UMaine Professor Helps Athletic Trainers Handle Sideline Pressure

University of Maine athletic training professor Alicia LacyAlicia Lacy was visibly upset. Her recommendation as an athletic trainer to sideline the high school quarterback who had just injured his ankle was being questioned by the team’s head coach, as was her professional capacity to even make such an assessment. The episode would inform the career decisions of Lacy, now an assistant professor of athletic training at the University of Maine, whose research and teaching curriculum addresses — among other issues — the kind of pressure situations she personally experienced on the field a decade ago. Beyond the classroom, the University of Connecticut doctorate recipient serves as a reviewer for multiple academic journals, volunteers with the Board of Certification to provide support for select initiatives, and is a member of the National Athletic Trainers’ Association Foundation’s Educational Resources Committee and the Korey Stringer Institute’s Medical and Science Advisory Board. AB senior editor Paul Steinbach asked Lacy to walk us through the evolution of her expertise.

What drew you to athletic training as a career focus?
That’s a great question, because I always preach to my students on the first day of class that it’s really important to tell your why, and at least understand why you’re pursuing a degree or doing whatever it is that you’re doing. When I was young, I was an athlete. I no longer identify as an athlete as I’ve gotten older, but I participated in quite a few sports. Soccer was a big one for me, and I was participating in our town’s annual tournament over the summer when I collided with an opponent, hyperextended my knee and fell to the ground. It was the first injury I really ever sustained when I was participating in sports, and lo and behold somebody ran onto the field and started talking to me and assessing the injury. It was probably a five-minute interaction, and I had really good conversation with him. When I found out he was the athletic trainer, that five-minute interaction was something that stuck with me, “This is really something I’m interested in, something I want to pursue.” So it was that moment, I think, and also just the fact that I love to help people — it’s in my nature — and knowing that athletic trainers are helping the physically active every day was something that really drew me to the field.

How old were you?
Oh, gosh, 10 maybe. I was young.

At UMaine, do you teach the nuts and bolts of athletic training, such as how to tape an ankle, or is it more about the theory of care?
We have two athletic training programs going on right now, but we’re teaching out our undergraduate athletic training program because of a nationwide change that was dictated to us by our accrediting body. So, we recently started our master’s program, which is still a professional program. Once the students complete our program, they can sit for the Board of Certification exam, and once they pass the exam, our certified athletic trainers can go out and practice in the field. What our curriculum really focuses on is giving the students the knowledge and skills that they need to be able to go out and be competent, caring healthcare professionals. A lot of the courses in our curriculum are about injury and illness prevention. Emergency care is a big one. Examination and clinical diagnosis — teaching students to be able to evaluate those injuries. Just like that athletic trainer came out to the field and looked at my knee and did an evaluation on my knee, we’re teaching the students how to do that, as well as rehab. Therapeutic intervention is a big one, as well, for athletic trainers — really taking somebody who’s physically active from point of injury back to a return to activity. That is what we’re focusing on in our program and producing athletic trainers to go out in Maine and beyond and help the physically active.

How many athletic trainers is UMaine turning out each year?
Well, we’re teaching out our undergrad program, so there are 22 in our undergrad program right now, because we only have junior and senior classes left. And then in our grad program, which we just started, we have five across both cohorts, but this is only our second year. We have a good number of students lined up, and we’re just really excited to continue to build the program.

Will students who complete the master’s program be able to practice in the field?
Our master’s program is a two-year program, but it’s still a professional program. It’s not like a post-professional, where they would already be credentialed going into our master’s degree program. We have students who receive their bachelor’s degree in a related field — maybe exercise science — and now they’re pursuing athletic training as a master’s degree, but it’s still the professional level. Both programs are turning out students who are ready to sit for the BOC exam and become autonomously practicing clinicians.

Do you have a feel for the average age and professional experience of athletic trainers working at the high school level in 2024?
I do not, and I’m afraid to even guess, because that’s all over the place. We have students who graduate from our program and immediately get jobs at the high school level. They’re fresh out of a program, taking a job at a secondary school or a high school, all the way up to professionals who have been in the secondary school setting for 30, 40 years. There is a very wide range of people who take jobs at the secondary school level. Some of them fall in love with it, and they’ll stay until they retire, so we do have some older, more experienced athletic trainers filling those positions. And then we do also have the ones who are fresh out of school who are interested in that setting as their job setting.

We hear of a nationwide shortage of athletic trainers, particularly at the high school level. Do you have any sense of what percentage of high schools across the United States still have no access to athletic training services?
I can actually give you some more set numbers for that, and that’s thanks to some work that’s been done called the Athletic Training Locations and Services Project, or the ATLAS project, spearheaded by the Korey Stringer Institute at the University of Connecticut. They’ve received funding for that project, as well, through the National Athletic Trainers’ Association. It’s looking at the level of athletic training services across the country in terms of secondary school access, and what they found, based on data collected as part of that project, we know that currently 53% of high schools in the United States have access to athletic training services. But I think what’s important to make known is that that’s not all full-time access. I don’t have the updated numbers, but in a 2019 publication that summarized the data on athletic training services across the country, of the schools that had access to athletic training services, about 47% received part-time services. So, we definitely have a shortage of athletic trainers, in general, in the high school setting, and I think we also have a shortage of full-time athletic trainers in the high school setting. We’re seeing that there’s a large percentage of those services being part-time when the athletic trainer is not always there. Now, I think we can agree some access to those services is certainly better than no access, but for schools with part-time services or no access, I think the biggest concern is that the actions and decisions that really determine whether a student-athlete lives or dies — I know that sounds drastic — but the actions and decisions that determine that are really falling on the responsibility of the coach. That’s a scary reality, especially knowing that coaches are not trained to handle a wide scope of life-threatening injuries, nor should they be, frankly, because that’s not part of their job. So, there is definitely a shortage. We’ve seen improvement over time, but we’re not anywhere near where any of us want to see that number.

Is it a situation where the talent pool just isn’t big enough to cover everybody? Is it big enough, yet schools don’t want to necessarily invest in those services for their student-athletes? Or is it a combination of both?
I think it can absolutely be both. I think in more rural locations, it’s harder to find qualified people close to those rural locations or find a qualified person willing to move to that rural location. But some other reasons that I’ve found through my research as to why there’s such a shortage of athletic trainers is budget — perceptions by administrators at the high school that they aren’t able to afford that position. Schools that are smaller in size likely have a smaller budget. “We have 90 student-athletes in our school, so why am I going to pay the money that would be required to hire an athletic trainer?” And then just a general lack of awareness of the profession and who athletic trainers are. I found through my research that there’s still some pretty common misconceptions, unfortunately, that athletic trainers are personal trainers, that athletic trainers are strength and conditioning coaches, for example, and not recognition that athletic trainers are healthcare professionals. I think when they hear they should have an athletic trainer, they think personal trainer, not somebody who can really be there to prioritize the health and safety of their student-athletes, make sure nothing catastrophic happens, and really help to reduce liability for the school or the school district.

Are there situations where had a school budgeted for an athletic trainer it would have saved a life? Do we go there?
I think that’s definitely where we go. There have been multiple instances, particularly with life-threatening conditions — emergencies, injuries, illnesses — where an athletic trainer is not present. And because of that, the life-saving care that should be provided was either not provided or was delayed, because 911 was called and EMS came, but that response time could be anywhere between five minutes all the way up to 30, 40 minutes depending on if it’s a rural location. And because that qualified person is not there, the worst-case scenario — and we’ve seen it happen — is the athlete dies. I mean, you think about the top causes of sudden death in sport, student-athletes collapsing from sudden cardiac arrest is a big one. Another common cause of sudden death is exertional heat illness. We see that particularly in the preseason leading into fall, where the temperatures are still relatively high. Athletes who are still dying from that — a completely preventable condition — a lot of time it’s because an athletic trainer is not there to recognize what’s going on, to provide the appropriate treatment. That is the unfortunate reality. And when you say, “Do we go there?” We absolutely do go there. There have been multiple incidences, unfortunately, where athletes have died because an appropriate medical professional was not onsite to provide that life-saving care. 

A fascinating focus of your research has been conflict resolution. An athletic trainer is on staff, so the school has gone that far, but yet the coach might disagree with the expertise that that athletic trainer is bringing to the discussion. Is conflict in the athletic training profession all but inevitable. Are newly minted athletic trainers almost guaranteed to face this kind of confrontation in their careers?
I don’t want to say guaranteed, because I know in talking to athletic trainers that they found themselves in settings and in places of employment where they haven’t been on the receiving end of significant conflict. Now, I will say there is probably a degree of pressure as part of an athletic training position. And I think a lot of that has to do with the nature of what athletic trainers are there to do and what coaches are there to do. It’s the result of competing values. We have athletic trainers who are there to make decisions that prioritize the health and safety of student-athletes, which is really in discord with coaches’ motivations to do what it takes to make the team successful and win games. I think a lot of the times when this conflict or this pressure is occurring, it’s really stemming from injury status. It’s stemming from return-to-play timelines, where a coach might be pressuring an athletic trainer to return an athlete to play before the athlete’s medically ready, because the coach wants them playing in an upcoming game. That’s where we see a lot of the issues occur. But I don’t want to say it’s something that occurs across the board, that it’s just something that every athletic trainer is going to face. That’s because when I did my research on this, I found specifically that while athletic trainers are reporting experiences of conflict and pressure, these experiences were relatively infrequent and certainly not universal. So, yes, some athletic trainers are experiencing pressure and conflict, others maybe are finding themselves in positions where they’re not on the receiving end of those things. I have to also consider whether the people who wanted to participate in my study were just naturally working in really good environments, where that pressure and that conflict wasn’t there. Maybe a greater number of the people in my study just weren’t in those environments, so I didn’t necessarily survey the ones who are really having conflict. That’s a possibility, and I have to be upfront about that. To get to your question, there is a degree inherently of having that pressure of the coach wanting to get that athlete back as quickly as possible. And the athletic trainer wants that too, right? We want the athlete to recover from the injury, recover from the illness, get back to play as quickly as possible and go on to be a successful athlete. So, while I think there’s values that are in discord, we want the same things, but the approach to get there is a little bit different.

Can you provide details of the confrontation you experienced?
I’d like to just make it known up front that this was an isolated incident, so it wasn’t something that I was facing every day. And if I have to think back about my two years at this particular school, I had a great relationship with a lot of the coaches, and even with this particular coach. It was really a one-time situation in the heat of the moment. But it was during my pursuit of my master’s degree, so I was fresh out of undergrad, and I had a graduate assistantship position as the athletic trainer for a local high school. It was a varsity football game. Our quarterback had sustained an ankle sprain, which was not the first time, and was very clearly showing some signs that he was not going to be able to continue participating. And if he was, it was going to be very detrimental. I decided to pull him from the game, and the coach was not thrilled about that idea at all. He came up to me on the sidelines, and very loudly — enough that the rest of the team could hear, the parents in the stands could hear — said, “You don’t know anything! You’re not a doctor!” And in that moment, I froze. It was like, “What is happening? This is not something that should be happening. We should be working together and then communicating about this — not necessarily me telling you what my clinical judgment is, and then you telling me I don’t know anything because I’m not a doctor.” In that moment, it felt to me that our skills, the skills and knowledge that athletic trainers have, were deemed less than physicians. And we actually had a doctor on the sidelines. Our team physician was there. So, I looked at her, and I said, “Can he go back in?” And she said, “Absolutely not.” And I said, “Well, there’s your doctor’s opinion — the exact same as mine.” So, it was that moment that I was like, “Am I really the only one facing this? Because if I’m not the only one, it’s really unfortunate that athletic trainers are being put in this position.” Athletic trainers should have the autonomy to be able to make those decisions. That’s why they’re there. And it really sparked my interest in pursuing this line of inquiry and trying to understand how often this is happening, and if athletic trainers are on the receiving end of conflict and pressure, who is the one causing that conflict and pressure

As part of your curriculum, do you try to instill in your students a sense of confidence, even assertiveness? “You might possibly face this. Here is how you handle it.”
Absolutely. Considering the hypothetical, “If you find yourself to be in this situation, how would you respond?” I’m going to be teaching for the first time a current topics class during the last semester for the master’s students’ second year — a seminar-based course where we just talk about the current concepts in athletic training and what’s new and exciting. And I do have a plan in that class to really focus on some conflict-resolution skills, because it’s likely at some point in their careers they will be faced with a difficult situation — whether it’s pressure, whether it’s conflict — where they really need to be able to take control of the situation and feel confident in doing so. And, I think, teaching them how to do that, giving them the heads-up that they could be facing it, is only going to be helpful for them in terms of addressing it effectively when they’re out in the field. We can pull a lot with this from nursing, because nursing has seen similar experiences with conflict and pressure in their environment, as well. I think turning to nursing as a guide and resource can be really helpful, because historically they’ve been addressing this in their curriculum for a lot longer than athletic training has. Just like you said, giving the students those scenarios, and talking through how they would handle it, and then maybe giving them some strategies to effectively manage those situations in real time, so that the health of the athlete is not compromised, but also the relationship between the coach and the athletic trainer is not compromised, right? I think that’s something that we need to prioritize, as well. Yes, as athletic trainers, we want to and should be prioritizing the health and safety of the student-athletes, but having a strong working relationship with coaches is so important when it comes to being able to do your job effectively as an athletic trainer. I think for both reasons — protecting the health and safety of the athlete, but also helping to protect that relationship and have that mutual trust and respect there — athletic trainers need to be able to handle those situations appropriately and quickly. Adding that to the curriculum in the class I teach next year is something that I’m absolutely going to be doing.

What was the vibe like the week after you pulled that kid with his ankle injury? Was it awkward with the coach?
I don’t even think it took the next week, because I really had an incredibly supportive athletic director who I was working with at the high school. He was there and witnessed the situation, and was immediately there to support me and talked to the coach himself for me. I was very hurt. I was visibly upset. He knew that I probably wasn’t in the right mindset to handle that situation right away, so he kind of took it upon himself to have that initial conversation with the coach. And then the coach ended up the next day, I think, coming up and apologizing, and we had a conversation about it, so it didn’t linger on further into the week. And I think it shouldn’t. I think those situations are things that really should be handled directly and as quickly as possible, instead of letting it linger, because that’s when we really see the detriment to the working relationships — and, ultimately, the health and safety of the student athlete.

I’m guessing an even more common trigger for these kinds of sideline confrontations is concussions. Did you ever face a return-to-play concussion scenario while you were an athletic trainer yourself?
Oh, yeah. I had plenty of patients with concussions in the time that I was working clinically. I actually didn’t face as much conflict with those as much as I faced pressure in terms of getting them back to play sooner. And I think a lot of that pressure is because, most often with concussions, the coaches aren’t seeing visible signs of injury like you would with an ankle sprain, where it swells and there’s bruising, and maybe they have an obvious limp. You don’t get that direct feedback with a concussion, because it’s relatively invisible. Now, yes, they might have a direct hit, they might stumble if we’re thinking about acutely when it happens, but in terms of the recovery process, you don’t really see those signs of injury. I think it’s easier for coaches to want to push and question and wonder when that patient is going to be ready to return to play. So, I would say I faced more pressure with concussions as opposed to true conflict. The coaches didn’t love when I said athletes weren’t ready to go back, but I think they also respected the seriousness of head injuries and tended to just accept that it was what it was, even if they weren’t overly excited about the athlete not being able to participate.

How do you feel about the general knowledge of head injuries that the typical high school coach possesses today and how that helps the athletic training process?
I definitely think coaches have more knowledge about it now for two reasons. One, because, just anecdotally, it’s being talked about more. It’s in the media a lot more. There have been movies about it. It’s very forward-facing, with Tua [Tagovailoa] on the Dolphins having whatever number concussions he’s had on the field. We’re seeing it happen in real time. I think that is feedback that really tells everyone — but coaches, too — at the secondary level how serious these concussions actually are, how serious we need to take the treating of concussions and making sure that athletes are recovering fully before they go back to play. So, yes, I think knowledge is increasing about it because of the fact that we’re hearing more about it and seeing it. But I also think, in general, coaches are becoming more accepting about these things because they were athletes at one time, and, more often than not, I think we’re seeing that people assuming coaching positions have interacted with athletic trainers before, may have sustained concussions themselves as an athlete before, and saw how it was properly treated and properly managed. So, there’s less argument, there’s less pressure, there’s less conflict, because they just understand that that’s what needs to be done and that that’s the proper process.

Is athletic training certification something that has to be updated periodically? Do you have to have proof of continuing education?
Yep. You have to take the initial certification exam, but athletic training is not a recertification by exam. Currently, we do not have to take another exam to test our knowledge after we’ve taken it the first time, but we do need to submit every two years evidence of continuing education — evidence of CPR, AED certification and things along those lines — to the Board of Certification.

You say “we.” You’re still certified?
Yes. I teach, but I’m still a certified athletic trainer, and a lot of universities require that for their faculty.

Do you ever work a Friday night football game to this day?
I do not. 

Anything about it that you miss?
There are aspects of it that I absolutely do. I miss the camaraderie. I miss the satisfaction of seeing a patient go from injury to return. There’s nothing more gratifying than that and knowing that you were a part of the process. I absolutely do miss those things, but I just fell in love with teaching when I was working at the high school, because I was a preceptor for undergraduate students at the University of Connecticut. Students pursuing an athletic training degree at UConn would come, and I would supervise them in a clinical setting. They would apply what they were learning in class to a clinical practice situation, and I, being certified, would oversee them. Because they’re not certified, they can’t practice autonomously. And just the teaching aspect of that — me teaching those students — was something where I was like, “I really love teaching. This is one of the favorite parts of my job right now.” So, I decided to forego more of the clinical practice side of things and pursue my Ph.D. so that I could teach in an athletic training program. And that’s gotten me to where I am today.

Do you feel like you’re a greater part of the solution in the position you’re in now, in the sense you’re creating more athletic trainers?
Yeah, exactly.

Hopefully the profession benefits just in terms of sheer numbers.
Absolutely. It does feel nice in that regard, as well, knowing that because of my teaching efforts, I’m helping to produce competent athletic trainers that can go on and fill positions of great need.