Athletic Trainers' Attitudes and Perceptions Regarding Exertional Heat Stroke Before and After an Educational Intervention
Death from exertional heat stroke (EHS) is preventable when evidence-based guidelines are followed. The assessment of core body temperature using rectal thermometry and the treatment of cold-water immersion for EHS has been established as the standard of care; however, rectal thermometry is still controversial. Athletic trainers (ATs) may lack knowledge and comfort with this skill, which could impact implementation. Examine ATs' current practices, attitudes, and perceptions regarding EHS before and after an educational intervention. Prequantitative/postquantitative experimental. Classroom. Twenty-five ATs in various athletic training settings. Educational intervention designed to increase knowledge and address negative attitudes and perceptions regarding EHS evaluation and treatment. Attitude and perception scores. Prior to the educational intervention, most ATs (86.9%, 20/23) reported that they use methods other than rectal thermometry to evaluate EHS. Of those who did not use rectal thermometry, their reasons included: lack of equipment/budget, concerns about liability/lack of consent (especially when dealing with minors), lack of training, and/or concerns about the privacy, embarrassment, compliance of the athlete. Cold-water immersion was chosen as the definitive method of cooling an athlete by only 41.7% (n = 10) of participants. Following the educational intervention, attitudes toward the use of rectal temperature to assess core body temperature (t[24] = 8.663, P < .001) and cold-water immersion treatment for EHS (t[24] = 4.187, P < .001) were significantly improved. However, while attitudes toward the use of other “cold” methods to treat EHS were not significantly changed (t[24] = 1.684, P = .105), perceptions regarding nonexertional influences on EHS were significantly improved (t[24] = 1.684, P = .105). This study demonstrated that a 3-hour educational intervention can improve attitudes and perceptions regarding the assessment and treatment of EHS in the short term. It is important that educational interventions use best-practice continuing education methods and include special attention to the barriers to evidence-based practice.Context:
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Exertional heat stroke (EHS) is a serious heat illness that can be caused by vigorous exercise, most often in a hot environment. It results when the body's temperature regulation system becomes overwhelmed and is unable to dissipate the environmental and metabolic heat. Exertional heat stroke is characterized by a core body temperature greater than 105°F (40.5°C) and associated central nervous system dysfunction. Exertional heat stroke is one of the leading indirect causes of death in athletes.1–6 While EHS is a concern for all organized sports, it is most prevalent in football, with approximately 3 EHS-related deaths occurring annually. Recent data show an alarming trend toward increasing frequency of EHS-related cases each year.7,8
If not recognized early and treated properly, EHS can result in multisystem organ failure and death. However, with immediate recognition and treatment, EHS-related deaths are preventable.1–7 Since the total time core body temperature remains above 40.5°C predicts the eventual outcome, current best-evidence is to recognize EHS early and cool the athlete as rapidly as possible.6,9 For example, some research demonstrates a 100% survival rate without complications when cooled within 30 minutes.9
Since 2002, the standard of care directs rescuers to assess core body temperature using rectal thermometry and treat EHS patients with cold-water immersion (CWI).1–4 Athletic trainers (ATs) are often the first health care providers on scene to recognize and treat EHS; thus, they should be prepared to use both rectal thermometry and CWI. Unfortunately, due to myriad factors, ATs appear unprepared to perform these 2 skills.
Research published since 2010 indicates that fewer than 20% of ATs use rectal thermometry to accurately assess core body temperature.5,10,11 Reasons for nonuse include: lack of knowledge (and the gap increases the further removed one is from their formal education), lack of comfort with the skill (because of being untrained and/or because high school athletes are minors), a concern over liability (due to the perceived invasiveness of taking a rectal temperature and/or a breach of privacy), and/or a lack of resources (including administrative support and/or finances).10–13 Those and other studies also demonstrated that approximately half of ATs are using CWI as the definitive treatment for EHS.5,10,11
One reason for the lack of knowledge and negative attitudes/perceptions regarding evidence-based EHS recognition and treatment might stem from a lack of formal education. A study14 published in 2011 demonstrated that athletic training programs were teaching the principles published in the 2002 National Athletic Trainers' Association (NATA) Position Statement on EHS, including rectal thermometry, but not providing authentic skill practice opportunities. The lack of hands-on training to build comfort and confidence was thought to be a major roadblock to its integration into clinical practice.5,14 This issue was partially addressed with the mandated transition from the 4th Edition Educational Competencies to the 5th Edition in 2014 which requires practical application during educational training.15–17
Athletic trainers play a vital role in the recognition and proper treatment of EHS; their prompt action can limit morbidity and mortality. However, some ATs do not possess adequate knowledge and skills regarding the recognition and treatment of EHS because they were educated before the 2002 NATA Position Statement4; their education programs did not provide authentic practice opportunities with the skills; and/or they have failed to seek the knowledge/skills since their formal education. Some ATs do possess adequate knowledge and skills, but there are real or perceived barriers to implementation that cause negative attitudes and perceptions. Kerr et al indicated an urgent need to increase education on proper assessment and treatment of EHS using the skills of rectal thermometry and CWI.5 Continuing education programming is one way to bridge this gap, as it can provide the practitioner with the chance to learn and implement the skills in a controlled environment which can directly support proper implementation. Since the issue forestalling implementing best practices for EHS is often the perception of lack of knowledge and comfort with the skills, educational interventions may serve as the solution. Therefore, this study examined ATs' current practices, attitudes, and perceptions on EHS before and after an educational intervention.
METHODS
Participants
Participants were a convenience sample of ATs who registered for and attended either of 2 continuing education sessions. Thirty-eight individuals attended the continuing education sessions, 25 (66%) of whom completed a prequestionnaire and postquestionnaire via paper and pencil. Therefore, the data analysis included those 25 (66%) participants. Participant demographic information is presented in Table 1.
Instrument
The questionnaire contained 3 sections. The first included questions regarding the attitudes and perceptions regarding assessment and treatment of EHS. The second and third sections included current practice and demographic questions. The first section included 19 items and was designed and validated by Burton and Mazerolle in 2011. Their research validated the instrument, identified the factor loadings, and established the appropriate level of reliability.18 The questionnaire contained 5 constructs: attitudes toward use of CWI (8 questions), coaches' support of EHS prevention (3 questions), attitudes regarding rectal temperature in EHS evaluation (3 questions), attitudes toward use of other “cold” methods (3 questions), and perceptions regarding nonexertional influences on EHS (2 questions). Participants were asked to rate their level of agreement with the statements using strongly agree (5), agree (4), neither agree nor disagree (3), disagree (2), and strongly disagree (1).
An additional 6 questions were added to the original instrument to further discern participants' current practices. Of these, 3 questions were open-ended inquiries about the ATs' current core body temperature assessment method, current EHS treatment protocol, and current return-to-play protocol, 2 invited participants to explain why they chose any other method other than rectal thermometry or CWI (if applicable), and 1 asked who would provide final clearance for an athlete to return to play after EHS.
In the demographic section, 2 questions asked participants if they have read the NATA's 2002 Position Statement4 (the 2015 Position Statement had not been published yet at the time of the study) and either the 2007 and/or 1996 American College of Sports Medicine Position Statements3,19 regarding exertional heat illness. Additional questions included information on past/current supervision of students in an accredited program, age, district, highest educational degree, duration of certification, current job position, and an estimation of the number of EHS cases they have treated in the past.
Procedures
Two 3-hour continuing education sessions were offered, and both were advertised as opportunities for ATs to update their acute care skills. The first course was advertised to local ATs. The second course was advertised as a workshop at a state annual symposium. Both sessions included the knowledge and skills that had been recently added to the Acute Care content area of the 5th Edition Athletic Training Educational Competencies: airway adjuncts, suction, pulse oximetry, glucometer, rectal thermometry, and simulated CWI.15 The sessions included a lecture using a PowerPoint, group discussion, question-and-answer time, and laboratory practice. For the rectal thermometry laboratory, participants were able to practice using 2 enema trainer models (wearing shorts), a DataTherm Continuous Temperature Monitor, several disposable rectal thermometers/sheaths, lubrication, and scissors. For the CWI laboratory, participants used a tarp, simulated water, and each other to simulate the “taco method” of immersion. Video was used to demonstrate immersion in a tub.
The 2 courses were designed and instructed by 2 athletic training educators with 35 combined years of experience as certified ATs and 23 years combined experience as athletic training educators. Care was taken to address the concerns found in the literature including lack of knowledge, comfort with the skill, practicality, liability concerns, privacy concerns, and resources. Athletic trainers could take part in the educational intervention (the continuing education session) regardless of whether they participated in the research. Registration was limited to 30 or fewer participants to ensure ample time to practice with the equipment.
The research proposal was evaluated and approved as exempt from regulation by the researchers' university Institutional Review Board. Participants were informed, and their completion of the questionnaire served as their consent to participate. Participant recruitment and data collection took place in 2013. Data were analyzed during the summer of 2014.
Data Analysis
The results were analyzed using SPSS (version 21; SPSS IBM, New York). Response frequencies were calculated for each individual Likert question. Additionally, the researchers calculated pre-educational and posteducational intervention scores for each of the 5 constructs: attitudes toward use of CWI (8 questions), coaches' support of EHS prevention (3 questions), attitudes regarding rectal temperature in EHS evaluation (3 questions), attitudes toward use of other “cold” methods (3 questions), and perceptions regarding nonexertional influences on EHS (2 questions). Four paired samples t tests and confidence intervals (95%) were calculated to determine whether significant differences existed between participants' pre-educational and posteducational mean scores for 4 of the 5 constructs. One factor, coaches' support of EHS prevention, was removed from the analysis because it did not address the ATs' attitudes and perceptions regarding exertional heat illness. Because 4 comparisons were made, the α level was set at P ≤ .0125 (.05/4).
RESULTS
Demographics
Of the 38 ATs who attended the continuing education sessions, 25 (66%) between the ages of 21 and 60 years old completed both the prequestionnaire and postquestionnaire. Most respondents reported that they were from District IX (n = 21, 84%), which is located in the southeastern part of the United States. The mean number of heat stroke cases that participants estimated they had treated was 1.13 ± 1.66 cases with a range of 0 (n = 13, 52%) to 6 (n = 1, 4%) cases treated. Additional participant demographic information and descriptive information are presented in Table 1.
Current Practice
Twenty-three participants answered the question: “When assessing and treating exertional heat stroke, what do you use for temperature assessment?” Ten (43.5%) reported using an oral thermometer, 7 (30.4%) reported using no thermometer—only signs/subjective, 3 (13%) reported rectal thermometer, 2 (8.7%) reported ear thermometer, and 1 (4.3%) reported other thermometer. Those who chose a method other than rectal temperature provided differing responses as reasons (open-ended questions and multiple responses allowed); the 2 most prominently cited reasons were lack of equipment/budget (n = 7) and concerns about liability/lack of consent, especially when dealing with minors (n = 7). Other cited reasons were a concern over the privacy/embarrassment/compliance of the athlete (n = 3) and a lack of training to perform the skill (n = 2). Twenty-four participants answered the question: “What do you use to rapidly cool a person suspected of exertional heat stroke?” Ten (41.7%) participants reported cold immersion, 5 (20.8%) reported ice bags and cold towels, 4 (16.7%) reported ice packs in armpits/groin, 3 (12.5%) reported cold towels, and 2 (8.3%) reported cold dousing.
Attitudes and Perceptions Before and After the Educational Intervention
Response frequencies for each of the attitudes and perceptions questions were calculated before and after the educational intervention. Results are reported in Tables 2 and 3, respectively. Scores were then aggregated for each of the AT related constructs. Because we aimed to determine whether the educational intervention changed the ATs' attitudes and perceptions, the factor regarding coach support was not included in the analysis. Internal consistency of the questionnaire without this factor (3 questions removed) was considered to be good (α = .728).
Two sets of questions were found to have both normal distributions and improvement in attitudes after the educational intervention. Paired samples t tests demonstrated statistically significant differences in attitudes regarding rectal temperature in EHS evaluation (t[24] = 8.663, P < .001) and attitudes toward use of CWI (t[24] = 4.187, P < .001). Two sets of questions were found to have somewhat nonnormal distributions. The paired samples t tests did not demonstrate statistically significant differences for attitudes toward use of other “cold” methods (t[24] = 1.684, P = .105), but did demonstrate statistically significant differences for perceptions regarding nonexertional influences on EHS (t[24] = −5.414, P < .001). Complete results are reported in Table 4.
DISCUSSION
A review of the literature revealed 3 studies that examined the various methods used to assess core body temperature and cool patients with suspected EHS. Fewer than 20% of ATs in those studies were using rectal thermometry, and only about half were using CWI.5,10,11 Similarly, our study found that 13% were using rectal thermometry and 41% CWI. Our study also corroborated existing evidence that the barriers to implementing evidence-based practice include, but are not limited to, lack of equipment/budget, liability/lack of consent (especially with minors), concerns of embarrassment/invasiveness/privacy, and lack of training.10,11
In 2016, Cleary et al examined participants' attitudes and perceptions before and after an educational intervention. They found that their educational intervention created an increased likelihood of using rectal thermometry, where 6.4% indicated they would use it before the intervention and 58.1% after.11 The paired samples t tests in the present study also demonstrated significant improvements between pre-educational and posteducational intervention attitudes toward the use of rectal thermometry and CWI. Pre-intervention scores indicated that participants believed that state practice acts and/or budget constraints would prevent the use of rectal thermometry, whereas postintervention scores revealed disagreement that those barriers were as prohibitive.
In practice, these 2 changes in attitude scores could translate to increased likelihood that the AT will assess and treat an athlete with suspected EHS properly. However, significant real or perceived barriers to implementation exist and are not all within the control of the AT.10–13 In addition, continuing education research demonstrates that short-term improvements in knowledge and/or attitudes do not necessarily correlate to long-term improvements or change of practice.20–25
Barriers to Optimal Health Care
Clear guidelines have been given to ATs via the NATA,1,4 the American College of Sports Medicine,3,19 and the Inter-Association Task Force2 demonstrating that rectal thermometry and CWI are the gold standards in assessment and treatment of EHS. However, knowledge is not the only factor that leads to evidence-based practice, and ATs are not the only health care providers who struggle to provide it.23–25 There are several types of barriers to optimal health care, including cognitive-behavioral, attitudinal or rational-emotional, professional barriers, and support or resources.20
Cognitive-behavioral barriers include a lack of awareness, knowledge, or professional/appraisal skills.20 A cognitive-behavioral barrier for ATs is often inadequate knowledge and/or skill. Some ATs believe that they can just use signs and symptoms to diagnose the various heat illness possibilities and do not fully appreciate the role of core body temperature assessment to provide an accurate diagnosis and determine when removal from CWI should occur. Educational interventions designed to bridge this barrier must include attention to the scientific evidence surrounding the evaluation and treatment of EHS. These educational interventions should be available to both ATs and school administrators who oversee ATs. Athletic training program curricula and continuing education programming should emphasize the importance of understanding and adhering to the established evidence-based recommendations.
Attitudinal or rational-emotional barriers and professional barriers seem to be common among ATs. While attitudinal or rational-emotional barriers include a lack of confidence in knowledge or skill level, feelings of lack of authority, and/or lack of outcome expectancy, professional barriers include perceived or actual professional boundaries, concern of litigation, lack of appropriate peer modeling, and/or individual characteristics like motivation, experience, age, and gender.20 Some ATs reported a fear of litigation if they take a rectal temperature on an athlete, especially a minor. However, they fail to recognize that their status as a credentialed health care provider provides the authority and mandate to do so. In order to address this barrier, 2 things should be examined. First, ATs, and the physicians/administrators who oversee them must understand that they are credentialed health care providers who have the authority and duty to treat EHS properly regardless of whether a patient may have some privacy exposure in the process. To put this into perspective, when applying an automated external defibrillator during cases of suspected cardiac arrest, ATs expose the chest because using the accepted standard of care overrides the concern for patient privacy. Both demonstrations of and practice opportunities for thermometer insertion can reaffirm that the skill can be done with minimal exposure and alleviate undue privacy concerns. Second, ATs and the physicians/administrators who oversee them must understand that, given their duty to uphold the established standard of care, they are at far greater risk for a negligence claim if they do not perform rectal thermometry for cases of suspected EHS.14
The last barrier, support or resources, included human and material resources, finances, and time.20 This barrier can be addressed by outlining the prices for the items that are needed to properly assess and treat EHS (rectal thermometer, thermometer covers, water-based lubricant, and baby pool or tarp for the taco method). These items can be purchased for a nominal price that is within a reasonable budget for most athletic training settings. Evidence suggests that, although an AT may support the evidence-based assessment and treatment of EHS, their overseeing physician and/or administrative authority may not. Athletic trainers who face this challenge will need to bridge this gap by providing these individuals supporting evidence for their use.
When exploring this study's results in relation to barriers, we found that, while the educational intervention was effective in changing immediate attitudes related to the use of rectal thermometry and CWI for EHS, the attitudes regarding the use of other treatment methods did not significantly change. This is concerning given the depth of evidence provided on the inadequacies of other assessment and treatment methods and could be explained by some of the very real concerns the participants had with the perceived administrative support at their school. During the educational intervention, many participants stated that they strongly believed that, despite their own knowledge and comfort with the evidence and skill, they would be met with a great deal of resistance by administrators, parents, and athletes. Some ATs also stated that their school administrator or overseeing physician explicitly prohibits the use of rectal thermometry despite evidence that it is the standard of care for EHS.
Transfer of Continuing Education Knowledge to Practice
The educational intervention in this study improved attitudes and perceptions about the assessment and treatment of EHS by addressing the barriers found in the literature. However, the ultimate goal of this kind of continuing education course is to improve patient outcomes. Neither this research nor the Cleary et al study11 assessed whether the participants' knowledge, attitudes, and perceptions improved over the long-term or if they translated to better patient care. In fact, there are very few studies in the AT literature that evaluate retention and/or transfer of knowledge/skill after completing a continuing education program.21 There is also conflicting evidence from other health care disciplines about whether continuing education programs have a positive effect on knowledge acquisition, knowledge retention, transfer of knowledge to practice, or improvements in patient care.22–25 However, a substantive body of evidence suggests that programs which are interactive/hands-on, combine didactic and laboratory experiences, and involve real-life problems are more effective at changing behavior than other forms of continuing education.24–26 Therefore, while the literature does support the continuing education program format offered in this study, it is unknown whether the knowledge and improved attitudes transferred to practice.
Since this study was unable to assess long-term attitudes, perceptions, knowledge, or EHS practice changes, future research should be longitudinal in nature to determine if these changes were retained after an educational intervention. In addition, the follow-up should assess whether the ATs purchased required equipment and implemented the learned evidence-based practice behaviors. Lastly, while the literature and anecdotal evidence suggests that barriers put upon ATs by administrators and other health care providers (eg, team physicians) may be significant, the researchers did receive several e-mails from participants who indicated that they had either purchased the items needed to carry out the standard of care and/or they had addressed the matter with their team physician and/or administration.
LIMITATIONS
Given the relatively small convenience sample used in this study, our responses cannot be strictly compared to previous research to determine if EHS practices are changing. In the future, it will be important to conduct a larger-scale study to explore whether the explicit requirement for rectal thermometry and CWI use mandated in the 2011 5th Edition Educational Competencies15 increased the use of these evidence-based practices for EHS evaluation and treatment. In addition, the study may have had a sampling bias because the ATs who participated sought out a continuing education course on the topic and, therefore, may have had more interest and willingness to learn.
CONCLUSIONS
It is apparent that most ATs are not using rectal thermometry as the definitive method of assessing core body temperature in a patient who is suspected to have EHS. Additionally, CWI is not being used as the gold standard intervention to cool an athlete who is suspected to have EHS. In this study, a 3-hour educational intervention using best-practice teaching methods and including special attention to the barriers to implementing evidence-based practice did improve attitudes and perceptions regarding the assessment and treatment of EHS in the short term. It is necessary to determine whether such an educational intervention will improve attitudes and perceptions in the long term and if these changes translate into evidence-based clinical practice and improved patient outcomes.
Contributor Notes
Dr Schellhase is currently Program Director for the Athletic Training Program in the Department of Health Professions at the University of Central Florida. Please address all correspondence to Kristen Couper Schellhase, EdD, Department of Health Professions, Athletic Training Program, University of Central Florida, 4000 Central Florida Boulevard, Orlando, FL 32816-2205. kristen.schellhase@ucf.edu.