Evidence-Based Practice and the Recognition and Treatment of Exertional Heat Stroke, Part I: A Perspective From the Athletic Training Educator

Participants

A total of 13 AT educators (11 men, 2 women; age = 46 ± 6 years, Board of Certification certified = 22 ± 9 years, teaching experience = 16 ± 10 years) took part in this study (Table 1). They represented 10 states and 6 NATA districts (Table 2). Of the 13 participants, 12 held terminal degrees (6 PhDs, 5 EdDs, 1 DA; 1 held a master's degree) and were AT educators, and 3 maintained clinical involvement in conjunction with their academic responsibilities.

Table 1. Demographic Data of Participants

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Table 2. Participant Demographics by National Athletic Trainers' Association District and Experience

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We created a database of potential participants with information from the Commission on Accreditation of Athletic Training Education (CAATE) Web site (http://www.caate.net/imis15/caate/). We used criterion sampling19 to recruit the participants randomly via e-mail before the 2009 NATA Annual Meeting in San Antonio, Texas. A recruitment e-mail containing information about the study's purpose, data collection timeline, and methods was sent to all program directors (PDs). Interested participants were screened and were included if they indicated serving as the PD or clinical coordinator (CC) within a program accredited by CAATE and if they had a minimum of 5 years of experience in that position (Table 2). We selected PDs and CCs because of their roles in curricular development and management of their programs; we believed they would know when and where information about EHS was being delivered to their students. Moreover, all participants indicated covering material related to EHS at some point during their academic careers, regardless of whether they were responsible for the specific content at the time of the focus group. Because of the exploratory purpose of the study and the participants' stated previous experience with the topic, we were comfortable with the makeup of this participant demographic. Initial recruitment before and onsite at the NATA Annual Meeting in 2009 yielded a total of 11 participants in the focus group sessions. We recruited 2 additional educators who indicated interest onsite but were unable to attend the onsite focus groups because of scheduling conflicts and previous obligations. Therefore, they were included in the follow-up telephone interviews. All participants provided written informed consent, and the study was approved by the University of Connecticut Institutional Review Board.

Instrumentation

Advantages to focus group interviews include interaction among participants, which improves the quality of data; confirmation of emergent or dominant themes; and focused responses to a particular topic or question.20 Keeping this in mind, we developed a set of open-ended questions based on existing literature, knowledge of the topic, and the research questions established before data collection. A panel of 5 experts that comprised 1 clinical AT, 2 AT educators, and 2 exercise physiology professors with extensive research experience with the topic of thermal regulation (>20 years) reviewed the document for clarity. Minimal changes were made to the guide after the review. A pilot study, which was conducted with a small group of AT educators (n = 3), was implemented to ensure that the structured interview guide was focused and appropriately based on the purpose of the study. None of the data collected during the pilot study were included in our study results because although they did mirror the study results, we wanted to ensure methodologic rigor and to reduce bias during data collection. As a result of the pilot investigation, only minor changes in grammar and order of questions were made to the instrument before data collection (Appendix).

Procedures

Three semistructured, in-person focus group interview sessions were conducted in San Antonio, Texas (focus group 1 comprised 5 participants; focus group 2, 2; and focus group 3, 4). During initial planning and participant recruitment, we had assigned an equal number of participants to each focus group; however, because of unexpected scheduling conflicts and people who did not report for interviews, the sessions had unequal numbers of participants. Upon arrival at the focus group sessions, all participants completed a background questionnaire. A moderator (S.M.M.), who was an experienced qualitative researcher with more than 5 years of experience, led each focus group interview, which lasted about 45 minutes. A second researcher (R.C.R.) participated by recording (both digital voice recording and video) the focus group sessions and taking field notes to aid in data transcription. Upon completion of the focus group, each participant selected a pseudonym, and all sessions were transcribed verbatim for data analysis. Two follow-up telephone interviews were conducted after the 3 focus group sessions. This step of methodologic triangulation19 was added to strengthen the study's overall findings; confirm the final themes, which we describe; and counterbalance the low number of participants in focus group 2.

All participants were provided copies of their transcripts from the interviews, and they reviewed these transcripts as a form of member checking. Other methods used to establish trustworthiness of the data included data triangulation and multiple-researcher data analysis, which is described in the “Data Analysis” subsection. Data triangulation was ascertained by conducted interviews, analysis of interview transcripts, and follow-up telephone interviews. Because we conducted several small focus group sessions, the crossover among groups also helped to intensify the data triangulation via qualitative inquiry.20 Follow-up interviews were used to confirm initial findings and support emergent themes.

Data Analysis

Interview transcripts were analyzed with open coding, which is a common tool used in exploratory studies.2021 Two researchers (S.M.M., D.J.C.) reviewed the transcripts independently to identify commonalities, which is a step used to ensure accuracy and reduce researcher bias during data interpretation.19 The researchers thoroughly read the transcriptions, examining the data for key phrases and wordings that participants consistently discussed. After a commonality was identified, a conceptual tag was given to capture its meaning. When initial data analysis was completed, the 2 researchers compared and discussed their findings. Although the conceptual tags assigned by the 2 researchers were different, the contents contained in those themes were analogous. After discussing the assigned conceptual tags (themes) and agreeing on appropriate representation of each emergent theme, the researchers shared their findings with another set of researchers (n = 4) as a final step in ensuring credibility of the findings. All involved with the analysis process agreed about the final presentation of themes even before negotiation. This group of researchers included 3 second-year graduate students (R.C.R., K.D.P., D.E.P.) with previous training in qualitative methodology and data analysis procedures and 1 AT educator and scholar (C.M.M.) who was not involved with the initial data collection procedures but was familiar with the research agenda. All agreed on the findings.

Educational Techniques

When discussing teaching methods used for the content related to the recognition and treatment of EHS, the participants acknowledged that although they didactically cover material, they often do not provide laboratory time for the development of skill competence and comfort with the techniques of T_re and CWI. All participants discussed the importance of the NATA position statement2 in the didactic portion of their curricula. Despite the vital role the position statement played in course development, the participants recognized a failure to address the hands-on component in the classroom or clinical setting. When directly asked how information about EHS is introduced to his students, Francisco stated,

It's hypocritical in that we say it [T_re and CWI is criterion standard], but we don't actually have our students do it [T_re and CWI], so as far as hands on, it's not even a good term for what we do [for the psychomotor skills of T_re and CWI].

A similar sentiment was expressed in a separate focus group session regarding instructional methods and delivery of content related to EHS. Barry commented,

It is mostly lecture. They are not [practicing T_re and CWI] at this time, although since the articles [Mazerolle et al22–25] have come out, we have started discussing [as a faculty] how we're currently doing it. But they [the students] don't see it implemented currently or practice the skills [in the classroom or clinical setting].

When asked more about providing students with the opportunity to practice the psychomotor skills associated with EHS, specifically T_re and CWI, all participants responded similarly: reliance on case studies, scenarios, or simulations to promote student learning but no use of laboratory time for hands-on instruction or practice of the skill sets. Gretta stated, “We do simulations; basically we provide scenarios [to the students] in the classroom [to provide real-time learning].” The scenarios discussed by the participants were designed to stimulate critical thinking through discourse but lacked actual implementation of the skill sets. All participants agreed about the delivery of content related to EHS: They provide their students with the cognitive knowledge related to recognition and treatment of EHS as outlined in NATA position statements but do not provide them with appropriate practice of those skills.

Educational Competencies

Consistently, the participants discussed the major barrier to implementation of T_re and CWI in their curricula: the lack of written documentation in the NATA educational competencies14 requiring the skill sets of T_re and CWI. Lynne simply stated, “It's not a competency, [so] we don't have to teach it.” Similarly, Tom stated, “I don't know how to give a good answer [for why we don't allow for practice time]. There has to be a mandate [for us to change our curriculum].” Furthermore, Bumble took a more proactive approach: “If it's going to be a standard of practice, then it should be an educational standard.” Francisco agreed that a divide exists between what happens in everyday practice and what has been established as the basic knowledge for an entry-level AT. He highlighted the influence of clinical expertise, practitioner beliefs, and EBP:

You [and I] know there is a disconnect. You look at the competencies; they are based on the Role Delineation Study, which is based on what the average AT does daily, and we are not doing that. So, the NATA position statement says the standard of care [is to use T_re and CWI], but we are basing our competencies on what we are doing, and we are not doing what the research says to do.

All participants agreed that, because of a lack of documentation about T_re and CWI in the psychomotor domain of the NATA educational competencies,14 programs and educators might choose to provide students with only cognitive knowledge instead of a combination of cognitive and psychomotor skills.

Previous Educational Training

Many participants mentioned that their own insecurities or lack of formal training within their academic preparation and continued professional development led them to avoid providing the same formal training to their students. Corky stated,

I think you know for the most part people [educators and clinical instructors] aren't comfortable with it [skills of T_re and CWI]. I think the other thing is that we start treating it as soon as we're suspicious and kind of almost skip that step [because we don't feel comfortable performing it].

Raymond supported Corky's statement:

I don't believe we are [providing hands-on training], and I think it is [because of] the [lack of] comfort [with the device] as well as the barrier regarding the access to the equipment [rectal temperature devices and immersion tubs]; either we don't have it in a classroom setting, or they won't have it in their particular clinic setting.

Tom lacked comfort with the skills but was in favor of having a professional development course to increase his comfort and training with the skill set. He noted, “I think it would be nice to have a course on it, demonstrating the process [correctly] and being able to do that [to help me relay the info on to others].” Lynne reflected on the importance of the integration of didactic materials into the clinical setting:

Even teaching your clinical staff first. I mean, if I can bring that knowledge back [from a workshop session on implementation] and I can offer that to my clinical staff, just the athletic trainers that work in my university, at least then if I go teach a class, I've got [Approved Clinical Instructors] that are modeling what I'm teaching and are comfortable with it [EBP], then they can reinforce its use with the student. I think that's how it has to be; everyone needs to be on board, including the PD, clinical staff, and the students.

The lack of proper training and continued practice with the skills of T_re and CWI appears to leave many educators uncomfortable providing their students with the same training. This same lack of training and confidence might influence clinical instructors' use of T_re and CWI and substantially limits a student's opportunity to gain competence in those skills.

Privacy/Public Opinion

Consistently, the participants discussed the sensitive nature of obtaining a rectal temperature as a barrier for its use in clinical practice. Tom responded,

Probably the public side of it [T_re], the public is not familiar [with the accuracy and necessity of the device]. It's one of those comfort things. It's almost at the point of where either you are a medical professional or you are not. This is just like anything else, like being in a hospital or wherever it is you have to do it [T_re].

Francisco stated, “We have to remove the taboos from it.” With regard to social norms, Barry commented,

I don't even think it's [T_re] an uncomfortable skill thing 'cause . . . we were all that way, using an otoscope and a stethoscope, and we're all teaching that. Even the ones who might not have been comfortable, you just learn how to do it and teach it. So it's more the uncomfortable aspect of the skill [T_re] itself. And I still, even massage at some point at some level, we don't want to teach massage for similar reasons, but we have all our students disrobe and get under blankets when they're doing massage.

Francisco also stated,

I try the best I can; once again, it's lecture based only. The best I can I try to equate it to [is that it's] like going to your physician's office. You have absolutely no problem . . . having a rectal exam or getting a testicular exam or something in a physician's office, but all of a sudden if you're the one doing it to someone in your peer group, then it's a little more, [there is] something taboo about it. We just need to [figure out a way to move around it]. I don't know a good strategy to get rid of that [taboo or stigma].

Doug echoed those concerns:

I can see it now. . . . We're going to have a lab [session], and we're going to go over [how to properly] insert the rectal thermometer. That wouldn't go over too well [with our school administrators]; we're not ready for that at our school.

Lola added from her own personal discussions with a colleague,

I don't think this [use of T_re] is going to happen in my professional career. It might happen in the group that comes in behind me, but it's not something that there is a school board that's convinced [of the importance] of this for the high school setting.

Discussing the issues of age and how it relates to obtaining a rectal temperature, Fred noted,

Those folks in traditional high school settings, they're not going to touch it because of liability issues. You take a rectal reading on somebody and they end up having a core temperature of 103, and then you're going to have a mother coming back saying, “Why did you do that on my child? She didn't have heat stroke.” Then you're going to have sexual harassment issues.

As discussed by this sample of participants, the influence of privacy and legal issues influenced their decisions to circumvent providing hands-on training for their students.

Educational Techniques

Athletic training students have been shown to be diverse learners, valuing a variety of teaching methods for learning; however, they need authentic experiences, including opportunities to implement their skills clinically,26 for learning and retention. Furthermore, Gould and Caswell27 revealed that students and educators typically use a concrete, sequential learning style that favors a hands-on approach to learning. After interviewing this group of AT educators, we found most rely heavily on a traditional style of instruction involving lecture and univocal discourse regarding EHS; they rarely implement or provide laboratory opportunities that foster skill development. Our findings are supported by those of Pagnotta et al,28 who investigated the knowledge, understanding, and experiences of ATSs with EHS and found a predominant use of lecture to deliver course material related to EHS and little or no laboratory time. This is problematic particularly with the T_re skill set because considerable comfort and training are needed for proper implementation.11 Without formal training (eg, feedback leading to skill development and proficiency), the ATS will not have the confidence to use this skill when faced with an actual case of EHS. This theory is confirmed by the results of Pagnotta et al,28 who recommended more hands-on experiences for increased comfort when addressing cases of EHS.

A common approach educators have taken is the use of scenarios or simulations to promote student learning, critical-thinking abilities, and skill development regarding EHS.2930 The use of simulations or scenarios to evaluate student learning and skill proficiency has become increasingly popular among ATEPs3132 because real-life opportunities often are limited,2930 particularly with medical emergency conditions such as EHS. The simulations discussed by our group of participants were informal and a means to create discussions among peer groups rather than to stimulate critical thinking or skill development because the students were not instructed to implement the skills but rather to speak hypothetically. A plausible solution to address the lack of hands-on training for the ATS involves continuing the mock scenarios and simulations but adding a degree of realism by having the ATS take rectal temperatures with an anatomic model, then cool a partner in a cold-water tub. Athletic training educators are encouraged to use the articles by Mazerolle et al,2425 who specifically addressed T_re and CWI in regard to lesson planning and course development.

Educational Competencies

The fourth edition of the NATA Athletic Training Educational Competencies14 does not specifically require the ATS to master the skill sets of T_re and CWI. It only provides generic guidelines related to the recognition, prevention, and treatment of EHS.14 This lack of documentation appears to influence many programs to avoid incorporating T_re and CWI into classrooms and clinical experiences. Lack of documentation within the educational standards in which educators develop their curricula was the major reason for not including those psychomotor competencies. This is paradoxical because the NATA Athletic Training Educational Competencies14 includes instructions to follow the recommendations of the NATA position statements as the most appropriate and current knowledge and skills required of an AT:

Program personnel should strive to include content and skills that reflect evidence-based knowledge and practice in all aspects of students' educational program, including students' clinical experiences. Because the knowledge within a profession is dynamic, information of current practice, as represented by appropriate position statements of various professional association/organizations, should be incorporated into the curriculum in a timely and accurate fashion. Current practice particularly applies to position statements issued by the National Athletic Trainers' Association, Inc.14

The fifth edition of the Competencies will be implemented in 2012. Therefore, AT educators must now incorporate the content that reflects the most appropriate evidence-based knowledge and the pedagogic techniques to ensure clinical proficiency as it relates to T_re and CWI, regardless of the educator's previous training, comfort level, or practice beliefs. As a product of lifelong learning and continuing education, ATs are solely responsible for remaining informed about the most current literature and clinical practice as outlined by the competencies and NATA Code of Ethics.1416 In the 2002 NATA position statement on exertional heat illness, Binkley et al2 clearly stated the importance of temperature assessment (via T_re) and the need for rapid cooling (via CWI if possible). The data we and Mazerolle et al11 have collected highlight the slowness of and resistance to the transition to these evidence-based recommendations. Given the seriousness of the condition in question, it is disappointing and surprising. We are thankful that the fifth edition of the educational competencies will have a much greater emphasis on core temperature assessment and rapid cooling. We are optimistic that this will motivate additional educators to improve training in this discipline.

Previous Educational Training

Athletic training is not the only medical profession concerned with the implementation of EBP. An investigation of physical therapists revealed that clinicians were more likely to use a rehabilitation technique they had learned during professional training rather than implement a recommended or established technique in which they had received no training.17 Similarly, a review of health care providers and physicians found that a lack of training or expertise and familiarity with a skill or technique was the most influential barrier to implementing optimal clinical care.18 Our participants discussed at length the notion of previous training as a barrier to classroom instruction and evaluation. Many of the educators did not receive formal training with T_re and CWI and therefore felt poorly prepared to demonstrate the skills to their students. Most of the discussions about EBP and EHS centered on T_re rather than CWI. Despite this finding, we know that ATs recognize CWI as the most effective cooling method but, for many reasons, do not use it clinically.

Unfortunately, the lack of comfort with performing a rectal temperature measurement also has led clinicians and educators to bypass this skill and begin cooling the athlete immediately. This is evident from the results presented by several researchers evaluating ATs' knowledge,1011 understanding,1011 and beliefs about EHS1133 and from some of the discussions with our sample group of educators. This lack of comfort is problematic because an AT might cool an athlete who does not have EHS, thus delaying appropriate care. For example, although cooling an athlete with exertional sickling (a potentially fatal ischemic response due to the sickle cell trait) might be part of treatment, immediate transport with or without cooling is more important.34 All participants lacked formal training in rectal temperature assessment, but they were open to the prospect of participating in educational seminars and workshops to help them gain comfort with this skill set. This is an important step as we continue to work toward implementation of best practices despite all practitioners receiving formal training with certain skill sets or techniques.

Privacy/Public Opinion

As Mazerolle et al11 found, this group of ATs felt that a certain taboo still is associated with obtaining rectal temperature, and this limits the ability of ATs to implement the technique they know to be valid and accurate. Ultimately, 3 problems regarding the teaching of rectal temperature assessment emerged. The educators were not certain about how to present the material accurately and effectively to their students. In addition, their students were unreceptive to learning the skill set because of the invasiveness of the techniques, which was reinforced by their lack of formal classroom training and lack of implementation in their clinical settings. Finally, the lack of public understanding of the use of rectal thermometers greatly influenced the educator's choice not to use the device in the classroom. Justifiably, ATSs practice life-saving skills on mannequins or something else that gives feedback. An anatomic model seems like a viable solution for taboos that exist in the classroom and allows the ATS to develop more comfort; however, it might not help alleviate the concerns or lack of understanding of the general public. The value of clinical experience cannot be dismissed; there is a high correlation between the ATS's clinical observations and the eventual implementation of skills.1718

The lack of public understanding and support maintains the taboo surrounding the use of T_re; researchers conducting 2 independent studies examining ATs' practice beliefs regarding EHS have supported this notion.1133 These taboos originate with parents, school boards, legislatures, and the like. The term T_re has been stigmatized and almost made synonymous with invasion of privacy or sexual harassment instead of being seen as the difference between life and death. Invasion of privacy and sexual harassment have been presented as excuses for why practicing ATs do not use the skill, which has been shown to save lives.2357–9 But would the need to remove a bra stop someone from applying an automated external defibrillator to save the life of a woman with myocardial infarction? Should a 17-year-old girl with EHS receive care that is inferior to that of an 18-year-old woman with EHS because she is a minor? The quality of medical care should not be compromised because of the age of the participant. Certainly, myriad precautions must be established before the use of T_re, but none should impede the delivery of optimal care.

To date, researchers have shown that rectal, esophageal, and ingestible thermistors are the only valid instruments to obtain an accurate temperature reading for a hyperthermic athlete.3536 The use of an ingestible thermistor or an esophageal thermometer is expensive and impractical for field application when compared with obtaining a rectal temperature.37 We believe that, despite their misgivings, misconceptions, and lack of comfort, ATs and AT educators must embrace T_re and CWI to prevent unnecessary deaths. As noted, some participants expressed concern over the potential for liability if T_re is used, especially if it is used with a minor. Although this is a legitimate concern, we believe the extensive civil litigation cases surrounding deaths from EHS offer a stark reminder that a litigation case with a survivor is far preferable to one in which the athlete has died, especially if the death could have been prevented with proper recognition and treatment of EHS. The burden of knowing you could have done more to prevent a death seems to outweigh the risk of occasionally doing more than was necessary.

Limitations and Future Directions

Our sample population of AT educators was small, which limited the generalizability of the results to all educators and ATEPs. In addition, although small sample sizes are sufficient for data triangulation in qualitative studies, the predominantly male sample might not accurately reflect the perspectives of female educators. To gain a larger perspective, future researchers should include a more homogeneous sampling rather than a male-dominated, more experienced group of participants. We also recognize that 1 focus group session was small (n = 2); although this was consistent with the other sessions, data saturation did occur, and 2 additional individual interviews were conducted to help reduce bias and add to the data generated. In the future, consistency in the numbers of participants in focus groups should be attained, but the groups should remain small in order to help develop relationships among members and enhance discourse. In addition, not all regions of the United States were sampled, and 5 of the 13 participants represented 1 NATA district; therefore, the data could be biased regionally. However, region should not play a large role in educational training because all accredited programs must follow consistent educational standards. Moreover, we randomly recruited participants with a mass e-mail sent to all PDs. Lastly, most participants had more than 15 years of clinical experience, so the study results might not apply to younger AT educators; this latter group would represent a more current paradigm of instructional preparation. However, based on the results generated by other researchers,3338 we believe our results represent the educational climate regarding EHS training in the United States. Furthermore, because ATs practice under the supervision and guidance of physicians, future investigators should examine physicians' beliefs about EHS and the type of formal training they received on T_re and CWI and should provide a detailed discussion of the influence these factors have on ATs' use of the devices.