after a concussion. ⁴ The research concluded that educators, who participated in the management of academic accommodations for a student with a concussion, demonstrated higher levels of concussion awareness and knowledge. ⁴ Consistent with other research, the faculty and staff in the current study who acknowledged previous participation in providing academic accommodations for students who had a concussion diagnosis demonstrated a greater awareness of concussion symptoms.

Our current research showed that faculty and staff members had a positive awareness of the impact of concussion for student’s academic and personal development. There was no correlation between participant’s awareness of concussions and the degree to which the participants answered knowledge questions about return to learn protocols. An individual’s awareness of concussion symptomology had little relation to his or her knowledge of the timeline for a student to return to an academic environment following a concussion. This finding supports the need for extending educational programs related to concussion management to faculty and staff. Time is often a confounding factor in gaining the support and participation in professional development activities. However, Carzoo et al. ¹⁷ concluded that even a 30-min concussion education program improved concussion knowledge for secondary educators.

Previous participation in athletics did not correlate with a higher knowledge or awareness of concussion symptomology. Our study identified that 82% of respondents reported previous participation in organized sports at various levels of competition. Although not significant overall, previous participation in organized sports could be a contributor to our findings that women have a higher awareness and knowledge of concussion symptomology because 57% of survey respondents were female.

Conclusion

This research is important to highlight the lack of knowledge and awareness of the management of concussions on college campuses. College administrators should be aware that while the preponderance of concussions typically occurs within the student-athlete population, other students that are on campus and participate in recreational activities or as a result of other accidents may experience concussions. Proper faculty and staff education on signs, symptoms and protocols to be followed after a student sustains a concussion are important for the students’ academic success. Creating an educational component related to concussion signs and symptoms and academic management for college faculty and staff is imperative for the best holistic approach to returning students to the classroom. This research revealed the importance of return to learn procedures that need to be instituted, communicated to faculty, and students are closely followed throughout the process. One solution is to include the development of a team including professors, ATs, physicians and other health care professionals to create a collaborative return to learn protocol. Return to play and return to learn protocols need to go hand-in-hand to keep all students safe and to decrease the incidence of improper care and handling of student concussion that contribute to prolonged recovery.