Arkansas’ Creation and Implementation of Health and Safety Legislation Utilizing Ambrose’s Requirements for Change

The health and safety of young athletes has been an area of concern for parents, coaches, administrators, athletic trainers, and other health care professionals for years. Every year, young athletes pass away while playing high school sports. Figure 1 provides an overview of the deaths, broken into 5-year blocks (8). These deaths encompass all deaths, including those from cardiac pathologies, head injuries, exertional heat stroke (EHS), trauma, and more (8). More recently, this issue has become an area of concern for policy makers and legislators, as evidence continues to suggest many of these deaths could have been prevented with proper prevention, assessment, and treatment (1). Many states are working toward adopting new policies for high school athletics on topics that range from concussions to cardiac events and heat illness prevention. Even with the increase in policy development, many struggle with how to facilitate such changes. Table 1 highlights some major health and safety policy changes that the state of Arkansas (AR) recently was able to implement. This case study describes how AR developed and implemented a large high school health and safety initiative, specifically Act 1214: An act to promote the health and safety of students in public school athletic activities through the use of athletic trainers and professional development for coaches; and for other purposes (10). This specific policy development was chosen because it was one of the first successful large-scale changes and could serve as a good illustration for other states looking to implement a similar initiative.Figure 1: High school sport fatalities. [Adapted from Mueller FO, Casa, DJ. Fatal and catastrophic injuries in athletics: epidemiologic data and challenging circumstances. In: Casa DJ. Preventing Sudden Death in Sport and Physical Activity. Sudbury (MA): Jones and Bartlett Learning; 2011.]Table: Various health and safety policies adopted in AR.On August 11, 2010, 15-year-old Tyler Davenport collapsed at the end of a practice (6). He had experienced an EHS and was taken to Arkansas Children’s Hospital (6). Two days later, on August 13, 16-year-old Will James was competing in football practice and collapsed (6). He too experienced EHS. He too was taken to Arkansas Children’s Hospital (6). Although their stories are similar, they also are different. Tyler’s school, in rural AR, had no athletic trainer (6). His coaches provided the initial care and immediately called for an ambulance (6). Will’s school, in Little Rock, employed an athletic trainer who quickly realized he was experiencing a heat illness and began cooling him in a locker room shower (4). He was transported when the ambulance arrived (6). Tyler and Will were both in the intensive care unit at the hospital when Logan Johnson, a 13-year-old basketball player arrived (6). He was transferred from another hospital and he too had experienced an EHS on August 13, but this time, it was at basketball tryouts in a sweltering gymnasium (6). Logan initially was cared for by the school nurse, who still happened to be on site, before being transported to the hospital. During this time, there were three families of young men experiencing the same condition at Arkansas Children’s Hospital (6). The families soon became friends, assisting each other throughout the difficult time (6). Word spread throughout the state of these young men who were experiencing a condition that is not only preventable but also 100% survivable if recognized and treated quickly (2,7,9). Will James was released after spending 3 wk in the hospital (6). He experienced kidney damage and required dialysis even after leaving the hospital. Logan Johnson also survived after spending 10 days in the hospital (6). Tyler Davenport spent 62 days in the intensive care unit before he passed away (6). Although Patti James’s son, Will, survived his EHS, she was determined to prevent another family from experiencing what the James, Johnsons, and Davenports had that summer (6). Because of the media attention received regarding these cases, several organizations within the state embarked on the change process. Organizations including the AR Athletic Trainers’ Association, AR EMS Association, physicians from local hospitals, and the AR Athletic Association individually looked inward to see what improvements could be made. In addition to the organizations, the parents of the EHS victims also were instrumental in creating the change, although using their personal resources and contacts, as well as sharing their stories with the media and lawmakers. These various constituents began to research the initial issue of heat stroke and contacted experts, including Douglas Casa and the Korey Stringer Institute (KSI, http://ksi.uconn.edu). As discussions progressed within the individual organizations, collaboration began to occur. As the process and discussions continued, other causes of death in sport were discussed and incorporated into the legislation. With the support and push from the parents of the children affected, and the assistance of the state legislature, AR Athletic Trainers’ Association, AR Athletic Association, AR EMS Association, and the state hospitals made a change (6). In April 2011, AR passed Act 1214: An act to promote the health and safety of students in public school athletic activities through the use of athletic trainers and professional development for coaches; and for other purposes (10). This legislation, which took effect August 2011, mandates that schools create emergency action plans for athletics, including heat illnesses, concussions, dehydration, communicable diseases, and other environmental emergencies (10). This bill also requires coaches to go through mandatory continuing education every 3 years on the topics listed previously (10). The bill also outlines a pilot program to employ a certified athletic trainer at the high school level (10). See http://www.arkleg.state.ar.us/assembly/2011/2011R/Acts/Act1214.pdf for the full bill. Additionally the AR Athletic Association implemented a rule that there must be a tub for ice water immersion on the sideline and ready at football practices. The state EMS association adopted the policy of “cool first, transport second” (3) for EHS patients, and the two major hospitals in the state, University of Arkansas for Medical Sciences and Arkansas Children’s Hospital, also adopted this policy. They also implemented means to cool aggressively an EHS patient if they arrive at the hospital prior to cooling. In 2012, AR adopted the “Preseason heat acclimatization guidelines for secondary school athletes,” set forth by the NATA-IATF (4). These guidelines, which mimic the National Collegiate Athletic Association’s heat acclimatization policies, describe a gradual phase in the process of activity and athletic equipment (4). This is to protect athletes and prevent heat illnesses, especially during August preseason practices. Figure 2 shows the timeline that depicts the events occurring in AR.FIGURE 2: Timeline of the events occurring in AR related to the creation and adoption of health and safety policies.One could assume that the death of one boy and the survival the two were the impetus for change in AR. EHS is consistently one of the leading causes of death in sport, and yet, many states have not made policies to help prevent its occurrence. AR is one of the first states to take a proactive step legally to address the health and safety of high school-aged athletes. Sudden death in sport due to EHS has affected high school athletes from AR; however the changes to the policies related to management just occurred in 2011. It appears as though more states are beginning to adopt policies and guidelines that protect the welfare of the student athlete. Soon after AR implemented their new policies, New Jersey became the first state to adopt the “Preseason heat acclimatization guidelines for secondary school athletes” (4,5). New Jersey was able to implement this change; however, it has not had an athlete die from EHS (5). Because these two states were able to implement health and safety polices for high school athletes, one following a tragedy and one without, the common link may be rooted in the process rather than the impetus. One leadership theory, Requirements for Change (1), could be used to explain why the initiative was successful in AR. Requirements for Change, by Ambrose in 1987 (1), graphically illustrates what is considered to be the necessary requirements for a change to occur (Fig. 3). The Ambrose model describes that when all components, vision, skills, incentives, resources, and action plan, are present, a change will occur (1). He even went on to explain the results when one component is missing. For example, if incentives are missing, a gradual change will result (1).FIGURE 3: Ambrose’s Requirements for Change. (Reprinted from Ambrose, D. Managing Complex Change. Pittsburgh: The Enterprise Group, Ltd; 1987.)Vision Ambrose describes for a change to occur, it must start with a vision (1). Without a vision, there simply will be confusion. In AR, one can associate the vision with Patti James and the leadership of the athletic trainers’ association, AR Athletic Association, and EMS group. Overall, the vision was to prevent another athlete from dying or experiencing what Tyler, Logan, and Will went through; however they had to be much more specific. Without a clear vision, the change cannot occur. Skills Ambrose then described that skills were necessary for changes to occur (1). When there are no skills, as described before, anxiety occurs. In AR, they recognized that they did not possess all the skills, so they turned to the KSI staff for the most up-to-date information. The staff assisted in providing the most current research and gave services and lectures to various groups. This ensured consistency and validity of the information being distributed to many different groups of constituents. It is important to learn from this that you (as the leader) may not possess all the skills; you just need to know where to obtain them. Incentives Incentives, meaning the reason people want to change (or follow your change), are important because without it, you simply get gradual changes. In many cases, especially as they relate to health and safety policies, you are going to not want a gradual change, as the information may become outdated. Incentives do not have to be physical incentives, but even emotional or moral reasons why a person should conform to the change are important. In AR, the incentive was preventing future deaths and hospitalizations of high school athletes. Had there not been the push from the families and increased media attention, the change process in AR may not have happened as quickly. For AR, the personal stories of athletes in their state were the incentive to change. For other states, we hope the stories of athletes elsewhere, and preventing such tragedies will spur the need for change, as was the case in New Jersey. Resources Resources also are needed for change to occur. Without resources, frustration occurs (1). In AR, the resources and the skills were very similar, as they asked for the KSI’s help with the process. The same important message applies to resources, and that is although you may not possess them, the most important fact is that you know where to obtain them. Action Plan An action plan is extremely important, as without it, false starts occur (1). Action plans should be clear and well thought out so that one can follow easily the plan. In the case of AR, they made their plan to create health and safety policies and had specific time frames for when they wanted certain things accomplished. Because they were having the policy in legislation, they had to set their timeline and goals around the legislative process. Conclusion In conclusion, because AR unknowingly had all of the Requirements for Change as outlined by Ambrose (1) and managed the change well throughout the process, they were able to develop and implement athlete health and safety legislation with out much resistance. Although AR did not use purposely the Ambrose model, when examining why their change process was so successful, one can see they had all the components. Using this model, other states also can implement athlete health and safety policies. Depending on the policy and the state, the specifics for each component may be different; however all the general terms still should be present for a successful change to occur. AR’s development and implementation of wide-scale high school health and safety policy changes also highlight the importance of collaboration between medical professionals and the education of all constituents, including medical professionals, parents, and coaches.

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