Background First-aid is a recommended injury prevention and risk management strategy in community sport; however, little is known about the sport-specific competencies required by first-aid providers.
Objective To achieve expert consensus on the competencies required by community Australian Football (community-AF) sports trainers.
Study design A three-round online Delphi process.
Participants 16 Australian sports first-aid and community-AF experts.
Outcome measures Rating of competencies as either ‘essential’, ‘expected’, ‘ideal’ or ‘not required’.
Results After Round 3, 47 of the 77 (61%) competencies were endorsed as ‘essential’ or ‘expected’ for a sports trainer to effectively perform the activities required to the standards expected at a community-AF club by ≥75% of experts. These competencies covered: the role of the sports trainer; the responsibilities of the sports trainer; emergency management; injury and illness assessment and immediate management; taping; and injury prevention and risk management. Four competencies (5%) were endorsed as ‘ideal’ or ‘not required’ by ≥85% of experts and were excluded from further consideration. The 26 competencies where consensus was not reached were retained as second-tier, optional competencies.
Conclusions Sports trainers are important members of on-field first-aid teams, providing support to both injured players and other sports medicine professionals. The competencies identified in this study provide the basis of a proposed two-tiered community-AF–specific sports trainer education structure that can be implemented by the peak sports body. This includes six mandatory modules, relating to the ‘required’ competencies, and a further six optional modules covering competencies on which consensus was not reached.
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It is now widely accepted that injuries, including serious ones, can occur during participation in community Australian Football (community-AF)1,–,3 and that injury prevention strategies, including the provision of appropriate first-aid, should be adopted.4 ,5 Previous studies have described the first-aid policies and associated practices of community-AF clubs6 ,7 and other Australian community sports clubs.8,–,10 Internationally, the qualifications, experience or knowledge of first-aid providers have been described across a range of sports and settings.11,–,13
First-aid providers are an important component of on-field injury management teams, providing support to both injured players and other sports medicine professionals. However, to our knowledge, no studies have been published in the peer-reviewed literature reporting the specific competencies – defined as the knowledge, skills and attitudes needed to effectively perform the activities required to the standards expected – required for first-aid providers in any community sport setting.
The Australian Football League (AFL), the national governing body for AF, considers sports trainers (ie, first-aid providers) part of the fabric of every club and that they play a key role in player preparation and safety at all levels. However, community-AF clubs, like their counterparts in other sports, have experienced considerable difficulty in recruiting and retaining suitably competent sports trainers.6 ,7 The AFL believes that the lack of community-AF–specific relevance of the currently available sports trainer education courses is a key factor contributing to this difficulty. As a consequence, the AFL also believes that potential community-AF sports trainers are reluctant to attend currently available education courses because they are perceived as time consuming, costly, including/focusing too much on some irrelevant content and not including/focusing enough on some relevant content. This article identifies the competencies that experts agree are required by community-AF sports trainers and proposes a community-AF–specific competency-based sports trainer education structure.
A Delphi technique14 was used to reach consensus among a panel of experts without engaging them in direct discussions.15 The Delphi technique is an anonymous process where experts communicate their opinions and knowledge, see how their evaluation of the issue aligns with others and reconsider and change their opinions, if desired, after viewing the findings of the group's deliberations.16 One advantage of the Delphi technique over other forms of consensus building (eg, committee meetings or focus group discussions) is that participants cannot be intimidated or inhibited from expressing their views by the presence of stronger or more hierarchically senior individuals who can dominate direct discussions.17 The major disadvantage of the indirect Delphi communication process is that participants cannot question or request further information or clarification from each other.
The University of Ballarat Human Research Ethics Committee approved the study protocol, which adhered to the fundamental Delphi principles of providing feedback to participants between rounds while maintaining the anonymity of participants.
Expert panel formation
The project team (comprising both authors, two community-AF administrators, an AF-specialist sports physician and an AF-specialist physiotherapist) identified a panel of 18 people from across Australia whom they believed had sufficient current involvement, experience, qualifications and knowledge in community-AF and sports trainer–related activities to be considered ‘experts’. These experts were initially informed about the study through an email from an AFL representative and recruited through a subsequent email invitation from a member of the research team.
The 16 experts who agreed to participate in the study included seven community football administrators; six sports trainers or medical officers in community-AF; two sports trainer educators; and one parent/coach. To confirm their expertise, the 16 panel members completed an online background questionnaire including items about their age and gender and 10 five-point scales (none, a little, some, a lot, very extensive) to self-rate their current involvement, experience, qualifications, knowledge and overall expertise in community-AF and sports trainer–related activities.
Questionnaire development and administration
For all three Delphi rounds, questionnaires were developed using SurveyMonkey software (http://www.surveymonkey.com), and panel members were emailed the hyperlink to the online questionnaire. Panel members were given up to 14 days to complete each questionnaire, and non-responders were sent up to two email reminders. There was a break of approximately 2 weeks between each round, and the whole process was conducted between August and October 2009.
Round 1 of the Delphi was used to identify all the competencies that community-AF sports trainers should have in an ‘ideal world’. An initial list of 74 competencies – organised into seven categories: role and importance (4 competencies); responsibilities (10); emergency management procedures and responses (5); injury and illness assessment and management (26); taping (5); injury prevention and risk management (16); and health promotion (8) – was developed based on: (1) a review of the nature and site of injuries to community-AF players; (2) current content of the Sports Medicine Australia and the Australian Rugby League sports first-aid/sports trainer education courses; and (3) the project team's expertise. Panel members were asked to: decide if, and how, each competency should be changed; comment generally on each competency; and suggest additional competencies. They were informed that their comments would be shared anonymously, through a summary report of the results of Round 1, with the panel during Round 2. The information gathered in Round 1 was collated and reviewed, and suggested changes/additions were included, if agreed as relevant by the members of the project team, in a revised list for Round 2.
In Round 2, a revised list of 77 competencies within the same categories was circulated to the panel members who were asked to rate each competency as either:
▶ ESSENTIAL – all qualified sports trainers must have this competency and no community-AF practice/training or match can go ahead unless someone with this competency is present.
▶ EXPECTED – all qualified sports trainers should have this competency.
▶ IDEAL – in an ideal world where money, time and other resources are unlimited, it would be good if a qualified sports trainer had this competency.
▶ NOT REQUIRED – if a sports trainer had this competency it would be of no value or use to the individual trainer or to the club/players they provide services to.
Panel members were encouraged to explain why they had given a competency a particular rating.
In Round 3, panel members received a de-identified summary of the Round 2 competency ratings and explanations and were asked to re-rate each competency using the same criteria. This gave them an opportunity to change their rating after reflecting on the outcomes of Round 2.
Figure 1 provides an overview of the three-round Delphi process used in this study.
Data from all three Delphi rounds and the background questionnaire were downloaded from SurveyMonkey and transferred into SPSS. Percentages were generated for each rating across each competency.
Compilation and use of the final list of competencies
In the literature, 75% agreement has been frequently accepted as the minimum level to represent consensus18 and the same was adopted in this study. Given this study aimed to propose a community-AF–specific sports trainer education structure, three levels of consensus were applied. A competency was accepted as ‘required’ by a sports trainer to effectively perform the activities required to the standards expected at a community-AF club if ≥75% of the participants in Round 3 rated it as ‘essential’ or ‘expected’ – these competencies were included as mandatory in the sports trainer education structure. To err on the side of including rather than excluding a relevant competency, the threshold level of agreement for excluding a competency was set higher. A competency was accepted as ‘not required’ if ≥85% of the participants in Round 3 rated it as ‘ideal’ or ‘not required’ – these competencies were excluded from the education structure. All competencies that were neither ‘required’ nor ‘not required’ were included as optional in the education structure.
Profile of the expert panel
Thirteen (81%) of the 16 panel members were aged 40–59 years and 15 (94%) were men. The self-reported ratings of current involvement, experience, qualifications, knowledge and overall expertise in community-AF and sports trainer–related activities are summarised in table 1. All of those who self-reported having a little/some (n=7) overall expertise in sports trainer–related activities also reported having a lot/very extensive overall expertise in community-AF. The following free-text responses provide an indication of the relevant expertise of some panel members.
One panel member described his expertise in community football as: “I have committed a life time to the . . . (name removed) . . . Football Club and the care and treatment of its players and injuries at all levels of the club. The . . . (name removed) . . . Football Club is a ‘way of life’ for me and not simply a weekend past time. Apart from the core sports trainers duties, I have actively involved myself in other club activities that benefit the club.” Another responded “I have been involved in community football for approximately 40 years as a player, coach and administrator”.
One panel member described his expertise in sports trainer–related activities as: “Very high, as I work with physios organising rehab programs for players. Taping players for training and game days, the standard has to be good. Have had experience with AFL teams so you have to be consistent. Have a good knowledge of how to treat and prevent injuries, how to stretch effectively before and after the game. Also conduct taping nights for other trainers throughout the . . . (name of region removed) . . .”
Based on Round 1, the number of competencies was increased from 74 to 77 for Rounds 2 and 3. Two new competencies were added and one existing competency was divided into two separate competencies. Some minor wording changes (eg, the word ‘immediate’ added in front of the term ‘injury management’ and adding or deleting examples) were also made to 10 competencies. Although some panel members suggested deleting some competencies from the original list, these suggestions were not acted upon because the purpose of Round 1 was to build a comprehensive list, not to reduce it.
Of the 77 competencies circulated in Round 3, there was consensus that 47 (61%) of them were ‘required’ by a sports trainer at a community-AF club. There was also consensus that four (5%) competencies were ‘not required’. There was no consensus on the remaining 26 competencies.
Within the ‘role and importance’ category, there was consensus that three of four competencies were ‘required’ (table 2) compared with 8 of 10 ‘responsibilities’ competencies (table 3); all ‘emergency management procedures and responses’ competencies (table 4); 22 of 26 ‘injury and illness assessment and management’ competencies (table 5); all ‘taping’ competencies (table 6); 2 of 17 ‘injury prevention and risk management’ competencies (table 7); and none of the ‘health promotion’ competencies (table 8). All ‘not required’ competencies were in the health promotion category.
The Round 2 free-text explanations suggest that, when a competency was rated as ‘ideal’ or ‘not required’, the competency was often considered beyond the scope of the sports trainers' role. For example, one panel member commented “I see the trainers' main role is managing injuries when they happen and the safety of the person injured. The role of injury prevention and risk management is the role of other people”, whereas another succinctly reported “Health promotion is not our job.” Some competencies that some panel members rated as ‘ideal’ or ‘not required’ were considered the responsibility of others such as the governing association, club administrators or coaches: “Many of these areas will be covered by others within the club, from team managers, coaches to fitness coaches depending on the setup of the club. It is unrealistic and rare to have a sports trainer looking after all of these areas” and “In some places, all games are played on the same ovals so the association does ground checks for safety.”
Proposed community-AF–specific sports trainer education structure
Based on the results of Round 3, figure 2 illustrates a proposed two-tiered community-AF–specific sports trainer education structure. The first tier (Sports Trainer) consists of six mandatory modules (The Role of the Sports Trainer 1; The Responsibilities of the Sports Trainer; Emergency Management; Injury and Illness Assessment and Immediate Management 1; Taping; and Injury Prevention and Risk Management 1) and includes the 47 ‘required’ competencies from this study. Sports trainers at a community-AF match or practice session would be expected to have completed all mandatory modules. The second tier consists of six optional modules (Health Promotion; Player Performance and Welfare; Playing Environment and Equipment; Injury Prevention and Risk Management 2; The Role of the Sports Trainer 2; and Injury and Illness Assessment and Immediate Management 2). Community-AF sports trainers would be encouraged to complete these optional modules. The specific competencies included in each module are shown in figure 2 using competency numbers cross-referenced to tables 2–8.
Although the original list of competencies circulated in Round 1 was comprehensive, the real value of the Delphi process was in Round 3. Through the consensus process, the responses of panel members were able to be used to categorise the original 77 competencies into: 47 ‘required’ competencies, 26 ‘optional’ competencies and four ‘not required’ competencies.
The competencies that were categorised as ‘required’ by sports trainers to effectively perform the activities to the standards expected at community-AF clubs could, for the purposes of education and accreditation, justifiably be considered mandatory. These competencies tended to be related to: understanding the role and responsibilities of a sports trainer in a community-AF club; assessing, responding to and appropriately managing community-AF–related emergencies; and assessing and managing common (lower limb injuries, open wounds injuries, soft tissue injuries) and uncommon but serious (an unconscious casualty, airway or respiratory distress) community-AF–related injuries. This is consistent with a risk assessment/management approach where the high-frequency (or likelihood), low or medium consequence injuries and low-frequency, severe consequence injuries are given highest priority.19
The fact that no consensus was reached on 26 competencies is also important and suggests that the panel considered it desirable but not necessary for community-AF sports trainers to have these competencies, and they could therefore legitimately be considered ‘optional’ in any education structure. These competencies tended to be those more related to: assessing and managing non-community-AF–related injuries that happen infrequently in a community-AF setting (eg, burns and stings; extremes of temperature); injury prevention (eg, preparticipation medical history and information; protective equipment and playing environment); player performance (eg, warm up and cool down; strength and conditioning); and the promotion of positive health (eg, nutrition; drugs; alcohol). The two community-AF–specific competencies in the Injury and Illness Assessment and Immediate Management category that were not considered ‘required’ may have been rated this way because trunk injuries are relatively uncommon in community-AF and overuse/chronic injuries are generally slow onset and less relevant to first-aid.
The panel members also agreed that four competencies (related to competence in drowning, fair play, skill development and equity in participation) were ‘not required’ and therefore could justifiably be removed from any education structure. It is likely that these competencies were rated this way because it is almost inconceivable that they would happen in a community-AF setting (in the case of drowning) or they are clearly the responsibility of others (coaches, umpires, administrators, etc.).
There has been considerable interest in using community sport to promote health.20,–,22 Although it has not been suggested that sports trainers/first-aid providers should be responsible for health promotion–related activities, because there are limited numbers of volunteers in community sporting organisations, sports trainers could be targeted to take on this role. Panel members in this study did not believe that the sports trainer role should include health promotion–related activities. Those advocating for health promoting community sports clubs will need to either negotiate with sports trainers to undertake this role or identify others to fulfil this role.
The most important outcome of this study is that community-AF sports trainer educators can now match their course content to the competencies that sports trainers need. This should minimise the risk of the education being irrelevant and potentially too expensive or time consuming. The study findings should also be used to ensure that any AFL first-aid–related policies for community-AF do not place unnecessary demands on sports trainers that will make them unwilling to take on the role.
It can be a challenge to recruit and retain expert panel participants using the Delphi method14 because of the continued commitment required from participants who are repeatedly questioned about the same topic, using a slightly modified questionnaire. Although the iterative nature of the Delphi method allows panel members to reflect on and alter their responses on the basis of anonymous feedback from others,23 it can also lead to substantial attrition among panellists between the start and the end of the process.18 One of the strengths of this study was the high level of initial engagement (89% of invited experts participated) and retention (100%) of experts. We can only speculate that the research topic; endorsement and active support of the sport's governing body; convenience of the online survey process; quick processing, summarising and recirculating of early-round survey data; and the engagement of end users in the early stages of policy research, all contributed to motivating the experts to engage and continue with participation in this study. A second major strength was the high level of relevant background possessed by the 16 panel members with over 50% self-reporting ‘a lot’ or ‘very extensive’ to all 10 categories included in the background questionnaire.
A number of limitations of this study need to be acknowledged. First, it may have been difficult for panel members to interpret the meaning of and distinguish between some overlapping competencies (eg, safety, risk management and injury prevention in the Role and Importance category). Second, the list of competencies included both ‘knowledge’ (eg, understanding the role of a sports trainer) and ‘skill’ (eg, being able to perform cardiopulmonary resuscitation) based competencies and panel members might have had difficulty comparing and rating these different types of competencies. Third, some competencies were more abstract in nature (eg, ‘health promotion’ and ‘equity in participation’) and panel members might not have understood these as well as they understood other, more specific and objective competencies (eg, ‘ankle’ taping and immediate management of ‘bleeding’). In addition, the standard required for a sports trainer to be considered competent was not considered in this study, and it is possible that different panel members may have interpreted this differently. Finally, the definition of community-AF used in this study was broad and included well-resourced state-league and large metropolitan clubs alongside less well-resourced smaller rural clubs, and clubs with senior players alongside clubs with junior players. Previous research suggests that it is difficult to develop standards (or in this case competencies) that are relevant and applicable across all types of community sporting organisations and all levels of competition.20
The competencies considered required by community-AF sports trainers include those related to understanding their roles and responsibilities, recognising and appropriately managing emergencies, assessing and immediately managing community-AF–specific common and potentially serious injuries and taping commonly injured joints. The expert consensus is that it is desirable rather than necessary for community-AF sports trainers to be competent in risk management, injury prevention, health promotion and the assessment and immediate management of non-community-AF–related injuries and illnesses.
What is already known on this topic
▶ Providing first-aid is a fundamental risk management strategy for most sports.
▶ Generic sports first-aid and sports trainer education courses are available, but these are not generally tailored to the needs of specific sports.
What this study adds
▶ To meet the context-specific requirements, community Australian Football (community-AF) sports trainer education should focus on ensuring that participants are competent in recognising and appropriately managing emergencies, assessing and immediately managing community-AF–specific common and potentially serious injuries and taping commonly injured joints.
▶ To avoid overburdening participants, optional community-AF sports trainer education should focus on: health promotion; player performance and welfare; playing environment and equipment; injury prevention and risk management; and the assessment and immediate management of common non-AF–related injuries and illnesses.
▶ The Delphi method is a useful and manageable research process for gaining expert consensus among community sport administrators and service providers.
The project was conducted through an active collaboration between the AFL and the researchers. The AFL members of the project team were as follows: Mr Lawrie Woodman (Manager Coaching, Umpiring and Volunteers), Mr Peter Romaniw (Community Development Coordinator), Dr Hugh Seward (AFL Medical Officers Association) and Mr Nick Ames (Consultant physiotherapist to AFL Junior Development Program). The study was conducted when the two authors were employed at the University of Ballarat, and the paper write-up occurred when they were employed at Monash University. The project would not have been possible without the dedication and commitment of the experts who participated in the Delphi process.
Funding This project was funded by a grant from the Australian Football League (AFL) Research Board. CFF was supported by an NHMRC Principal Research Fellowship (ID: 565900). AD was funded by the AFL grant during the conduct phase and an NHMRC Project Grant (ID: 565907) during the write-up phase.
Competing interests None.
Ethics approval The study was approved by the University of Ballarat Human Research Ethics Committee.
Provenance and peer review Not commissioned; externally peer reviewed.