Athletic Training Educators' Pedagogical Strategies for Preparing Students to Address Sudden Death in Sport

Participant Recruitment and Data

Predetermined participant selection criteria¹⁴ included being an AT faculty member employed in a Commission on Accreditation of Athletic Training Education (CAATE)–accredited program who taught content regarding preventing sudden death in sport. To help facilitate participant recruitment, an e-mail explaining the study and steps for data collection was sent to 75 program directors (PDs). The use of PDs as gatekeepers was necessary,^14,15 as currently there are no databases in existence from which to access individual instructors within CAATE-accredited programs. The programs selected represented a random distribution by region and size of the institution. The PDs both read and forwarded the e-mail to any prospective participants at their institution. Those who were interested in participating contacted the investigators directly to initiate data collection procedures. In total, 2 rounds of e-mail solicitations reached potential participants at 150 different CAATE-accredited programs.

The recruitment process yielded 12 participants (8 male and 4 female) from a variety of institution types, including private, public, and baccalaureate-, masters-, and doctorate-granting colleges and universities. These individuals had been board certified for 15 ± 9 years, had worked as faculty members for 13 ± 8 years, and had 11 ± 10 years of clinical experience (Table 1). Data analysis revealed redundancy and saturation with these participants.

Table 1. Participant Demographic Data

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Data Collection

Participants began the data collection process by completing a background questionnaire through SurveyMonkey. This questionnaire collected general demographic data and used Likert-scaled questions to rate participants' perceptions about how and to what depth sudden death in sport was taught^11,12 in their curriculum and the general sequencing of the topic in their program (Appendix 1). Next, participants completed a semistructured telephone interview that used researcher-developed, open-ended questions (Appendix 2). This format was selected because of the flexibility afforded to explore the topic in depth and ascertain each program's individual characteristics.¹⁴ Interviews were conducted at the participant's convenience during the spring semester of the academic year, and lasted approximately 30 to 45 minutes. All telephone interviews were transcribed verbatim, with participants given pseudonyms.

The interview guide was developed by the same 5-member research team who developed the survey instrument, and included 2 AT educators, 2 graduate assistant athletic trainers, and 1 qualitative researcher. The members used the existing literature on sudden death in sport,^11,12 educational methods,¹⁴ and the research agenda to develop the open-ended questions. Two experts with backgrounds in sudden death, AT, and emergency medical care who were not involved in the data collection procedures reviewed both the survey questionnaire and the interview guide before data collection. Their feedback was used to update the data collection tools, and included several formatting items, removal and addition of questions, and rewording for clarity. A pilot study was conducted, after the initial review by the experts, with a small cohort of AT educators (n = 2), and generated further minor revisions to both the background questionnaire and interview guide. The data generated in the pilot was not included in the final analysis.

Data Analysis and Trustworthiness

Data were analyzed using the inductive approach as described by Thomas.¹⁶ Using the research agenda and questions themselves, this systematic approach included several steps, including (1) an initial evaluation of the transcripts to gain a holistic understanding of the data, (2) labeling specific incidents to represent their meaning, and (3) categorizing similar labels into a conceptual model. Frequencies, means, and standard deviations were all calculated for items on the background questionnaire, including both the Likert-scaled questions and the basic demographic information.

Research procedures credibility and data trustworthiness were established using 3 strategies: (1) methodological triangulation,¹⁴ (2) participant verification,¹⁴ and (3) multiple-analyst triangulation.^14,17 Using information from both in-depth phone interviews and the survey questionnaire helped triangulate the results,^14,17 and participant verification was secured by allowing the subjects to review and edit their transcripts before analysis to ensure accuracy. Three researchers, including 1 graduate student and 2 experienced qualitative researchers, autonomously analyzed the data. All 3 coders were in agreement in the final presentation of the data.

Current Trends

The dominant theme, current trends, was expressed by the AT educators' selections of materials related to sudden death, which were driven by current NATA position statements, information discussed within the media particularly related to case studies or policy changes, or a combination of both factors. Several AT educators discussed the recent NFL policy changes regarding concussion evaluation and management protocols as important issues to discuss with their ATSs. Tim said,

I mean me personally [for my class] I teach the head, neck, and spine. We spend a lot of time on concussions. I'm not going to lie, simply because there's so much out there right now [media and literature] and it's really a hot topic right now.

Other AT educators developed course materials, as well as structured their curricula around the current NATA position statements dealing with sudden death, such as those on cervical spine, concussion, and exertional heat illnesses. Kevin reported,

One thing that I've done in the past several years in the classroom, and this is my core athletic training courses [only ATS]. I incorporate the NATA position statements and position stands. I have quizzes over those particular materials.

Athletic training educators know that the hot topics of concussions, cervical spine injuries, and cardiac conditions are pressing issues currently being addressed by state legislatures, and that prevention and treatment methods are under constant scrutiny and change. Damon states,

I am very aware of all the different concussion legislation in our country regarding the occurrence of head injuries and the prevention of sudden death; so it is really kind of a combination of different things [that influence me], but I would say those [conditions] are the predominant areas right now and are important for discussion.

Athletic training educators noted that the increased media coverage reinforced pertinent topics related to sudden death, and that the media can strongly influence their ATSs, as many watch professional sporting events and will critically evaluate how potential injuries or conditions are managed. Diego shared a question he fielded in his class:

Case and point there was a case last year [reported in the media] with an NFL football athlete [cervical spine injury]. They removed his helmet and put towels underneath his head. They didn't remove the shoulder pads, they log rolled him, and took him off on a stretcher. My students wanted to know: “Why did they do that? Why did we see an NFL athlete go off the field [with no helmet and shoulder pads still on]?”

Awareness of current case studies, as depicted by real life, media, or the literature, was an important factor for this group of AT educators' decisions regarding course development and presentation of materials to the ATS.

Regional Bias

Regional bias, the second theme, illustrated the influence of the AT program's (ATP's) location within the United States. Participants reported spending an average 4% of their entire curriculum time on EHS, with 2 participants located in hotter climates each reporting 10%. The educators felt that certain conditions, such as heat illnesses, are more prevalent in the South/Midwest, and because of that, they made sure to cover those topics more in depth. Conversely, others were quick to afford less time on conditions that were unlikely to occur in their geographical region. Paige, who is located in the southern region of the United States, said,

I definitely think the regional part of our current location dealing with hyperthermia, the high prevalence of sickle cell trait–positive athletes and the interactions [treating heat illnesses], plays a significant role. As far as where they go afterwards I don't really think that matters as much as we focus on things that they are dealing with currently.… The primary influence is where we are now [in the heat].

Debra explained how her program location influences her decisions by saying,

I try to make things relatable to their clinical setting. Especially being in the South and exposed to the heat. I just try to make things applicable for all my students because we are more likely to see a heat injury over something else.

Similar to Debra's comments, Paige went on to share,

We definitely talk about sickle cell; we talk about hyperthermia. We talk about cardiac a lot because we've either had instances previously in clinical sites or just being in the South we see situations with sickle cell and hyperthermia. I definitely think our location of our school influences the conditions we deal with, such with hyperthermia, and the high prevalence of sickle cell trait athletes.

From a different perspective, Damon, who is from a northern state, shared how his students probably don't have the same breadth of knowledge regarding heat-related illnesses as ATSs from the South:

I think the graduates of our [AT] programs and most of the programs in New England, just don't share the same understanding of heat illness things, hyponatremia as a student graduating from the University of Alabama or a student graduating from Louisiana State.

Our results suggest that the participants perceived specific conditions as regional, rather than as a result of genetic predisposition, training, or other environmental factors, and that they assigned the most course and curriculum time to teach those that were most prevalent in their area. Barry states, “I think we [as educators] have done a good job in our program really examining heat-related issues and concussion types of stuff related to sudden death. We really need to prepare our students for what they're going to face the most [in the clinical setting].”

Clinician Experience

Athletic training educators drew from their own personal clinical experiences to facilitate ATS learning. These experiences greatly influenced course development, materials covered, and time spent on topics pertaining to sudden death. A few of the AT educators had prior experience managing a case of sudden death. This gave them perspective, respect for the seriousness of the condition, and a realistic understanding of the condition's management. All but 3 of the participants were active clinically at the time of the study, which also helped facilitate their professional experiences and perceptions related to sudden death. One educator, Kristina, who served in a dual role, shared one of her personal experiences of sudden death: “It sticks in your head forever, so you are going to prepare your [future] athletic trainers for that experience, comparable to the one you had.” The educators realized how profound an authentic experience could be, and therefore tried to integrate them into their pedagogy to promote ATS learning. They also realized that it was likely that one of their own ATSs would face a similar situation in the future. Paige said,

The fact [as an undergraduate student] I experienced one of my athletes going into cardiac arrest in the middle of football [practice]. I want everyone to have an understanding of their role and [appreciate] the importance of prior preparation. That is why we practice emergency action plans and all the related items.

Athletic training educators believed that sharing their personal experiences could improve ATS comprehension of both the seriousness of sudden death and the importance of skill development and personally connect the student and educator. John explained,

I spend a fair amount of time on concussions because I like concussions. That has always been one of my particular interests [clinically]. It is [story telling] one of the ways you can get students to actually pay attention. So yes, I think past experience does in fact matter and I think it for sure influences people [and their teaching practices].

Although there are different reasons that affect the depth to which certain subjects relating to sudden death in sport are taught in undergraduate programs across the country, AT educators agreed that they try to touch upon all causes.

Instructional Methods

When asked to discuss their use/selection of instructional methods regarding sudden death in sport, the 2 most popular methods cited by educators were real-time learning and clinical education experiences based on exposure to authentic educational experiences that fostered critical thinking. The content the participants used, on the other hand, came primarily from the NATA position statements (Table 2).

Table 2. Use of NATA Position Statements in ATP Curriculums^a

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Current Trends

The NATA requires ATP educators to teach students specific competencies to prepare them to be successful entry-level ATs.¹ In addition to the content outlined in the educational competencies, AT educators also used situations from the Internet, the news media, and nationally televised athletic events in which ATs were called onto the field to care for an athlete as platforms to discuss sudden death with their students. Using real-life situations can have a powerful effect on ATSs, and create teachable moments for students to reflect on and critique the final outcome. Athletic training student learning is driven by application to real-life learning opportunities.^2,3 Moreover, with an interest in or a love of sports as a natural attractor for a career in AT, our results illustrate that our educators are aware of their ATSs' knowledge of trending topics in the sports world and make curriculum decisions with this in mind.

With policy changes on medical treatment in professional sports, new literature continually being published, legislative changes, and lawsuits filed against athletic departments when an athlete dies all serving as headlines in today's media, the AT educators in our study felt compelled to spend more time on cardiac conditions, concussions, spinal injuries, and heat illnesses. Today's AT educators are challenged with addressing not only the educational competencies, but also those sudden death topics that appear to be more prevalent or frequent. During the summer of 2011, the hot topic with extensive media buzz was the collective bargaining agreement that led the National Football League to changes rules related to the duration of time off, number of full-contact practices, and number of full-padded practices to improve the athletes' safety.²⁰ Because of both the high-profile nature of the changes related to concussion management and the likelihood that their students would manage many concussions during their careers, our educators felt the need to spend more time covering this material. In addition to the probability of occurrence in clinical practice, changes in legislation regarding AED availability and media coverage of exertional heat illness deaths also prompted the participants to increase coverage of cardiac conditions and EHS.

Regional Bias

Our data suggest that the geographical location of the ATS's undergraduate institution influenced how much curricular time was spent on certain sudden death conditions. This was particularly evident with participants from the South and Midwest regions of the United States, where the likelihood of managing heat-related conditions was increased, devoting more time to ensure student competence. The Korey Stringer Institute²¹ reported on their Registry of Sudden Death in Sport that out of 13 cases of heat illness related sudden death in 2011, only 3 occurred in the north. Although the educators from northern regions educated their ATSs about heat illnesses, because of the perceived reduced likelihood of occurrence, they dedicated less time to covering the material. This is further supported by our data that showed that the majority of participants dedicated 4% of their curriculum to EHS, whereas the 2 from hotter regions devoted 10% of their curriculum. Regardless of region, students must be trained to manage all potential causes of sudden death, because it is unlikely that they will all continue to work in a single environment for their entire career.

Clinical Experience

Like the findings of Mazerolle and colleagues,⁹ our data indicate that AT educators' personal clinical experience can affect their selection of instructional methods and concepts to be covered within their curriculums. Athletic training students value the opportunity to relate to and receive authentic experiences in order to learn and retain the information presented. For example, dental school instructors often use personal stories or clinical cases to stimulate discussions and provoke critical analysis of the case presented.²² This approach also helps ATSs process the information being taught and see how it's relevant and transferable to their clinical practice, often giving insight that cannot be found in a textbook.²²

Athletic training educators who have managed a sudden death in sport have the unique ability to drive home a scenario's authenticity; and although previous experience alone does not imply clinical effectiveness, it does give them firsthand knowledge from which to draw realistic details. In short, instructors who use their own experiences to create educational scenarios make learning more meaningful, increase their students' motivation to learn and integrate AT content knowledge,⁵ and possibly influence them to volunteer at local community events where these conditions are more likely to occur. In this study, participants who had treated a sudden death in the past were comfortable relaying presentation, treatment, outcome, and debriefing information to their ATSs. Shared clinical experiences also give students a better understanding of how potentially deadly conditions can occur, and, if they are managed properly, how an AT can save an athlete's life. Regardless of pedagogical strategy used, realistic scenarios and real-life experiences are critical for students to develop competence and confidence and implement the best clinical practices.^23,24

Instructional Methods

Educators use a variety of instructional methods to target students' different learning styles;^2,3 however, it appears the best method to prepare students to manage a case of sudden death in sport is to provide the most authentic educational experiences possible. The use of authentic, integrated tasks, in which knowledge and its application are learned together, has been proposed as a way to make the student-to-practitioner transition less problematic.¹⁹ In fact, a recent study identified that the a lack of authentic learning experienced was a complaint of students as it related to their lack of comfort with making psychosocial intervention decisions. Two popular methods include providing students with instructor-driven simulated learning scenarios in a classroom or lab and relying on the students' clinical education experiences to provide actual cases. Previous studies have shown that, even though ATSs are provided with appropriate knowledge to recognize and treat EHS, they are apprehensive to practice the most appropriate methods when necessary.^6,7,9,10,18 The aim of providing students with the most realistic experiences is to develop their clinical thinking skills and prepare them to translate cognitive knowledge into psychomotor skills.²⁴

Limitations/Future Research

Our study did have a few limitations, the first of which was the small sample size. Because some programs used multiple courses and educators to teach material related to sudden death, our participants might have spoken from limited experience not reflective of their entire program. Although having a small sample is common in qualitative studies, it does limit the ability to transfer these result to all ATPs. The second limitation was that not all districts were represented in the participant pool, possibly concealing regional bias. And lastly, 8 out of 12 participants had 10 or more years of experience as a faculty member. A younger sample set might have used different instructional methods that would have changed the emergent themes. Therefore, future research should further explore these themes with a larger, truly representative participant pool and question instructors from other medical professions about the value they place on currents trends and regional influence. How ATSs evaluate media reports in comparison with information their educators convey and their individual knowledge acquisition over their academic career should also be explored.