Facilitating students’ return to school following a concussion: Perspectives of Canadian teachers and school administrators

Abstract An estimated 20 percent of adolescents in North America have sustained a concussion. Teachers and school administrators are responsible for supporting following concussion to return to school. The purpose of this study was to describe the perspectives of Canadian teachers and school administrators with supporting returning to school post-concussion. This qualitative study was guided by an interpretivist philosophy. Semi-structured interviews with grades 7–12 teachers (n = 13) and school administrators (n = 5) were coded inductively and analysed using reflexive thematic analysis. We organized the data into five themes: 1) Educator roles differ for administrators and teachers; 2) Students’ symptoms affect their learning; 3) Students should have access to academic accommodations; 4) Students benefit from social support, compassion, and empathy; and 5) Concussion education and management processes are lagging. In Canada, teachers and administrators have different roles when supporting students returning to school after a concussion and those roles influence their engagement with the students and their awareness of students’ needs. Lack of concussion education and concussion management processes at schools may affect how students are supported following a concussion. Our findings can inform the development and implementation of supports to facilitate return to school for students following a concussion.


Introduction
Concussions are a public health and school health concern as approximately 20 percent of children and adolescents will sustain a concussion in their lifetime (Veliz et al., 2017).Children and adolescents are expected to recover from a concussion within one month, with up to 30 percent experiencing persisting symptoms that may affect their ability to return to learning and to the school environment (Reed et al., 2021;Zemek et al., 2016a).A one-month recovery accounts for approximately 10 percent of a student's school year or 20 percent of a semester.If not adequately supported, the time to recover from a concussion may greatly affect students' academics, physical activity, and social engagement.Thus, school supports for students following a concussion are essential.
Current recommendations to support recovery following a concussion include a gradual return to cognitive activity including return to school and academic accommodations (Patricios et al., 2023;Purcell et al., 2019;Putukian et al., 2023;Reed et al., 2021).Many educators have extensive experience providing accommodations to students with a variety of health conditions and learning needs such as learning disabilities or developmental disorders (Polloway et al., 2003;Scanlon & Baker, 2012).However, accommodations recommended for concussion are much more dynamic, changing day-to-day or week-to-week as the student recovers, which educators may find more challenging to implement in their classrooms than accommodations for chronic or persistent conditions (Davis et al., 2017;Zemek et al., 2016b).Additionally, the student's symptoms, available school resources, access to school concussion management processes, or concussion education may all affect educators' abilities or perspectives on how best to support students following a concussion (Dreer et al., 2017;Joyce et al., 2020;Kasamatsu et al., 2017;Kirelik & McAvoy, 2016;McAvoy et al., 2020;Purcell et al., 2019;Romm et al., 2018;Sarmiento et al., 2019;Thompson et al., 2016).
Research conducted in both Canada and the United States suggest there may be some differences between teachers and administrators in their roles, responsibilities, and perspectives pertaining to supporting students returning to school following a concussion (Heyer et al., 2015;Romm et al., 2018;Sarmiento et al., 2020;Shepherd et al., 2023).Teachers are directly involved in the daily lives of students and are tasked with implementing accommodations in their classrooms (Romm et al., 2018).Also, teachers are aware of students' pre-existing health and learning needs; therefore, teachers can help determine what additional supports may be most appropriate to facilitate students' return to school (Dreer et al., 2017).Administrators' roles may be more high level, such as implementing policies, such as concussion management practices and protocols, outlining which accommodations teachers can provide, or coordinating with other school stakeholders, such as parents/guardians or health care providers (Heyer et al., 2015;Lyons et al., 2017;Romm et al., 2018).
Despite increasing attention to issues regarding return to school, research that explores the perspectives of both teachers and school administrators in supporting students returning to school following a concussion in Canada is limited.Much of the existing research aiming to understand return to school has been conducted in the United States, which has return to play legislation in all states and return to school legislation, policies, or guidelines in other states (Fetta et al., 2023;O'Neill et al., 2017;Thompson et al., 2016).In contrast, Canada has only one province with concussion legislation (Government of Ontario Ministry of Heritage, Sport, Tourism, and Culture Industries, 2020).Also, some Canadian provinces and territories outline concussion policies or protocols relevant to the school setting (Government of Ontario Ministry of Education; Government of Quebec Ministry of Education; Government of Yukon Education Ac, 2019).Additionally, much of the current return to school literature is conducted with nurses and athletic trainers, who are not often employed in Canadian middle or high schools, or is conducted in the collegiate setting (Dachtyl & Morales, 2017;Heyer et al., 2015;Joyce et al., 2020;Kasamatsu et al., 2017;Romm et al., 2018;Runyon et al., 2020;Sarmiento et al., 2019;Weber et al., 2015Weber et al., , 2019;;Welch Bacon et al., 2017;Williamson et al., 2018).Therefore, the purpose of this qualitative study was to describe the perspectives of Canadian teachers and school administrators who support students in grades 7-12 returning to school following a concussion.

Philosophy
This qualitative study was guided by an interpretivist paradigm, which assumes a relativist ontology, or that there is no single reality and experiences inform one's reality (Lewis-Beck et al., 2011), and by a subjectivist epistemology in which interpretation of the participants' experiences is influenced by the researchers' experiences and together both participants and researchers cocreate knowledge (Lewis-Beck et al., 2011).Please see Supplementary 1 for complete author positionality statements.

Theoretical framework
We used the Canadian Model of Occupational Performance and Engagement (CMOP-E) to guide this study (Polatajko et al., 2007).The CMOP-E is a conceptual framework that can be used to understand the interactions between person (e.g., teacher, administrator), environment (e.g., school culture, school building), and occupation (e.g., implementing academic accommodations, supporting students at school) to inform one's occupational performance and engagement (Polatajko et al., 2007).The CMOP-E can be used to understand the perspectives of educators with supporting students following a concussion and identify areas of strength and areas that can be targeted for intervention.

Participants
We interviewed five school administrators and thirteen teachers who taught or supported students in grades 7-12 in Canada.School administrators included principals, vice-principals, and guidance counsellors.Teachers taught a range of subjects including both academic courses (e.g., math, language arts) and option or applied courses (e.g., physical education, trades).Participants included those from urban and rural settings, and from public and private schools (see Table 1).We recruited participants via word-of-mouth or through participation in a survey inquiring about their experiences with school-based concussion management practices.

Data collection
I (Author 1) conducted all interviews via Zoom between January 2021 and May 2021.The interviews were scheduled to be 40 to 60 minutes in duration.The median interview time was 48 minutes (range: 22-59 minutes).Interview questions aimed to understand educators' knowledge of concussions, concussion management at school, how educators could support students following a concussion, resources to support concussion management at school, and what educators would like to see in the future to support students returning to school following a concussion.See Supplementary 2 for interview guide.
This study was approved by the University Research Ethics Board (REB18-2107).

Data analysis
The interviews were audio recorded using Zoom and then transcribed verbatim via Rev.com (Rev, 2020).I verified all transcripts against audio recordings.NVivo v.12.0 supported the data coding and organization (QSR International, 2020).
We coded the data inductively using the reflexive thematic analysis process outlined by Braun and Clarke, which acknowledges the researchers' subjectivity in the development of themes and study findings (Braun & Clarke, 2019).The data analysis process included: 1) data familiarization through verifying and reading transcripts; 2) generation of initial codes, reading each transcript and coding each transcript line-by-line; 3) grouping similar codes together to generate themes; 4) reviewing and revising themes; 5) defining and naming themes in consultation with the authorship team; and 6) writing descriptions of the themes with supporting quotations (Braun & Clarke, 2019).Although the steps are listed sequentially, they were completed iteratively and recursively, and codes and themes were revised throughout the peer debriefing process and in consultation with the authorship team.Author 2 served as a peer debriefer.We first analyzed the administrator interviews and the teacher interviews separately to understand their unique roles in the school setting, then we reviewed the codes and themes from administrators and teachers as a full data set, contextualized using the CMOP-E (Polatajko et al., 2007).

Rigor
Rigor was supported using a reflexivity journal in which I (Author 1) recorded my thoughts throughout the interview process, coding rounds, peer debrief sessions, and discussions and consultations with co-authors (Cypress, 2017).The reflexivity journal acted as an audit trail of the work completed and decisions made including coding decisions, which helps to support findings that the themes were co-created from the data (Creswell & Poth, 2017;Whittemore et al., 2001).Peer debriefing provided further opportunity to discuss how I may have influenced the analysis process and discussions with Author 2 provided opportunities for critical reflection (Braun & Clarke, 2021;Cypress, 2017;Whittemore et al., 2001).Also, during the interviews, I checked-in with participants to clarify understanding of school-based principles and language, specifically surrounding words that have different meanings in school-based settings than in day-to-day use (e.g., accommodations, modifications).Discussions with co-authors ensured analytic processes were aligned with an interpretivist philosophy and the CMOP-E (Lewis-Beck et al., 2011;Polatajko et al., 2007).

Results
The study findings resulted in five main themes: 1) Educator roles differ for administrators and teachers; 2) Students' symptoms affect learning; 3 Students should have access to accommodations to support their return to school; 4 Students benefit from social support, compassion, and empathy while returning to school; and 5) Return to school education and processes are lagging.See Table 2 for examples of supporting quotations.

Educator roles differ for administrators and teachers
Administrators provided support to teachers to enable teachers to support students.This included providing personnel support, such as reallocating educational assistants or administering an assessment for a student, providing access to concussion education, recommending accommodations, and communicating to teachers what supports students may need.Most administrators were removed from the student's daily life and some noted that they may never meet with the student.Participant2-Administrator described their role saying, "Mine would be at arm's length.I mean, it'd be mostly the teachers who would work with the re-entry side of things".Administrators discussed how teachers were able to provide accommodations without consulting administration: "In our school, I think teachers should have the . . .confidence to do that and the ability to just move forward with it without . . . .admin input" (Participant3-Administrator).However, administrators would become involved if a student's return to school became complex.Participant12-Teacher expanded saying, "You have a little bit of say as a teacher . . .but some stuff will come from admin if it's a more serious time duration out and what they're able to complete".
Teachers believed that accommodating and supporting students was part of their job, even if it increased their workload.Interestingly, teachers wanted administration to be more involved in supporting students with a concussion.Teachers wanted administrators to be the point-person and coordinate the student's care including communicating with the student and their parents/ guardians and disseminating relevant information to teachers.

Students' symptoms affect learning
Students' symptoms affect their engagement at school and their ability to learn.While teachers were more likely to discuss physical (e.g., headaches, sensitivity to light) or cognitive (e.g., memory, attention) symptoms and how the symptoms could affect the student at school, administrators also discussed emotional or psychosocial symptoms (e.g., anxiety, social isolation) students may experience following their concussion.Participant3-Administrator said, "It impacts them physically, because they're physically uncomfortable in the classroom a lot of times, because of noise or excess  Teachers were more likely than administrators to discuss the impact of students missing too much school, such as falling behind in classes or not meeting curricular learning outcomes.Moreover, some teachers expressed that they or their colleagues believed students should not attend school while symptomatic: "'Nope, not my problem.Send them home until they're better.Come back when you're better'" (Participant15-Teacher).This perspective may contribute to students missing more school and having less access to learning materials they need to meet curricular outcomes.

Students are honest most of the time when discussing symptoms and functioning
Educators believed most students were honest about their symptoms and students were unlikely to lie or malinger.In contrast, they believed students may be more likely to underreport their symptoms because they may not want to be stigmatized or want to return to "normal" school, or to sports faster.Participant14-Teacher described how students may both overreport and underreport symptoms: "And on both ends of the spectrum, right?Sometimes they will have really bad symptoms, so they don't have to do those exams, or they have no symptoms because they want to keep playing and don't want to tell you about it".

Students should have access to academic accommodations to support their return to school
Students should have access to accommodations including changes to coursework (e.g., altered assignments, decrease coursework) or to the school environment (e.g., quiet room, reduced sound).While teachers expressed a desire to accommodate students, some accommodations were not practical or feasible in the classroom setting.For example, Participant8-Teacher said, "On a piece of paper, all these accommodations look great, but in actual practice, sometimes some of them just are not feasible to do".Participant6-Teacher expanded on barriers to providing accommodations to students following a concussion: With the extra time, we try.Sometimes it just doesn't work . . .having an extra or twice as much time to write a test, sometimes it does work . . .But sometimes just the knowledge isn't there because they have been away, they did miss time, they weren't able to retain information . . .And extra time doesn't help that.Teachers discussed how limited preparation time, educational assistant support, equipment, facility resources, and large class sizes affected their ability to support students.Participant12-Teacher said, "Time is probably number one . . .we're not given the time that we need to even be successful in just general teaching . . .concussions become an extra layer".While most educators said their school had some resources, they elaborated by saying they needed additional personnel and facility resources to adequately support students.Limited environmental resources, such as no access to quiet spaces or no lights that dimmed, as well as limited budgets reduced educators' abilities to provide accommodations to students.Some teachers discussed how accommodations such as smaller quizzes or assignments allowed them to assess the student's learning, while also ensuring the student continued to meet learning goals.However, these accommodations aligned with outcome-based learning approaches could affect students who had to take standardized exams as all relevant testable material was imperative to the students' success.Nevertheless, one administrator who taught at a public school said all accommodations were feasible to provide at their school, attributing this to their school culture and the educators' willingness to support students.

Accommodations can support students' emotional and psychological well-being
Accommodations allowed students to scaffold their learning by increasing the challenges as their symptoms resolved.This approached created opportunities for students to be successful, and lead to an increase in confidence.Participant4-Administrator said, "It's also about the confidence of getting back to 'normal', right?And so, if an accommodation will . . .help them regain that confidence, I think that goes a long way".

Students need to advocate for academic and social and emotional support
Educators discussed that students need to self-advocate for accommodations and school supports.Participant1-Administrator explained that if students do not advocate for support, they may become lost in the system: "I really, really, really need kids to self-advocate, because I can't manage the number of challenging situations that emerge.So, if students don't reach out and ask for that level of support, we're not able to provide it".Teachers shared how self-advocacy and communication extended beyond the acute period following a student's concussion diagnosis and included ongoing communication about what support the student requires throughout their recovery.However, teachers also discussed that a student may need to trust and feel comfortable with the teacher to self-advocate, which could affect a student's access to supports.

Physicians' notes may not be necessary for students to receive school supports, but they can guide care
Perceptions of the purpose and need for physicians' notes to facilitate students' return to school differed between administrators and teachers, even when they were employed by the same school.All administrators explained that physicians' notes were not necessary; however, physicians' notes "[are] helpful on our end because it gives us direction as a school" (Participant4-Administrator).On the other hand, teachers were more likely to request physicians' notes from students; physicians' notes supported the legitimacy of the injury and lead some teachers to be more accommodating.

Students benefit from social support, compassion, and empathy while returning to school
Supporting students extended beyond providing accommodations and included being compassionate, empathetic, understanding, sharing experiences, and ensuring students had access to social support through educators, guidance counsellors, peers, and family members.Participant4-Administrator discussed the importance of sharing experiences with, "You share your experience and it makes you feel better that somebody else has that experience".

Educators want more school-centred concussion education
Although many educators had received some concussion education through sport participation or coaching, the education did not include aspects of return to school or how to support students in the learning environment.Most educators wanted concussion education: "I think having PD [professional development] on it would be a pretty good starting point for all teachers so they're not kinda sitting there, not knowing what to do" (Participant9-Teacher).Stepwise return to school protocols including lists of possible accommodations that could be provided to students were desired for concussion education.Participant13-Teacher discussed wanting more information about what supports are most helpful for students, "I would like to have more knowledge on it, and I'd like to know more about what would be the best, like most effective types of accommodations".

Return to school processes are often not implemented and stakeholder communication is lacking
Most educators' schools did not have formalized return to school concussion management practices to support students following a concussion, but they would like one at their school.Some educators noted that their school had a return to play protocol or were familiar with graduated return to physical activity protocols.Participant14-Teacher, who is also an athletic therapist, said that not only does their school have a return to school protocol in place, but students are also asked symptom-specific and subject-specific questions to better identify what supports they need and to facilitate ongoing and open communication with the student and teachers.Participant14-Teacher expanded on their school's concussion management process: I have a questionnaire that I have them do . . .I'll ask some specific questions about math class, about science class, about English class . . .that's the biggest thing with students is I find if you ask them how they are, they don't do it.But if you actually have them sit down with a piece of paper and rate it on a scale of zero to five or whatever, they-then you're like, "Oh, okay.Tell me about this.Tell me about this".
Most educators wanted a process that outlined a list of academic accommodations by symptom or by subject area.Teachers requested administration be responsible for developing a return to school plan with tailored supports for students after concussion and then disseminate the plan to teachers.Participant11-Teacher shared their vision for a streamlined concussion management plan, "Right from the onset of the injury . . .administrator . . .I don't know if we should call it triaging, but that injury and what actually they feel it [accommodations] is necessary".On the other hand, some administrators reported that they were not involved in the daily lives of students; therefore, they would not be involved in "triaging".
Communication about a student's functioning was a key component to supporting the student returning to school following a concussion."We understand things better when I hear it from the parents, the administration, the student or the patient, and myself.If we work together, communication is always better (Participant10-Teacher)".While some schools had effective channels in place such as in school portals, case conferences, or email threads, other educators shared that ongoing communication about a student's functioning was lacking.Some educators explained how occasionally they are not informed that a student has sustained a concussion, or if they are notified, they often received no follow-up communication about the student's status or recovery trajectory.Participant6-Teacher suggested schools add an indicator to the online attendance form to identify a student sustained a concussion, saying, "If that popped up and said . . .'concussion' next to their name in attendance . . .I could see that help".Overall, educators wanted inclusive and ongoing communication amongst all school stakeholders.

Discussion
This study sought to describe the perspectives of grades 7-12 educators with supporting students returning to school following a concussion.Both teachers and administrators were aware of the cognitive and physical symptoms that students could experience and how these symptoms could affect learning and engagement in the school environment.Administrators also identified the psychological symptoms students may experience and how these personal or environmental factors could further affect students' return to school.Teachers held the onus of supporting students in the classroom with academic accommodations or social support unless the return to school process was complex, at which point administrators may become involved.Teachers believed it was part of their job to support students following a concussion.However, limited knowledge of how best to support students with a concussion and limited access to school resources affected teachers' ability to provide support to students.
Educators acknowledged students' need for academic accommodations; however, they wanted students to self-advocate to get support.Self-advocacy was also identified as a strategy to facilitate return to school in a study by Runyon et al (Runyon et al., 2020).Although expecting students to selfadvocate promotes an important life skill, educators need to be cognizant of the abilities and experiences of these students.Students may not be aware that they need to advocate for themselves and if they have not accessed accommodations in the past, they may not know what accommodations are available nor how to access them.Further, there may be a power dynamic between students and educators, and thus students may not feel comfortable advocating for supports to a person in a position of power.Additionally, students may be symptomatic and thus may not have the cognitive capacity to navigate the return to school process.Creating a concussion process that is supportive of students, and that students are aware of and know how to access, may provide a foundation for students to advocate for themselves while working within their cognitive capacity.
In our study, most educators discussed resource barriers including limitations in personnel, equipment, time, and facilities to adequately supporting students.This was similar to perspectives of teachers in a qualitative study by Romm et al., where teachers shared that resource and time constraints, such as large class sizes, affected their ability to support students following a concussion (Romm et al., 2018).We found that most teachers and administrators agreed that resource barriers affected student supports whereas Romm and colleagues noted a difference in perspectives between teachers and administrators on resource availability (Romm et al., 2018).Formalized school concussion management processes that outline specific accommodations or pathways for students to return to school may provide clarity for how teachers can support students in their classes and highlight resource limitations that may hamper supporting students returning to school following a concussion.We found that most schools did not have formalized concussion processes in place to support students' return to school.This may have affected communication amongst school stakeholders and may be one reason why educators felt they did not have the appropriate institutional structures in place to properly facilitate a student's return to school.In many studies conducted in the United States athletic trainers or school nurses are identified as individuals who support students returning to school after a concussion (Kay et al., 2018;Runyon et al., 2020Runyon et al., , 2020;;Tricia et al., 2016;Weber et al., 2015Weber et al., , 2019;;Welch Bacon et al., 2017, 2017;Williamson et al., 2018;Wing et al., 2016).However, both school nurses and athletic trainers are uncommon in Canadian schools (Shepherd et al., 2023).Although teachers identified school administrators as the likely pointperson, similar to findings by Romm et al (Romm et al., 2018) administrators did not view themselves as point-persons.Nevertheless, leveraging existing resources such as school administrators as point-persons for students following a concussion may be a more effective strategy as these stakeholders are already employed at most schools in Canada.
The CMOP-E can be used to conceptualize the different factors (i.e., person, environment) that can impact educators' ability to engage in their occupation as a teacher or school administrator (Polatajko et al., 2007).Our findings highlight that teachers' and school administrators' occupational performance and engagement for their respective roles are affected by environmental factors such as school resources or school culture; person factors such as the belief of the legitimacy of students' symptoms; and occupational roles including providing academic accommodations to support students.Our study brings light to the strong interactions between the person and environment, such as empathy and school culture, and to the gaps, such as resource limitations and lack of education.Strong interactions should be leveraged, and gaps should be addressed to support occupational performance of educators in supporting students following a concussion.

Strengths, limitations, and future directors
Our study is one of the first to explore the perspectives of both teachers and school administrators in supporting students returning to school following a concussion.Future research should aim to better understand the differences between teachers and school administrators in supporting students with the goal of using this information to develop school-based concussion management processes that incorporate the perspectives of educators.Our study also included perspectives about concussions arising from any mechanism of injury, rather than solely sport-related, as is often the focus in concussion research.Therefore, the educator perspectives in our study may be more reflective of the student population and how students sustain concussions.
Although we sought participants with a breadth of experience, including variation in teaching subjects, most of the participants in this study had prior experience with concussions through one or more of sport participation, coaching, or teaching physical education or sports medicine classes and thus may be more familiar with the impact of concussions on returning to school than other educators.Future studies could explore the experiences of educators without prior concussion education/training or sport participation in supporting students with a concussion.

Recommendations for facilitating return to school in Canadian adolescents
• Schools should develop and implement return to school policies that outline gradual return to physical activity and gradual return to school protocols.
• Schools should discuss roles and responsibilities of teachers and school administrations for supporting students following a concussion and these roles should be clearly communicated to students and their parents/guardians.
• Schools should have clearly outlined communication channels to ensure students are adequately supported when returning to school following a concussion.
• Concussion education should be provided for all school stakeholders and should include topics and information relevant to middle and high school settings.The education should outline ways in which students may be affected with possible solutions identified.
• School stakeholders should identify available resources to support educators in facilitating students' return to school and should identify strategies to address resource gaps.

Conclusions
This study provides an increased understanding of Canadian grades 7-12 teachers' and school administrators' perspectives in supporting students returning to school following a concussion.Educators want to support students through academic accommodations and social support; however, minimal education and training, limited resources, and lack of school concussion management processes hamper the implementation of supports for students.Streamlined processes and communication strategies internal to schools may enable a more successful return to school for students

Table 2 . Additional quotations to support themes Theme Examples of Quotations to Support Themes
1. Educator Roles Differ for Administrators and Teachers If you get your prep time, it's a little bit easier because you've got that extra time built into your schedule already.If you don't have any prep time, it becomes a little bit more of a ...I'm not going to say a 2.1.Students are honest most of the time when discussing symptoms and functioningIn my experience, I would say, no . ..I don't think for the sort of the more critical sort of educational-type accommodations, I haven't seen that or at least I have no reason to think that I've seen that (Participant5-Administrator).(Continued)

Table 2 . (Continued) Theme Examples of Quotations to Support Themes
. ..And then they have worry and anxiety ...because they don't know [what]to expect . . .when they come back".Administrators' inclusion of the emotional and psychosocial symptoms provided a more holistic understanding of the multifaceted ways concussions can affect students returning to school.
A lot of students are pretty shy, and they don't like to open up about things or talk to you about things.But if you say, '''kay what do you need?"And if they're not willing to provide me with information I wouldn't be able to provide any or know of any accommodations if they don't tell me (Participant9-Teacher).3.3Physicians' notes may not be necessary for students to receive school supports, but they can guide care It almost feels like if they don't have a doctor's note, they're self-diagnosing, and it's harder to, not that I don't believe them, but it gives you that, like you said, that that piece of proof.And so, you have a desire to actually spend more time accommodating at that point (Participant7-Teacher).there.You literally could read the poster, do the protocol.So, something like that for return to academics would be nice too (Participant16-Teacher).light