Table 2.

Thematic map of concussion-related responsibilities as part of New Zealand Rugby’s (NZR) CMP

Theme		Responsibility	Definition of responsibility	Illustrative quote
1	Policies and support	1.1 Develop and implement policy	To develop or implement policies, protocols or guidelines specific to concussion management.	‘Yeah, I think too there needs to be a real, I suppose structure or system in place put in by the school just to outline what’s your procedures.’—Team lead
		1.2 Resource provision and support	To provide human resources/trained personnel, or other forms of service or financial support.	‘…if it’s a player from one of the rep teams, you’ll often find…that the manager or the coach will go out and you know, keep in contact with that person… but I just don’t have the time or the resources…to do what I’d like to do.’—PU representative
2	Rugby culture, and general management	2.1 Support players’ welfare and safety	To promote a safe game culture; oversee, lead or support actions related to general player welfare, health and safety.	‘Within our organisation, we actually have a separate focus on safety and research but it all folds into quality of experience, the game has to be safe for it to be a quality experience or we have mutual interest with our Rugby Smart Division which looks after this.’—NZR representative
		2.2 Buy-in, attitudes and behaviour	To facilitate change by fostering buy-in for concussion-related initiatives, relationships and work towards developing favourable concussion attitudes and behaviours. Two sub-categories, ‘team culture, trust and support’ (eg, fostering trust) and ‘compliance’ (eg, adhering to the game rules) formed part of this category.	‘…our community is four and a half million people, you know the All Blacks and our Black Ferns affect the general psyche of millions of people every weekend. We could be doing more to influence mum and dad, nana and granddad, uncle and aunty because they’re the ones that influence our kids.’—NZR representative
		2.3 Communication between stakeholders	To act as a high-level conduit for information sharing and decision-making; facilitation of communication and action of communication between stakeholders to allow optimal concussion management; or to communicate one’s medical history (eg, history of concussion and other injuries).	Parent A: ‘need to make sure that the schools are doing the right thing by our children.’ Parent B: ‘Consistency.’ Parent A: ‘Yeah, consistency through all channels of rugby… So, if your kid goes to [school name] intermediate, plays junior rugby here, and he can’t play for his club but then turns out for [school team name] on a Wednesday – ‘ Parent B: ‘And plays, yeah.’ Parent C: ‘Cause he doesn’t say anything.’ Parent A: ‘Yeah. So, is there a cross-communication? I mean that would be pretty hard but, how would you do that?’—Parents
		2.4 Injury reporting and administration	To report and record serious injuries utilising information systems within the rugby system.	‘Primarily it is to actually be on the administrative end and that is to receive the serious injury reports around concussion injuries, so this is from all levels of rugby whether it’s right at the top of the Magpies but say primarily during the club rugby season from club rugby senior grades of all levels, secondary schools right through all the grades and junior rugby as well…’—PU representative
		2.5 Education	To provide or support the delivery of concussion specific education initiatives.	‘…like education with like all the players, coaches, managers and like blood pressure, like education that everyone has to, so everyone’s on the same page…’—Player
3	Individual capabilities	3.1 Knowledgeable about concussion	To be knowledgeable about concussion and concussion care (including the self-pursuit of self-education and the rules of the game pertinent to concussion (eg, stand down period).	‘Well if your kids been concussed then you find out as much information as you can.’—Parent
		3.2 Knowledgeable about first-aid	To be knowledgeable and/or have the capability to act as a first responder in an accident.	‘We do stipulate in our plan that all of the well there needs to be someone with(in] you routine that’s trained in first-aid; they supply their own first-aid kits just because, we as competition managers aren’t there on the day. Half the time we are, but half the time we are not so schools need to be self-sufficient.’—PU representative
		3.3 Authority and leadership	To demonstrate authority and leadership through decision-making, supervision and influence.	‘…we set culture right from the outset of the field, or as soon as we drop the kids off, that’s it until full time. They belong to the coaches, parents don’t go on the field or make any decisions from the side-line, it was all the coach. They made the decision on play or not play.’—Parent
		3.4 Enforcing protocols	To monitor and enforce concussion protocols and consistency in management between stakeholders.	‘Somebody [a player] dobbed in and said, ‘if you have a concussion can you still trial for reps?’ Like, you literally have a concussion—are you seriously asking this question? So the concussion happened on the Wednesday, he was knocked out cold, but the rep trials were on Saturday and it’s not part of club rugby, so he can still trial right? …I just pulled rank and the mother abused me. And I’m like, ‘you talking to me isn’t going to change anything. He’s not playing, he’s not trialling, and if I see that he is trialling he will not be in the team.’’—PU representative
		3.5 Role multiplicity and task shifting	To take more responsibility and make more decisions if the actor primarily responsible for duty is unavailable.	‘Well yeah like(a co-worker)and I last year were working with the physio; he’s done so much stuff that he, just sort of took over that side [of responsibility). Just cause he had that obviously experience but, so and this year, having to make the decisions ourselves, yeah, it was challenging but a good idea.’—Team lead
4	Intervention following a suspected concussion (in the context of the NZR Concussion Management Pathway)	4.1 Disclose	To tell someone about a suspected concussion, whether personally experienced or externally observed.	‘…I’m forever reinforcing to them [players] about it’s important to communicate to us as coaches, that if you get a head knock so that we can manage it, and so sometimes they’re reluctant to say anything because they don’t want to not play or they think they can’t go back on.’—Coach
		4.2 Spot and recognise (awareness)	To be aware/alert to concussions, in self and others.	‘Awareness that there could be an issue…so coaches are obviously out there, but they’re watching the game; they need to be watching that [when] a players gone down, could there be a concussion issue? They don’t necessarily have to know what to do, but they should be aware that something’s going down and to call it.’—Parent
		4.3 Log concussion	To be responsible for logging concussions specifically via the CMP phone-based application.	Interviewer: ‘Were you involved in logging it in or did your medics take care of that for you’ Coach 1: ‘It’s my physio’s job to log that in’ Coach 2: ‘Same our medic’ Interviewer: ‘And you’re happy with them doing that?’ Coach 2: ‘Yip’—Coach
		4.4 Remove	To remove self or others from field following a suspected concussion.	‘Oh you’ve just gotta pull the pin, you’ve just gotta go off I reckon’.—Player
		4.5 Stop game	To stop the game following a suspected concussion.	‘Stop the game, like recognise what’s happening and then deal with the situation.’—Player
		4.6 Use blue card	Referee issuing a blue card during game play as part of the game rules.	‘If it’s a blue card, which we have in senior club rugby and secondary school grades that have official referees here in [PU), is to make sure that the referees know what their responsibilities are as well.’—PU representative
		4.7 Acute medical management	To provide on-field medical support following a suspected concussion, including assessment of injuries, deciding if return to play is appropriate and diagnosing injuries.	‘Being able to identify it on field when it happens… you’re like firsthand, you’re the first person sort of dealing with it in, like deal with it.’—Team lead
		4.8 Leadership and logistical management/coordination as part of acute incident	Where an actor undertakes a leadership role specifically in the acute phase of an injury. For example, delegating an actor’s role, using authority to override other’s decisions about return to play and undertaking the immediate coordination of care for the injured player	‘My role [is] to remove them from the field, to monitor them and ask them questions and get some symptoms, and then I would definitely not let them back on and I’d communicate with their parents and encourage them to go and see a doctor.’—Coach
		4.9 Acute on-field support	To provide support on the field following a concussion incident, which includes supporting the coach and/or assisting with transferring duty of care (eg, following up with the injured player on the side-line).	‘I think it’s to take the duty of care away from the coach as quickly as possible, just out of a bit of respect for his, you know, amount of position and coaching… basically responsibility for your kid, that’s what I’m trying to say.’—Parent
		4.10 Diagnose	Providing a medical assessment of the player for a diagnosis of concussion.	‘I went to the doctor and then that’s when they like diagnosed it…’—Player
		4.11 Seek diagnosis and treatment	Advising players to seek medical help specifically following a suspected concussions.	‘My coaches were the ones that said go to the doctor and get it checked out and one of my teammates, ‘cause she’d been concussed earlier on in the year…’—Player
		4.12 Follow recovery protocol	Specifically following aspects of the gradual return to play and graduated return to learn protocols; to guide players through, or be an active participant (to action) in the GRTP and GRTL, treatment and individual rehabilitation.	‘So as a player if you get a head knock, obviously, it’s your role and responsibility to look after yourself and make sure you go through your proper steps. But like if you know you have a concussion make sure you get off the field and then following on from that doing what you need to do listening to the physio doing a rehab.’—Player
		4.13 Manage recovery process	Manage, oversee and coordinate the recovery and clearance process, ensuring the recovery protocol is followed, including training and medical clearance.	‘… if someone has been concussed just go through the stats to get them back to play and try to take charge of that with the coaches. Organise the appropriate training around that time.’—Team lead
		4.14 Follow-up	The general actions of follow-up on player’s diagnosis status, recovery and subsequent management, including players’ progression through the CMP.	‘Just ongoing monitoring because sometimes, stuff, just some of the mild stuff carries on for quite a while, even though it’s mild…’—Coach
		4.15 Clearance	To seek or provide medical clearance as a prerequisite for players to return to play.	Coach: ‘We had a few cases this year where we’ve had to send the boys ah suspected to send them to the medical to see the doctors’ Interviewer: ‘And they were diagnosed at that point?’ Coach: ‘No, they were cleared but we sent them through to just go through the process.’—Coach
		4.16 Quality of care	To deliver healthcare that is multidisciplinary and consistent in objective and optimal management.	‘…our GP (general practitioner) refused to clear him [the player). She doesn’t like rugby, she doesn’t like people playing rugby and was not going put her registration at risk by clearing him…she went, ‘3 weeks! Minimum of 3 weeks!’ …There was a knowledge deficit of hers but also her personal opinion clouded her professional judgement.’—Parent
		4.17 Responsible for Baseline testing	To conduct, champion and/or use baseline concussion assessment either before, or after a suspected concussion has occurred	‘Interviewer: What roles and responsibilities does your child’s coach have around concussions? Parent: um definitely the baseline testing would be the first educating the parents and the kids.’—Parent
		4.18 Use portal	To use a bespoke online website, which grants general practitioners access to players’ baseline assessment, as part of NZR’s CMP	My experience that I had with the testing was when I took one of my players to the medical and the doctor didn’t use the website and he used his own tool. I can’t remember what the form, was but yeah, so maybe there’s no use of you having that base(line] test if the kids are not going to use it when they go to a medical.—Coach

CMP, concussion management pathway; GRTL, Graduated return-to-learn protocol; GRTP, Graduated return-to-play protocol.