Is It Aide Appropriate?

Student aides can make an enormous contribution to your high school athletic training program. But you need to first understand how to supervise them and what you can appropriately delegate.

By Kenny Berkowitz

Kenny Berkowitz is an Assistant Editor at Training & Conditioning.

Training & Conditioning, 13.7, October 2003,

At Palo Verde High School in Tucson, Ariz., Head Athletic Trainer Bart Peterson, MSS, ATC, tells two stories about working with athletic training student aides.

In the first story, everything goes the way it’s supposed to: After a collision on the football field, Peterson assigns an athletic training student aide to shadow a wide receiver for signs of a possible concussion. To make sure the player doesn’t go back onto the playing field, his helmet is hidden. But 15 minutes later, while Peterson is busy working on another athlete, the wide receiver has found his helmet and is back on the sidelines, trying to check himself into the game. Because there was an aide watching the whole time, Peterson was able to intervene and keep the student-athlete from injuring himself again.

In the second story, which happened about eight years ago, nothing goes the way it should. Because Peterson is busy covering another team, a student aide travels with the volleyball squad to an away game, where a player lands hard after making a spike. Instead of relying on the home team’s athletic trainer, the aide improperly assesses the injury and wrongly sends the student-athlete back into the game.

It was a bad mistake. The student-athlete had suffered a moderate-to-severe ankle sprain, and her parents stopped just short of taking the school to court. The side benefits of the incident was that the school administration recognized the importance of using certified athletic trainers—an argument Peterson had been making all along.

“It was a learning experience for all of us,” says Peterson. “It showed why we have certified athletic trainers. It showed why athletic training student aides shouldn’t be placed in a position where they’re working unsupervised—because if they make a decision that goes beyond their abilities, they put everyone at a liability.”

Laws & Guidelines
In setting up a program for athletic training student aides, the first step is finding out what kind of tasks your state and school district will allow your aides to perform. There are no laws that specifically regulate athletic training aides at the high school level, but there are inferences that can be drawn from laws that regulate medical professionals, college athletic training aides, and the behavior of minors in general.

The rules do vary widely from state to state and district to district, however, so you need to start by researching local guidelines, meeting with peers at other high schools, and talking to a lawyer who is familiar with your local and state regulations. (For the NATA’s perspective on following federal and state laws, see “Keeping It Legal” below.)

When asking for legal advice, it’s important to start with the right questions, advises Jim Berry, MEd, ATC, NREMT, Director of Sports Medicine and Head Athletic Trainer at Myrtle Beach (S.C.) High School, who presented a talk on “The Appropriate Use of the Athletic Training Student Aide” at last spring’s NATA convention. “What does your state say about students working in the athletic training room?” Berry offers. “Is there any specific language that addresses high school students? Is there any specific language that talks about how old students have to be before they participate in your program?

“Next, look at local guidelines,” Berry continues. “What does your school district say about using students as aides? Are there written policies about what student aides can do? Again, the rules are going to vary from district to district, and you have to make sure you’re following those standards. You have to know what the rules are before you can start designing your program.”

For example, in Arizona, Peterson faces strict regulations and has decided to take a conservative path in determining what his aides should and shouldn’t do. “My kids aren’t going to do an assessment without me,” says Peterson, who’s taken his stance with advice from the Arizona Athletic Trainers’ Association. “My student aides are not going to decide on a treatment protocol, and they’re not going to initiate a treatment protocol. I encourage them to tell me what they think should be done, because that helps them think like athletic trainers. But they aren’t allowed to initiate a treatment without my approval.”

On the other side of the country in South Carolina, state regulations allow Berry to delegate many more tasks—including applying ultrasound and taping ankles—to his student aides. But Berry draws the line at letting his aides apply either procedure without him in the room, and he advises other athletic trainers to do the same.

“There are too many certified athletic trainers who allow high school students to do things they shouldn’t be doing, like applying a modality to the athlete without the presence of a certified athletic trainer,” says Berry. “There are minors treating minors, and in my opinion, that’s not appropriate. Now, no one can convince me that my aides aren’t capable of applying an ultrasound head to an athlete’s body and keeping it moving for five minutes. But do I let my students do that on their own? Absolutely not.”

It’s also important for everyone to understand that, if the certified athletic trainer is not present, the coach is the ultimate authority for the student-athlete’s health and safety—not the student aide. “Our coaches have enough faith in our more experienced aides that they’ll listen to their opinions, and they’ll ask them to help take care of our athletes,” says Berry. “But your coaching staff has to understand what is and is not appropriate for your kids to be doing.

“If I’m not comfortable with a coach’s understanding of the limits,” he continues, “I won’t send my aides out with them. The coaches are ultimately responsible for whatever happens, and they need to understand that.”

Setting these types of policies is only the first step. Berry also spends time thoroughly explaining to his student aides the boundaries around what they can and can not do. “It’s your responsibility as a certified athletic trainer to make sure your student aides understand their limits,” says Berry. “My students are very clear. They know where the line is, and they don’t cross that line. Because they know that if they do, they won’t be allowed into the training room anymore.”

However, the above cautions shouldn’t scare high school athletic trainers away from using aides. In Berry’s view, when they’re trained and supervised well, athletic training student aides can make enormous contributions to your ability to do your job well.

“It’s about running your training room efficiently,” he says. “I can teach an aide to tape an ankle just as well as I can tape it myself—in fact, I’ve had some students who tape ankles better than I do. So once an aide has proven to me they can tape an ankle, I’ve got two or three more minutes that I can use to do something else.

“Last year, when I had four senior student training aides, I was free to evaluate injuries and talk on the telephone with doctors,” continues Berry. “I didn’t have to worry about whether the basic, everyday taping was going to be done, because my athletic training aides knew what they were doing.”

“If you can train your student aides to do some basic record-keeping, you can save yourself a lot of time,” adds Dale Blair, MS, ATC, CSCS, Sports Medicine Instructor and Head Athletic Trainer at Wenatchee (Wash.) High School. “It’s like when you go to a doctor’s office, and the nurse greets you, asks about your basic complaints, and takes some notes. That’s one of the roles I give to my aides. It helps me get some information, and it teaches them how to take a medical history.” (For thoughts on complying with HIPAA when delegating this task, see “Privacy Issues” below.)

“A lot of times we sell high school students short on knowledge,” continues Blair. “They can soak up a lot of information, and with proper training and supervision, they can be an invaluable asset to your athletic training room.”

The Application Process
Because of the importance of knowing their limits, aides should be carefully chosen by athletic trainers. At Downingtown (Pa.) West High School, Head Athletic Trainer Joe Iezzi, ATC, recruits his athletic training student aides with a series of school intercom announcements during the first few days of classes. But before they can even join his program, the candidates have to fill out an application, complete with a parent’s signature.

“The application asks for their name, what they’ve done, where they’re working, what kind of experience they’ve had with first aid, and whether they’ve ever been involved with sports in any way,” says Iezzi. “They have to write a 300-word essay about why they want to be involved, and they have to have it signed by a parent.

“Right off the bat, that usually weeds some people out,” continues Iezzi. “But for the ones who stay, it says something about their dedication and work ethic. It shows me that this person is ready to give the time and effort necessary to do their job well.”

By the end of the application process, Iezzi usually has a group of two to five student athletic training aides, which he thinks is a manageable number of students to supervise. At Chino Hills (Calif.) High School, where Athletic Director Mike West, MS, ATC, runs a vocational program that draws 15- to 20 student aides at any given time, the screening process is even more rigorous.

“First, they fill out an application,” says West. “Then, they give us references from their teachers based on their behavior in class, and provide us with a transcript that shows their grades are acceptable. After that, there is an interview, where we ask about their interests, why they want to be in this environment, and what their goals are.

“I want people who can demonstrate leadership skills,” continues West. “I need people who are going to take charge in an emergency, and not just sit there saying, ‘What am I supposed to do?’ Of course, the interview makes them all nervous. But if they’re able to look me in the eyes and answer my questions, I know I’ve found what I’m looking for.”

Starting Slowly
Once on board, aides can be given tasks gradually. At Downingtown West, Iezzi starts his athletic training student aides with basic tasks that don’t require any medical knowledge at all. They clean and inventory the training room, fill the coolers with ice, and prepare the medical kits before games and practices. Working from a detailed checklist, his aides stock the golf cart for home games and load the van for away games. Iezzi encourages all his aides to take his school’s first aid class, and if they don’t, they can’t expect to advance to more complex tasks in the training room.

At Glenbrook South High School in Glenview, Ill., Head Athletic Trainer Brian Robinson, MS, LAT, ATC, calls his state guidelines “severely limiting,” and thus takes a cautious approach to delegating duties. At the start of the year, his first-year aides spend most of their time observing. As the season progresses, Robinson gives them more responsibilities, such as helping load the golf carts with supplies to cover home games and working on the sidelines to keep athletes hydrated.

With help from his school’s health instructors, Robinson requires his students to be certified in first aid and CPR before he’ll allow them to begin work as official athletic training student aides. Once they get their certificates, his aides are allowed to do preventative ankle-taping, act as first responders to injuries, and use a radio to communicate with Robinson from a nearby competition.

“If we have two games on adjacent fields, I’ll give a walkie-talkie to one of our student aides, and if someone gets hurt, they’ll call me over right away,” says Robinson. “That way, the aides become another pair of eyes and ears for us. And sometimes, they’ll notice an injury before I do, which makes them very valuable to the program.”

At Wenatchee, which offers a vocational program in sports medicine for about 25 students every year, Blair starts the year by giving each aide a student handbook and first aid training. “Even before we start class, everyone has to read the student handbook,” says Blair. “We talk about their role in the program and the kind of things they can and can’t do. Then we go through all our first aid procedures, before any emergency could possibly arise.”

Every day, Blair’s students attend a one-hour class, followed by three to four hours in the athletic training room, where they are exposed to a wide variety of situations. During that first year, they’re put to work under Blair’s direct supervision, taking medical histories, keeping records, practicing basic evaluation skills, applying ice bags, and taping ankles. They also spend time studying their student handbook and observing athletes in their exercise routines, as well as help out around the athletic training room by filling coolers and stocking equipment.

Iezzi, Robinson, and Blair also allow their first-year aides to assist on simple exercises with rehabbing athletes. “Let’s say an athlete is throwing a medicine ball,” says Robinson. “We’ll have one of our student aides play catch with them. That way, the aide isn’t considered to be directing anything—they’re helping us implement our protocols. They get a little one-on-one interaction with the athletes, and they feel some responsibility for helping them get back on the field again, which is the best part of the job for most people.”

After teaching student aides the basic skills they’ll need to begin, many athletic trainers test their students before giving them additional responsibility. Blair, for example, conducts quarterly evaluations of all his student aides.

“We have written exams to test their knowledge of the classroom material and hands-on tests for them to demonstrate they can use that knowledge in a practical manner,” he says. “We have 18 different areas where they need to show competency. Even if these are skills they won’t be using every day, it’s important for our students to know them.”

At Chino Hills, West has set up a checklist to test his student aides’ level of proficiency, and he also expects them to pass a series of competencies before they can be rewarded with new tasks. “I have a check-off sheet, and before I actually put them in the field, they have to prove they’re ready,” says West. “One of the first things they do is become first aid and CPR certified. And before they’re allowed to do any preventative taping on our athletes, they have to prove that they’re proficient at it.”

West then assigns student aides to travel with a team based on who has worked the hardest and learned the most. “In the fall, I rotate the student aides, so they get a sense of the different teams and I get a sense of who I can rely on for each of the sports,” he says. “Then during the winter I take the ones I feel are best and give them the prime jobs with specific teams.”

Teaching Success
Along with delegating to and overseeing your aides with the utmost care, it’s important to take the time to reward your students—both in material and non-material ways. At Wenatchee, Blair provides special awards to his student aides.

“We have a Student of the Quarter award, which is partly based upon the recommendation of their peers, although I make the final determination,” says Blair. “We give our aides on-field recognition, and each year, we pick a distinguished alumni from our program. We also have a year-end ceremony with various awards, and the student aides can earn letters, just like the athletes, if they travel with a team and work a certain number of hours over the course of a season.”

To reinforce the idea of being part of a team, Blair outfits his aides with shirts, sweatshirts, and team jackets. “We want them to see themselves as part of our sports medicine team,” he says. “That sense of teamwork and camaraderie are probably the most important reasons why they’re here. Getting everyone together for activities is sometimes difficult, but we really try to do things as a group.”

West makes sure the athletic teams honor their aides. “The teams embrace their aides, and give them sweatshirts and T-shirts to make them really feel they’re a part of the squad,” he says. “That’s very rewarding for the aides, and it motivates them to keep going.”

Less obvious forms of reward include providing them with mentoring and direction. Peterson, for example, requires his students to continually set goals to know what direction they want to go in. “Goal setting is a constant thing here, because as soon as the aides achieve one goal, they have to set a new one,” he says. “At the first student meeting of the year, we set program goals and individual goals, and then about once a month we see how we’re doing.”

Berry feels that showing aides respect is critical. “They shouldn’t be in the training room just to give us an additional pair of hands,” he says. “We need to respect our student aides—respect their knowledge and their abilities. We have an obligation to make sure they’re learning something every time they come into the training room. It may be something small, but we’ve got to teach them something they didn’t know the day before.”

Peterson adds that trust is important, too. “Your aides have to trust you to give them the skills that they need,” he says. “They have to trust that you’re not going to put them in a position where they can fail. They may have to struggle, but if they have your trust, they’re going to succeed.”

Case in point returns us to Peterson’s second story: Peterson made sure the student aide who misdiagnosed the volleyball injury never lost his trust. Today, she is a certified athletic trainer herself.

SIDEBAR: Keeping It Legal
Given the current climate of parents threatening to sue and administrators worrying about their school’s legal liability, what do you need to know before starting a program for high school athletic training student aides? What do the laws say about student aides?

“Legally, there is no such thing as a student athletic trainer at the high school level,” says Richard Rogers, Government Affairs Manager at the National Athletic Trainers’ Association (NATA). “There is nothing officially defining them, because they don’t exist. Of course, we know they’re there. We know they provide a service. But there are no laws dealing directly with them, and even though there are lots of new state regulations, none of them specifically deals with student trainers at the high school level.”

Rogers says there is an important distinction between athletic training students at the college level, who are recognized by law in many states as officially pursuing athletic training as a course of study, and high school students, who aren’t recognized at all, and are only seen as pursuing a general diploma. Without having a legal definition to work with, the NATA has chosen not to write a policy for working with athletic training student aides. Instead, Rogers advises high school athletic trainers to consult their school attorney or district officials for answers to any questions about legal liability.

“If athletic trainers call me, there isn’t anything I can tell them,” says Rogers. “There’s nothing in writing, because the law doesn’t address it. Basically, we tell people, ‘Go talk to your school’s attorney. They should be able to tell you what you can do.’”

SIDEBAR: Privacy Issues
With the implementation of the Health Insurance Portability and Accountability Act (HIPAA), it’s imperative that athletic trainers take precautions to guard the privacy of their athletes’ health care. The Federal Educational Records Privacy Act (FERPA) also requires the protection of most student information.

“The athletic training room is a public place, and because of the nature of what we do, there’s really no way to absolutely guarantee everyone’s privacy,” says Jim Berry, MEd, ATC, NREMT, Director of Sports Medicine and Head Athletic Trainer at Myrtle Beach (S.C.) High School. “But if your student aides are dealing with medical records, they need to understand that this is confidential information that can’t be discussed with anyone else.”

In his athletic training room, Berry makes sure to continually emphasize the importance of confidentiality to his student aides, posting a sign where everyone can read it that says: “What you hear here, what you do here, what you see here, stays here when you leave here.”

“Our student aides realize that they’re in a special position,” says Berry. “We stress to them that they can’t go back to their classroom and say, ‘The star quarterback sprained his ankle in practice yesterday, and he may not play on Friday night.’ They take a lot of pride in knowing that there are privacy issues. And they do a good job of keeping information to themselves, because they know I’m not going to tolerate it if they don’t.”