Article Text

Original research
Educator perspectives on concussion management in the college classroom: a grounded theory introduction to collegiate return-to-learn
  1. Zachary Bevilacqua1,2,
  2. Donetta J Cothran1,
  3. Devin J Rettke1,
  4. David M Koceja1,
  5. Thomas F Nelson-Laird1,
  6. Keisuke Kawata1
  1. 1Kinesiology, Indiana University Bloomington, Bloomington, Indiana, USA
  2. 2Exercise Science, Rochester Institute of Technology, Rochester, New York, USA
  1. Correspondence to Dr Zachary Bevilacqua; zwbihst{at}


Objectives To gather the perspectives of collegiate instructors regarding how concussion is managed within the college classroom. To introduce the themes surrounding collegiate return-to-learn (RTL) and the classroom management of students with concussion.

Design Qualitative grounded theory.

Setting Large, public university in the Midwest.

Participants Twenty-three college instructors participated in a private, semistructured, audio-recorded, one-on-one interview. Participants included 12 males and 11 females. Interview recordings were transcribed verbatim, followed by an iterative process of open-coding and axial-coding, performed by two researchers.

Results Three themes emerged from the coded data: (1) awareness—external knowledge of concussion and previous experiences, (2) legitimacy—medical note provided and no note provided and (3) accommodating the student—instructor’s role and feasibility of the accommodation. Psychosocial factors such as small class sizes, graduate-level students and an instructor’s empathy appeared to influence an instructor’s decision making when accommodating a student recovering from concussion.

Conclusion These novel data provide foundational evidence regarding how college instructors perceive and subsequently manage concussion within the classroom, while also offering accuracy to aims of subsequent collegiate RTL investigations

Article summary RTL is an emerging field within concussion management, yet is grossly underexplored within the college setting. By utilising a grounded theory approach, this article introduces the themes that dictate the landscape of RTL for a college student.

  • neuropathology
  • trauma management
  • public health

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information. Technical appendix, statistical code, and dataset available from the Dryad repository, DOI: [include DOI for dataset here].

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:

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Strengths and limitations of this study

  • A grounded theory approach was used to discover the themes surrounding this unexplored field of collegiate return-to-learn.

  • One-on-one interviews allowed participants to express private and individualised perspectives.

  • Six trustworthiness measures significantly mitigated author bias.

  • Data was gathered from a variety of instructors, however, a School of Health represented 65% of the study sample.

  • The data represents the views of a large, public university and may not be widely transferable to other (smaller, private) universities


In recent years, management of concussion injury in school-aged individuals has been centred around re-integrating students back to the athletic field, known as return-to-play (RTP), as well as the classroom, referred to as return-to-learn (RTL). RTL is a gradual, individualised process that parallels RTP in both its aim and its importance. In fact, literature would indicate that completion of an RTL progression should take priority over an RTP progression,1 as consensus statement guidelines state that ‘children and adolescents should not return to sport until they have successfully returned to school’.1 Furthermore, DeMatteo et al2 asked the question of ‘what comes first’ between RTL and RTP and found that while these protocols can successfully be completed in tandem, the final stages of an RTP protocol should be postponed until an RTL progression has been fulfilled.2 Despite its significant position within the spectrum of concussion management, RTL surprisingly remains overshadowed by RTP studies.

To date, systematic review of RTL data has concluded that factors like age, grade level and course load must all be considered when returning a student to the classroom.3 For example, high school students reported a greater quantity and severity of symptoms, in addition to experiencing a delayed RTL, versus both middle and elementary students.4–7 Moreover, high school students had significantly more school-related problems, diminished academic skills and increased concerns about the academic repercussions of their injury, again versus middle and elementary students.7 Lastly, inappropriately timed increases in both cognitive load and school attendance were seen to exacerbate symptomology.4 8–11 These findings collectively suggest that a relationship exists between higher levels of academia and increased post-concussion difficulties; yet, the extent of this link is unknown, given that RTL research has produced minimal findings beyond the high school setting.12–14

The lack of college-aged RTL data is puzzling, considering that the collegiate environment presents students with several distinct challenges. For instance, because attending college incurs a financial undertaking, students may have to carry part-time employment simultaneously to engaging in highly competitive and rigorous curricula.15 Students are also tasked, possibly for the first time, with living on their own or among unfamiliar persons of different ethnicities, socioeconomic backgrounds, countries and ages.16 Lastly, college students are viewed as autonomous learners, which requires them to quickly adopt effective adult-like traits, such as time management. By acknowledging the various challenges that a college student encounters, coupled with the association between premorbid anxiety levels and prolonged concussion recovery,17 18 it is reasonable to suggest that appropriate support within the classroom could alleviate the cumulative stress that students encounter while on campus. In fact, a significant body of literature would attest to the importance of instructor–student interactions and its positive effect on outcomes like attitudes towards courses, increased studying and higher average grades.19–26 In the event of a concussion, an instructor could continue to exhibit this support, chiefly through the implementation of classroom accommodations. Instructors also have the greatest amount of school-related contact time with students, making their perspectives on how students with concussion are supported throughout their recovery, increasingly valuable.

Because college students experience a unique set of stressors and circumstances, it becomes prudent to explore the characteristics specific to this setting. Furthermore, due to the paucity of college-aged RTL data, investigators should begin this exploration by utilising an approach that will uncover the foundational themes within the college setting. In doing so, subsequent research will have a backdrop in which to reference, offering accuracy to future aims. Therefore, by implementing a qualitative grounded theory approach, the current study sought to use the perspectives of those close to students, collegiate instructors, to introduce the themes surrounding collegiate RTL and the classroom management of students with concussion.



Twenty-three college instructors from a large, public institution were included. Participants were derived from five schools on campus: Public Health, Business, Education, Public and Environmental Affairs and Optometry. Participants satisfied two inclusion criteria: (1) current non-tenure-track (NTT), tenure-track (TT), adjunct (ADJ) faculty with teaching responsibilities and (2) have previously taught a student with concussion in the college classroom within the past 10 years (not in a physical activity setting). We chose to exclude experience within physical activity-based courses considering that they place a demand on cardiorespiratory physiology, which resembles an RTP course of management. Eligible participants were identified via Qualtrics survey (Qualtrics Survey Software), distributed by email. Once identified, participants voluntarily signed an informed consent, demographics were gathered (table 1), and the interview was conducted. Permission to conduct interviews was given by the Indiana University Institutional Review Board and given exempt status.

Table 1


Patient and public involvement

No patients involved.


Data collection was performed using a semistructured, private, audio-recorded, one-on-one interview approach. Interviews took an average 62 min to complete, were recorded using a voice recorder and were conducted in a closed-door location of the instructor’s choosing. The interview guide (online supplemental appendix 1) consisted of eight semistructured questions, which affords the interviewer latitude to alter question order, to extract extensive detail from the instructor.27 All interviews were conducted by a single researcher.

Interactive materials—card sorting activity 1

Within the interview, instructors were asked to sort 10 index cards, each of which containing the name of an individual or entity on a college campus (online supplemental appendix 2). Cards were sorted into one of the two categories, identifying whether an individual(s) was part of the ‘RTL team’, or ‘not RTL’. Furthermore, instructors were asked to sort these cards twice, first using the criteria who do you believe is currently part of a return-to-learn team on campus?, and then a second time using the criteria if you were in charge of creating a return-to-learn team for campus, who would you include?’.

Interactive materials—card sorting activity 2

Instructors performed another card sorting activity, analogous to the one described previously; however, this activity required instructors to rank the feasibility of 16 commonly requested RTL adjustments and accommodations into one of three categories: ‘very feasible’, ‘somewhat feasible’, ‘not feasible at all’. The feasibility ranking referred to an instructor’s ability to implement that accommodation in the classes they teach. The chosen accommodations were taken from previous work by the authors.13


Each interview was transcribed verbatim, as to capture useful vernacular used by instructors. The online transcribing software service Temi was used to transcribe the interviews. The final accuracy of the transcript was carefully reviewed by the same researcher who conducted the interviews.

Data analysis

Two researchers used inductive reasoning to independently open-code and axially-code all transcripts.28 Collegiate RTL is an unexplored field and as such requires a grounded theory approach to inductively generate novel themes for future research. Using Microsoft Word, segments of text were assigned codes, embodying their meaning. Codes of similar nature were grouped together to identify their overarching theme,28 and final codes were matched and confirmed between both coders, through an iterative discussion process. Two mandatory criteria needed to be satisfied for a theme to be considered overarching and significant: (1) the theme had to include matching codes from at least 80% of the sample, and (2) themes must possess enough heterogeneity between one another. Ensuring heterogeneity between themes confirms that all themes truly represent a robust, yet standalone, characteristic of the research. The cut-off of 80% representation was selected as it indicates significant homogeneity among instructor perspectives, without unnecessarily excluding themes that could not reach unanimous representation. Subthemes were also independently identified by each coder. Following the initial round of subtheme identification, final subthemes were agreed on by both coders, again through an iterative discussion process. To report the overall perceived feasibility of an accommodation from card sorting activity 2, each category was assigned a numerical value (very feasible=1, somewhat feasible=2, not feasible at all=3). Each time an accommodation was considered ‘very feasible’ by an instructor, it would receive a score of 1; and so on for the remaining two categories. With this, an average feasibility value could be calculated for each individual accommodation. Feasibility values were calculated for the collective sample, as well as NTT and TT cohorts individually.

Trustworthiness measures

Trustworthiness, or methodological rigour, was maintained through credibility methods29 (triangulation, member checks, peer debriefing, two-coders) and confirmability methods29 (audit trail, journaling). Utilising several measures ensured that researcher bias was substantially mitigated during all stages of the investigation.


Collectively, 89 codes were consolidated into three overarching themes (1) awareness, (2) legitimacy and (3) accommodating the student. These themes, and their accompanying subthemes, embodied instructor’s perspectives regarding concussion in the classroom. Here the crux of each theme will be presented, and supported with instructor quotes.


The first theme of awareness refers to an instructor’s broad exposure to concussion. This exposure can be dichotomised into (1) external knowledge of concussion, and (2) internal previous experiences, of which instructors could possess one, or both.

External knowledge of concussion

Several instructors derived their understanding of concussion from a variety of sources (news, television, scholarly research, etc), yet, no one external source appeared to predominate. For example, when asked the question when I mention the word concussion, what thoughts come to mind? And what sources are you drawing from?’, instructors responded:

…I am up to date more than most, especially because we have concussion research that happens in our own school, in our own department

…I know the news side, the CTE’s in the NFL players

…I'm sure you're familiar with the scene from The Office where Dwight gets a concussion. He ran his car into a fence and gets a concussion, jumps out of his car and throws up, and then immediately gets back in his car and starts driving. And then for the rest of the day he’s a little bit off… he’s not himself and his brain doesn't seem to be able to keep itself on track and focus.

Previous experiences

When asked the same question regarding concussion, some instructors recollected personal experiences as their primary source of understanding concussion. Again, answers differed in detail, however, having a personal history or exposure to concussion (sustained themselves, by a friend/family member or professional experience working with concussion patients) afforded these instructors to offer greater detail regarding the symptomology and pathology of concussion. Examples of greater detail included:

…The brain actually smashes against the skull. There’s headaches, cognitive challenges, concerns with noises, bright lights. But these are all personal experiences. I also think of potential brain injury, brain swelling.

…I have a friend who had a midbrain injury with concussion. She went over the handlebars on her bike, had a helmet on, still ended up with a midbrain concussion. She had vertigo, headache, and all kinds of problems that went on for almost two years.

…I worked inpatient psych on a locked unit with adolescents before I came back to the collegiate environment. [I] Came to understand and appreciate the brain in different ways.


This second theme of legitimacy represents how instructors internally substantiate a student’s claim of having a concussion and their request for accommodations. Concussion is not always an outwardly recognised injury and, as such, obscures an instructor’s already limited ability to identify the presence of a student in need of accommodation. In turn, this theme focused heavily on the presence of a medical note, indicating that an injury was present and that medical care was received. The resulting subthemes were (1) medical note provided, or (2) no note provided.

Medical note provided

Responses revealed several reasons as to why an instructor would rely on a medical note prior to awarding accommodations to a student. Perhaps the simplest reason is that instructors acknowledge that they should look to the medical professionals for the health status of their students. For example:

…the legitimacy comes from the external note, or email. I wouldn't trust my own instincts on something medical, I wouldn't have a clue. So I rely completely on the people who are the professionals.

…it was helpful in that I was given information directly from the medical professional because it helped me provide legitimacy to the claim. I'm sure you can imagine there are often a variety of claims about different types of things, and so it’s very helpful when you immediately get the notice.

…If there’s some sort of indication (doctor note or university email) that there’s a challenge with a student, and they've spoken with us (instructor), and it’s legitimate, it’s very helpful. It allows me to quickly ignore any kind of, ‘well when was this?’ or ‘did that actually happen?’, type questioning.

…I want a note. I want a note before I excuse an exam, excuse a quiz, excuse a paper.

Furthermore, while students will inevitably receive their documentation from varying healthcare providers, instructors expressed their preference to receive documentation from a university-affiliated entity (eg, campus health centre, disability student services).

No note provided

If a student was unable to produce medical verification of their injury, instructors were forced to lean on a multitude of factors as they rationalised the decision to either provide or withhold accommodations. These factors included (1) class size (small vs large), (2) student classification (graduate vs undergraduate) and (3) instructor’s empathy. Individually, these factors had a positive or negative implication over an instructor’s choice. For example, instructor comments on class size indicate that smaller classes are of benefit:

…The smaller number makes a little bit more of an intimate setting, and you get to know people as individuals. And more importantly, you get to know personalities.

…If the question is, do you think class size effected my ability to effectively respond to the concussion situation? It’s a yes.

Instructors also voiced an inclination to trust graduate students over undergraduates. For instance:

…To be very honest with you, and not to sound disparaging towards undergraduates, but I talked to my colleagues who teach undergraduates, and we were all undergraduates at one time. But undergraduates don't come to class sometimes, they're not a serious in their scholarship. So sometimes, I think instructors have to be a little bit more rigid with undergraduates. With a graduate student, they're semi-professionals in a sense, so they trust them.

…She had offered to bring a doctor’s note, but I said that it wasn't necessary. It’s a graduate level course, so I go with the fact that they're grad students, and if they're lying, then it’s beyond what I care to get into

Lastly, intrinsic predispositions like empathy appeared to significantly impact an instructor’s approach when managing a student with concussion.

…I tend to be the over-trusting one (instructor). I rarely find that a student will put something that important (injury) on the table and be lying about it. It’s kind of the way I like to approach life. I just think it’s a better way to live.

…I love them. I do, I love my students. They’re little people, they’re far from home. I think they’re stressed with being at this huge university and figuring it all out. And so I don’t need to be one of their problems.

The opposing factors described here swayed instructor responses to various degrees. In turn, figure 1 gives a visual interpretation of how each of these psychosocial variables foreseeably dictated an instructor’s decision making.

Figure 1

No note provided: factors influencing an instructor’s decision to allow accommodations.

Accommodating the student

This final theme encompasses the instructor’s approach to assisting a student recovering from concussion. This theme signifies that the student’s injury has been legitimised via documentation or other psychosocial factors and speaks to the duties in which instructor’s feel responsible for executing, in addition to the feasibility of accommodation requests. Heavily inspired by the interview card sorting activities, the subthemes include (1) instructor’s role and (2) feasibility of the accommodation.

Instructor’s Role

Card sorting activity 1 asked instructors to determine the members of a collegiate RTL team. Under the first criteria, 70% of instructors believed they were currently part of an RTL team. When asked to explain why they were not part of the team, the remaining 30% reported:

…I’ve never been asked to be part of a return-to-learn team for injured students.

Under the second criteria, 95% of instructors believed that they should be part of a collegiate RTL team. Given this high percentage of self-inclusion, the follow-up question was asked, ‘what role do you believe you should have on the team?’. The responses were consistent:

…Supportive. To help that student do as well as he/she can until they become a rehabilitated student.

…To help that student become successful in my class despite the diagnosis of concussion.

…My role is to receive input from other (team) members, and then to discuss with students, what are your goals? Do you want to wait a couple weeks? Do you want to try to fight through this? What are your goals, and how can I help you to achieve those?

Instructors also consistently excluded three individuals from the RTL team, regardless of sorting criteria: parent, campus police and coach. Instructors noted:

…FERPA prevents me from having any conversations with parents.

…Simply, campus police has nothing to do with Return to Learn…Coaches, they should have no authority over that.

Lastly, when asked to identify the most important member of the team, instructors were equally split between three members: medical provider, disability student services, and the student.

Feasibility of the accommodation

The results from card sorting activity 2 are shown in table 2. Across the sample’s entirety, instructors perceived ‘wearing sunglasses’ and ‘excused from exams’ as the most and least feasible requests, respectively. When broken into quartiles, the most feasible requests (wear sunglasses in class, additional time on assignments, additional time on exams) represent academic adjustments, whereas the least feasible requests (decreased workload, excused from assignments, excused from tests) are classified as academic accommodations. Once these trends were identified, instructors were subsequently asked, ‘what makes these requests less feasible, and these more feasible?’. Regarding the least feasible requests, instructors responded:

…We need to have demonstration of knowledge, which would come from assignments and tests, to be confident that this student is moving along an academic pathway and truly learning.

Table 2

Accommodation feasibility rank order

…I need to know that they [students] know the material before they leave my class.

Regarding the most feasible requests, instructors responded:

…I'm going to say this. These [pointing to the less feasible cards] are extra work for me.

…The question of whether a person cares about a student (to accommodate them) is secondary to, do I, or don’t I have time to deal with this.

The introduction of time as a constraint to helping a student by NTT instructors was an insightful addition to this subtheme. On further probing, we discovered that an instructor’s rank may restrict their availability. Several NTT instructors commented on the suspected hardships they believed their TT colleagues would experience. One NTT instructor nicely summarised:

…At an R1 institution, understand what’s driving the bus. Research, publications. The teaching is important, but I think the research and the publications are more important. So you know, there are probably some individuals who think, ‘I'm teaching this class because I have to, but this (research) is really where I'm going to invest my time’, and now I have to deal with a student in my class who has this condition that we don't know how or when it’s going to resolve. And I have to deal with that when I'd rather be chasing a grant or writing a scholarly paper. So I could see where dealing with concussions are problematic for some in the academic setting.

A second instructor added:

…Someone has a hundred things to do, they have time to do 10 of them, and now a student (with concussion) says ‘hey, can you meet?’. And for a lecturer who’s all about students and doesn't have this other research, says ‘sure you can come into my office and take this test that you missed’. For a PhD [tenure-track] it’s, I don't even know where to fit this in. It’s a second priority of a second priority.

To explore if these claims held merit, we asked tenure-track instructors the following question, ‘is there anything about being tenure track, or your job description and duties, that you think would impede you from assisting a student with a concussion?’ Responses included:

…I don't think so. Not that comes to mind. I do compress my teaching into a very narrow window, so that I can focus on my research the bulk of my time during the year… I tend to take my teaching very seriously, and when I think about how students are paying to be in the classroom and the investment they're making, I view it as my job and moral responsibility to bring as much as I can to that context. And so my attitude toward compressing it is, yeah, my research is going to slow down a little bit during this period, of time, and that’s something I've prepared for.

…No, not that I can think of.

While only two TT instructors were asked this question during their interview, the remaining TT participants were followed up with via email to offer their input; however, no others replied.


This study is the first to gather an in-depth perspective of how collegiate instructors perceive and manage concussion in their classrooms. While each of the discovered themes independently represent an important aspect of concussion management, they collectively embody the landscape instructors must navigate as they attempt to support their students. Because this study offers the genesis of themes pertinent to collegiate RTL, our discussion will not inspire deductive reasoning or conclusions from the data. Instead, grounded theory allows us to insightfully discuss the implications of our data and guide the aims of subsequent investigations with a higher degree of accuracy.


Previous studies have expressed the importance of educating RTL team members about concussion in an effort to improve patient outcomes3 12 30; however, concussion awareness (external knowledge, previous experience) did not appear to influence our sample’s consistent response to concussion management in the classroom. This contrasts previous research, which indicates that knowledge discrepancies exist between academic disciplines. Specifically, business faculty and staff in a collegiate setting have exhibited significantly less knowledge and awareness of concussion versus health science and humanity disciplines.12 Identifying this contradiction prompted us to question why our sample displayed a homogeneous understanding of concussion. One possible explanation can be offered by Mokris et al,12 who indicated that awareness of concussion is significantly higher in collegiate faculty that have previously provided accommodations to students with concussion versus those who have not. Given that our inclusion criteria required previous experience with concussion in the classroom, we can corroborate Mokris’ findings and begin to understand the origin of our cohort’s uniform voice towards concussion.

Despite an instructor’s perceived knowledge of concussion, nearly all expressed a desire to receive medical documentation from students. The exception to this pattern was seen in instructors who conveyed an empathetic position towards their student’s hardships. In fact, empathy appeared to greatly influence an instructor’s decision to award accommodations even in the absence of such documentation (figure 1). Human behaviour research would indicate that this trend was not simply a coincidence, as both sex and age have been identified as significant predictors of altruistic decision making; with older individuals and females revealing greater altruistic tendencies.31 More importantly, altruistic decision making is significantly mediated by emotional empathy, instead of reasoning.31 This supports two of our findings. First, it offers insight as to why instructors still desired medical documentation from students despite their knowledge of concussion or its effect on classroom activities. Second, it helps explain why an empathetic instructor provides students with a greater chance of receiving classroom accommodations when medical verification is absent. Contrary to previous research,32 these findings collectively require us to question whether targeted concussion education is the most effective method for establishing uniform decision making from instructors. In fact, previous research buttresses this statement as Glang et al33 report how an online concussion course can significantly increase knowledge of concussion in general education teachers, but fails to instil long-term (6-month) application of this knowledge (p=0.92). This evidence suggests that concussion education does not lead to significant changes in classroom management of concussion, which in the context of our findings, would still leave instructors requesting medical documentation for legitimacy and guidance. We should note, however, that while concussion education may yet play a supportive role within collegiate RTL, perhaps access to medical care and diagnosis would yield greater uniformity of outcomes.

Researchers should also consider the unknown perspectives of instructors who have no exposure to concussion, no experience with it in the classroom or both. Do these instructors display a different outlook towards concussion and its accommodation in the classroom? Also, if empathy truly effects instructor decision making and is not significantly mediated by concussion awareness, then instructors who did not meet our inclusion criteria could theoretically exhibit similar decision making profiles as our sample. Future investigations should be mindful of these possibilities.


Perhaps the most robust and consistent pattern to arise from this study was an instructor’s desire to legitimise a student’s request for accommodations. While instructors sought out expert opinion as a confirmation of disability, there were those who also highlighted the need to keep supportive opportunities fair and equally available within the class. Post-concussion accommodations often include privileges like extended time to complete assignments, however, allowing these requests for only one student prompts an instructor to seek a valid reason for doing so. Medical documentation will not only confirm a need for assistance but will also maintain the status of a fair classroom environment. Interestingly, nearly all instructors expressed a desire to receive medical documentation, however, no one addressed the possible struggles of obtaining such documents.

Requiring a student to receive medical care prior to granting accommodations not only ensures that the health of the student is under proper medical supervision but it also imposes a financial burden on them. In fact, this burden may be more tangible than expected, as nationwide survey data indicates that nearly 60% of colleges (150 public from 42 states and 133 private from 32 states) have concerns about underinsured students attending their institutions, as dictated by a student having ≥US$1000 deductible plan.34 To complicate matters further, some institutions do not offer health insurance plans to their students or do not require students to carry health insurance while enrolled.35–37 Of greater concern, however, is that disability service offices at select universities have clearly recognised concussion as a covered disability,38–40 while others have remained ambiguous in their scope.41–43 Impressionably, this conveys the notion that students at certain institutions may not receive accommodations for their concussion. This is particularly troubling, considering that recent amendments to the Americans with Disabilities Act (ADA) marked the inclusion of traumatic brain injury as a recognised disability by the federal government, mandating that faculty provide accommodations when official documentation is endorsed by the institutions disability services office.44 What is more, the ADA suspended its ‘transitory’ regulation tied to disability criteria (ie, <6 months).44 This means that individuals suffering from mild forms of brain trauma (ie, concussions), despite its temporary nature, can still receive disability assistance. These amendments are the first ever to provide college students with guaranteed classroom accommodation following concussion; however, qualifying for these services requires presentation of medical documentation outlining the disability, which to our previous point, may be a significant barrier for students to overcome. Furthermore, it should be clarified that a note from a qualified medical provider, while significant, is not the equivalent to an endorsed document from a school’s disability services office, given that the former is a medical opinion, and the latter is a federally backed call-to-action. Our participants, however, perceived both equally, which bodes well for students.

Until concussion injury is ubiquitously legitimised for college students, we must continue to wrestle with the intricate decision making that instructors undergo in the absence of medical documentation. As seen in figure 1, the logistical and psychosocial characteristics of an instructor and their classroom can dictate the acquisition of concussion assistance. For instance, instructor responses seemed to tether a disadvantaged position to larger classes and undergraduate students (figure 1). Pragmatically, a large lecture hall does not afford an instructor the opportunity to gain an interpersonal connection with many of their students, and therefore could hinder an instructor’s ability to view requests from those students as impartial or truthful. This was supported by the opinion that undergraduate students are ‘not as serious in their scholarship’. In contrast, teacher–student interactions within smaller classes were portrayed as ‘intimate’ and ‘personable’, allowing instructors to learn about their students as individuals. Divergence between how instructors referenced large and small classes lends us valuable insight as to how concussion symptomology may be interpreted in each of these settings. To explain, concussion injuries are often accompanied by psychological symptom profiles (irritability, anxiety, sadness, etc), which are not always outwardly recognisable. In turn, having a preinjury ‘baseline’ of a student’s behaviour and tendencies within the classroom could not only alert an instructor as to any deviations from the student’s norm but also be used as evidence to support a student’s undocumented claim of having a concussion. In addition to smaller classes, instructors also suggested that trust was implicitly given to graduate level students, given their assumed professional status. While this benefits students pursuing post-graduate studies, these students are typically not the majority enrolled at an institution, therefore leaving the larger student population in jeopardy. The overall uncertainty of how an instructor will internally rationalise a student’s request for help is a predicament we refer to as ‘teacher roulette’, which was hinted at by one instructor:

…You're (the student) kind of at their (the instructor) mercy. It’s like, ‘oh, I got one that’s accommodating….I hold the keys to all the gates, and the students know it.

Classroom elements like size or graduate students pose an interesting, and perhaps biased, line of thought from instructors. Future investigations should cautiously explore and add clarity to these initial patterns. Moreover, the experiences of previously concussed undergraduate and graduate students should be gathered to see if their first-hand experiences substantiate the potential inequities identified here.

Accommodating the student

An instructor’s ability to help a student with concussion is seemingly corralled by what they believe their role to be, in addition to the feasibility of what is being requested of them. Consistently, our instructors believed that their role within an RTL team should be peripheral and responsive. This triangulates their desire to receive confirmation of injury from medical personnel. Additionally, no instructor identified themselves as the most important member of the RTL team, reaffirming their position as a peripheral contributor. It should be noted, however, that the external stance of an instructor is not indicative of lessened importance. Instead, it is perhaps drawing attention to the view that concussion is first and foremost a medical concern, and while academic faculty and staff play a pivotal role in the seamless reintegration of academic tasks, the course of treatment should be directly supervised and adjusted by medically trained personnel.

The rank order (table 2) of academic supports stratified which requests may face pushback by an instructor. Triangulation of this data to instructor responses allowed us to detect a temporal undertone associated with an accommodation’s feasibility. Therefore, we hypothesise that instructor’s views of feasibility stem from a balance between the work required to implement an academic support and the time needed to do so. To explain, the academic supports that were scored as very feasible (wear sunglasses in class, additional time on assignments, additional time on exams) all possess a ‘hands off’ quality, requiring no additional demand on the instructor. In contrast, somewhat feasible accommodations (audio lectures, limited computer work) may require instructors to create alternative assignments or separate audio-recordings of their lectures. Therefore, it can be speculated that the implementation of an adjustment or accommodation by an instructor is inversely correlated to its time commitment. This correlation, however, does not appear to be the chief influence for the scoring of our least feasible accommodations (decreased workload, excused from assignments, excused from tests). Instead, instructor responses suggest that maintaining course integrity is the driving factor. Curriculums, particularly those within accredited programmes, set forth a course of instruction designed to ensure that students have acquired a specific level of skill and knowledge prior to degree maturation. In turn, instructors likely feel responsible to safeguard the standards of their respective departments by upholding the integrity and rigour of their individual courses. Additionally, courses within a curriculum are routinely arranged in a manner that requires a student to display prerequisite knowledge prior to advancing to the subsequent course. Therefore, a student forgoing an entire exam/assignment would contradict this principle. It should be noted, that while excusing exams/assignments were labelled as unacceptable, all instructors reported that they would be willing to postpone these items until the student had recovered.


The present study is not free of limitations. First, this study was conducted at a large, public institution; therefore, faculty at other colleges and universities (eg, smaller, private) may possess idiosyncratic perspectives unique to their setting. Second, while adjunct instructors were eligible to participate, none volunteered, which necessitates their opinions be gathered as data indicates that nearly 50% of the faculty positions at degree granting institutions are adjunct or part-time.45 Third, our cohort included five academic disciplines, however, 65% belonged to a college of Public Health, requiring future works to achieve more even representation. Lastly, because certain health disparities are the result of race and ethnicity, it is possible that an instructor’s perspective towards injury and illness is influenced by their background. Because the studied university is comprised of only 31% minority faculty,46 ethnic and racial heterogeneity must be a chief component of follow-up inquiry.


This is the first study to outline RTL management in the collegiate setting. Of primary importance, the themes generated here not only illustrate the foundational characteristics of collegiate RTL but also provide a platform for future collegiate RTL research to build from. Medical verification of concussion has emerged as a significant theme within the college setting and, when absent, renders students open to the unpredictable rationale of their instructors. The impact of concussion education efforts on collegiate faculty is also under question, as the various levels of concussion awareness among instructors did not appear to alter their inclination to legitimise a student’s claims. Instructors also wished to receive medical guidance as peripheral members of the RTL team and may be reluctant to implement accommodations that infringe on the integrity of their course or require significant time commitments. The presented findings, while not universally transferable, are meant to represent a credible, transparent and robust depiction of our cohort’s voice regarding the management of concussion within the classroom.

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information. Technical appendix, statistical code, and dataset available from the Dryad repository, DOI: [include DOI for dataset here].

Ethics statements

Ethics approval

Ethics approval to conduct this research was received from X University Institutional Review Board and given exempt status.


The authors acknowledge the support of the 23 instructors who voluntarily participated in this research.


Supplementary materials

  • Supplementary Data

    This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.


  • Contributors ZB designed the research idea. DJC, DMK, TFN-L and KK refined the study protocol and study implementation. DJR acted as the second coder of the data. All the authors contributed to the writing and editing of the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.