Concussion and Head Injuries in Context. A Mixed-Methods Inquiry of Stakeholder Knowledge, Management, Culture, and Practitioner Experience in Scottish Professional Football

Robertson, E (2026) Concussion and Head Injuries in Context. A Mixed-Methods Inquiry of Stakeholder Knowledge, Management, Culture, and Practitioner Experience in Scottish Professional Football. Doctoral thesis, Liverpool John Moores University.

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Abstract

Concussion and head injuries has emerged as a pressing health issue in contact sports, with increasing scrutiny on the long-term neurological consequences of head trauma. Despite national policy developments and growing public awareness, there remains a limited understanding of how concussions and head injuries are recognised, interpreted, and managed across the multiple stakeholder groups involved in Scottish football – including players, coaches, parents, and performance staff. This PD in Applied Sport and Exercise Science investigates the complexities of concussion and head injury management in Scottish professional football through a practitioner-led, mixed-methods inquiry. Against a backdrop of increasing concern around concussion and head injuries in sport, this Doctorate explores how stakeholders understand, respond to, and manage concussion and head injuries, paying particular attention to the cultural, organisational, and ethical dynamics that shape football practices in the real world. This Doctorate was also shaped by the author’s dual role as a practitioner and researcher within an elite football setting, enabling a deep insight into both the formal and informal processes that govern concussion care. This PD unfolds through a qualitatively dominant mixed-methods design, comprising three interlinked studies.

The aim of Study 1 (Chapter 4) was to survey key stakeholders across Scottish professional football to examine their knowledge of concussion symptoms, their understanding of management protocols, and their decision-making in head injury scenarios. Study 1 was a cross-sectional survey design comprising three core sections: (1) general knowledge-based questions, (2) signs and symptoms recognition, and (3) scenario-based decisions regarding return-to-play. The survey was distributed online and completed by 333 participants: players (n = 160), parents (n = 91), coaches (n = 49), and performance staff (n = 33). The results from this study indicated that while most participants had a general awareness of concussion as a serious health concern, considerable variation existed in symptom recognition and confidence with protocol adherence. For example, although dizziness, confusion, and headache were widely recognised symptoms, less common symptoms such as sleep disturbances and emotional irregularities were frequently missed. Over half of the participants in the players group reported having sustained a head injury, yet 52.5% of the players who participated stated they had never received formal information or education on the subject. Similarly, with the coaches, 30.6% had not received any training in concussion protocols, and a concerning number of parents (78%) reported having no head injury education, despite being key figures in post-incident observation and decision-making. Scenario-based responses revealed confusion around when it is safe to RTP, with frequent inconsistencies between knowledge and decision-making. Players and parents in particular showed a tendency to underestimate the severity of mild symptoms, whereas performance staff were more forthcoming in their responses, likely reflecting their greater formal training. Notably, a large proportion of respondents across all groups were unaware of their club’s formal concussion policy or its return-to-play criteria. These findings highlight the critical need for standardised, role-specific concussion education and for greater communication within clubs regarding policy enforcement and best practice.

The aim of Study 2 (Chapter 5) was to explore the lived experiences and organisational practices surrounding concussion and head injury management within a single professional Scottish FC. Using a qualitative case study design, semi-structured interviews were conducted with 17 participants representing five stakeholder sub-groups: players (n = 4), coaches (n = 5), parents (n = 5), and performance staff (n = 3). Interviews were analysed using inductive thematic analysis, focusing on how concussion is managed in real-time, and how club pressures and cultural norms influence behaviour. The results from this study revealed a consistent theme of “lack of knowledge” across all participant groups. Coaches and parents commonly expressed uncertainty about their roles and responsibilities in concussion incidents, often deferring to others or relying on personal judgment rather than established protocols. Coaches acknowledged that, despite having received some formal education, much of their decision-making relied on experience and instinct. Parents, meanwhile, voiced a lack of confidence in identifying symptoms and were often unaware of how long a player should rest or when to seek medical advice. Performance staff demonstrated greater knowledge but described limitations in standardised implementation due to ambiguities in role boundaries and resource constraints. Organisational culture was marred by implicit expectations to prioritise performance over welfare, leading to subtle forms of protocol avoidance or efforts taken to minimise the risk. Several participants described examples of returning players to training prematurely due to match-day pressures or insufficient time to follow staged recovery guidelines. Coaches felt conflicted when balancing care for the player with pressures to maintain team competitiveness. These findings highlight how the lack of education contributes to inadequate concussion management. The interviews also revealed that communication between stakeholder groups was often fragmented, leading to confusion and missed opportunities for consistent care.

The aim of the final study – Study 3 (Chapter 6) – was to build on the themes identified in the previous studies by offering a reflexive, insider account of the ethical and emotional tensions involved in concussion care. This study adopted an autoethnographic approach, providing a first-person narrative of the researcher’s lived experience managing concussion rehabilitation as an applied sport and exercise scientist embedded within a professional Scottish FC. Drawing on field notes, observational data, informal staff conversations, and personal reflections, the autoethnographic account explored how concussion was managed behind the scenes, outside the view of formal reporting or policy. Central themes included ethical conflict, role ambiguity, and emotional labour. The autoethnography also illustrated the constraints faced by non-medical practitioners in implementing head injury protocols. Despite having knowledge and concern, the researcher’s influence was often marginalised by hierarchical decision-making structures or unspoken norms that discouraged challenging authority. This study contributed a unique insight into concussion care and demonstrated the importance of critically examining practitioners' voices, emotions, and ethical judgements within the culture of performance sport. It also emphasised the importance of qualitative methodologies, such as autoethnography, for capturing the lived complexities of managing health risks in high-performance environments.

A meta-thematic integration process was conducted to synthesise findings across all three studies. Areas of convergence included a shared understanding of key concussion symptoms and a collective recognition of the seriousness of the issue. Divergences were evident between reported knowledge and observed behaviours, with some stakeholders demonstrating high cognitive awareness but failing to apply it in practice. Complementary insights emerged from the alignment between the autoethnographic reflections and the interview data, particularly in relation to institutional silence, implicit norms, and emotional labour, all of which are shaped by the five dominant themes: knowledge-practice gaps, cultural pressures, education gaps and inequity, role ambiguity and hierarchy, and communication breakdowns.

The overarching contribution of this thesis lies in its ability to bridge the gap between scientific knowledge and applied practice. By situating concussion management within the lived context of Scottish professional football, the research challenges the view that concussion protocols are purely medical or educational issues. Instead, it positions concussion care as a relational, culturally embedded process requiring ethical attentiveness, interdisciplinary dialogue, and systemic change. The findings suggest that improving concussion outcomes necessitates not only enhanced education but also cultural transformation at club and organisational levels.

This Doctorate also holds significance from a practitioner development standpoint. The methodological journey from quantitative survey to reflexive autoethnography mirrors the researcher’s own transition to a reflective practitioner. The research process catalysed a critical engagement with professional identity, epistemological assumptions, and the emotional demands of care in high-performance sport. As such, the thesis contributes to the growing field of practitioner-led research in sport science and reinforces the value of reflexivity, positionality, and methodological pluralism in applied doctoral work.

hn conclusion, this PD offers a practice-informed, context-sensitive exploration of concussion management in Scottish professional football. It advances knowledge on stakeholder perceptions, organisational culture, and ethical practice, whilst also demonstrating the utility of mixed-methods research in capturing the complex interplay of factors that shape concussion care. The thesis provides actionable recommendations for practitioners, policymakers, and educators, including the need for tailored training programmes and stronger interdisciplinary collaboration. These insights are timely and relevant, particularly as Scottish football continues to grapple with the long-term health implications of head injury and the ethical responsibility to protect players' wellbeing.

Item Type:	Thesis (Doctoral)
Uncontrolled Keywords:	concussion; head injuries; football; high performance sport; player welfare; concussion management
Subjects:	R Medicine > RC Internal medicine > RC1200 Sports Medicine G Geography. Anthropology. Recreation > GV Recreation Leisure > GV561 Sports
Divisions:	Sport and Exercise Sciences
Date of acceptance:	2 March 2026
Date of first compliant Open Access:	3 June 2026
Date Deposited:	03 Jun 2026 08:32
Last Modified:	03 Jun 2026 08:32
DOI or ID number:	10.24377/LJMU.t.00028631
Supervisors:	Roberts, S
URI:	https://researchonline.ljmu.ac.uk/id/eprint/28631

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