The findings are presented from the three categories highlighted in Table 3: micromanagement on health-and-safety; player health-and-safety awareness improvement; and rugby physical contact nature. The first category focuses on players health-and-safety related visible actions which are monitorable and instructional by rugby management staff. The themes included are player hygiene and player health condition surveillance. The second category is directed at the importance of improving players health-and-safety awareness, which is critical for ensuring players fully understand and follow safety return guidelines. The themes included are player awareness education, player reporting awareness and RTP after unwellness. The third category focuses on the physical contact nature of rugby that may be of concern as a particular risk during COVID-19 pandemic, such as collisions and tackle on the pitch. All categories and subsequent themes were illustrated with interviewees’ quotes for readers’ understanding and consideration. Interviewees are designated as P1 to P15 to maintain anonymity and confidentiality.
3.1 Micromanagement on Health-and-Safety
3.1.1 Player Hygiene
While highly susceptible to infectious diseases due to close physical contact and potential bodily fluid interaction (sweat and saliva), most infectious diseases are preventable among rugby players by promoting good hygiene practices in the changing rooms and on the field of play . Rugby organisations usually pay more attention to player hygiene when preparing for an upcoming competition, as P12 suggested, the precious opportunity to attend an international sports game may be ruined because of a player’s bad hygiene habits.
We educate players on hand washing and provide alcohol gel in camps and things like that. Because if somebody gets a trouble, or gets the flu or chest infection, they can't perform. It doesn't matter what they've done. And with training. And it's the same when you see like things like the Olympics. And you know, people trained for four years and they eat something dodgy and get a bug and it's all gone. And so we will be trying to promote that from very, you know, from the young players come in to representative sides like just hand washing, and not sharing water bottles. (P12)
Since infections can spread from one player to another by direct contact between broken skin, mucous membranes, infectious lesions and secretions, the worst consequence in the current pandemic context could be an outbreak of COVID-19 if one player becomes infected and contaminates other players and staff without exhibiting any symptoms. It is common for rugby players to share the use of communal items such as water bottles, rugby kit, towels and other equipment during daily routines. Because the lifespan of COVID-19 on various surfaces ranges from hours to days , this will be a significant issue for RTP. Therefore, specific hygienic habits such as frequent hand-washing, frequent cleaning of personal equipment and kit and the priority use of individual equipment should be developed among the players as part of their daily routine for illness prevention rather than a preparation just for competition, as P13 suggested:
Well, you know, what do they do in terms of um, preventing getting ill? So do they wash their hands? You know, you know whatever behaviours so do you wash your hands? Do you use it? You know you come into a cafe and then and wash your hands. Uh, do you get vaccinations and what do you do around your eating? You know. Um, so what are the behaviours that they are showing? So how do they act around other people who are sick and not well, and where you know so if somebody was sick … you are you know this way. So, so looking at what they do at a behaviour level that might show that they have an awareness of their own health. (P13)
The micromanagement of specific health and safety control measures relating to hygiene involves physical distancing, hand hygiene, mask-wearing, the prohibiting of team handshakes, on field spitting, and sharing of drink bottles and towels. These restrictions can be challenging, so appointing a field health and safety officer to ensure players follow the prescribed hygiene guidelines can be considered a necessity for RTP .
3.1.2 Player Health Condition Surveillance
In rugby, medical staff play an important role to keep players’ healthy and safe, but the interaction between players and medical team may also cause the concern during COVID-19 pandemic. In an elite rugby team, players with unwell symptoms can immediately be assessed, diagnosed and treated by the medical team in the rugby club, as P12 described:
Yeah, if anything goes in and goes, oh, I have a bit of a sniff, a little bit of a cold. They'll be given like a nutritionist downstairs. She gives off and gives them a little pack. And it has like vitamin C, zinc and hydration like you know, uh, maybe get more sleep or you know, what, what they're changing might be adopted… (P12)
However, in this instance, medical support is primarily aiming to maximise players’ fitness and readiness to perform rather than ensuring their general health and wellbeing or indeed that of other players and support staff. The focus is on the individual rather than the potential impact on collective health and wellbeing.
We would have protocols then around the player in terms of entry medicals. So we do entry medicals on them. We do exit medicals. It’s the whole load of process and procedures to ensure that health and safety be that from their wearing, be that from how we manage certain injuries analysis to how we screen them, whatever. And then there is the whole system of support we put around them, medical to ensure that they stay healthy and perform to the best. Because in the elite environment, it's not just that you want them healthy, we want them healthy and performing to their best. (P13)
In relation to an individual infection this level of medical consideration is appropriate. However, given the nature of COVID-19 and its capacity to infect people in contact, collective health and wellbeing needs to be considered. As an individual’s health condition is significantly related to their ability to resist infection, the professional treatment and advice from medical team is essential to support individual players health and the capacity for their safe return to play. But now that medical treatment must be cognisant of the potential impact to other people surrounding the individual during illness and when they return to play. In particular, medical staff need to pay special attention to blood injuries which could occur which may expose players to a greater risk of infection than previously considered for biological infections such as herpes simplex virus and Staphylococcus aureus . As aforementioned, medical support staff are usually accessible at pitch-side during the match day to provide the players within match time treatment once accidents / incidents happen.
We had the physio on site and from an injury point of view, you know, you’re looked after on pitch, they were, they were there all the time. You would see the physio and be treated (P6)
Nevertheless, this type of spontaneous contact between medic staff and player implies that it cannot be adjusted to consider the requirement of social distancing as the very nature of such treatment is to ensure the evaluation of health and prevention of further ill-health. By necessity the medical staff must physically interact with the players, just as primary healthcare workers are inevitably exposed to confirmed Covid-19 patients . Consequently, precautionary measures will need to be taken for close contacts that are often spontaneous. In addition, specific controls will need to be adopted to reduce the potential for infection such as specific personal protective equipment for medical support staff (e.g. face shields with an underlying face mask, disposable smocks and gloves). All such physical interactions will need to be logged during a match and if any subsequent infectious disease symptom occurs decisions will need to made in relation to suspension of activities and contact tracing in line with specific guidance . To minimise the risk, non-essential personnel should avoid treatment areas in accordance with the social distance guidelines . Additionally, physiotherapists must ensure hand hygiene before and after treatment and encourage athletes to shower before and after treatment. If unwell, team medical staff must not provide treatment to an athlete in an effort to prevent cross contamination to another athlete or staff member. Unwell athletes should be instructed to see their own general practitioner and must not receive any other type of medical servicing such as injury assessment from the team medical staff until they have been cleared as COVID-19 free .
Normally, a principal aspect of the function of a referee is to make on-the-fly decisions from a neutral perspective to ensure the game is carried out following established rules and norms of play. As interviewees explained, the role of the referee is crucial to players’ safety during competition:
First, my first issue is the safety that player, when that secured, then I’ll decide as a referee whether it's foul play or not. So my number one issue is not, oh, oh my goodness, that's foul play. I worry about that player in a minute. I, my number one concern is what, so what happened? And do I need to stop the game for this player. Once that happen, if the answer to that is yes, that's the first primary focus. And then when that, when people have arrived on the scene to treat that player, the referee is no longer needed at that stage, then they can move to stage two, which is, right, what caused this? Do I need to do anything but to address it? (P10)
Referees are critical to health and safety. In fact, they're probably the most important. Referees’ first job is to make sure that the game’s run in a safe manner… If the referees control of the match, that's the point where the health and safety of the players can come into question. (P11)
So the role of the referee yes, is very important. And he is the first point of contact and he will call on the medical staff or the physio or anybody else that he thinks is needed. He will stop the match. So yes, his role is important. (P7)
The referee as an authorised party with commanding power on pitch is vital for ensuring players’ health-and-safety on the pitch, they therefore need to be cognisant of the transmissibility processes of COVID-19 especially when there is a minimum number of stakeholders that are required to deliver a rugby match safely to avoid the possibility of virus transmission . If a limited-contact version of rugby game was developed in the pandemic context , the referees will need to be trained with the updated rules to be capable of immediately distinguishing a foul play that could have ramifications for COVID-19 infection.
Health surveillance systems have been prevalent in professional level rugby to maximise team performance by timely evaluating individual player’s health-related condition . Consequently, most players have already adapted to this level of micromanagement as a form of health and wellbeing monitoring.
Kidman is an online software, we spend a lot of money on having every player is on there, every player has a profile. And on it or their, in the illnesses and everything is managed the training that they do. And that all of our doctors and physios if they see a player, they're putting all the information on there about what they've done, what they've seen and what. And so then, we know exactly what players are sick or injured…if somebody's appetite is always like ten of ten, they love their foods, they're always on … and suddenly drops to six, and the alert will pop up on Kidman. So there're the team like the physio where the doctor, coach will see it and they know to go checking with the players and say, you know, you ok? (P12)
So once again using technology like gps trackers, heart rate monitors, those sorts of things to be able to be individually looking at players in a training environment and, and remove them from training if they're starting to hit, um areas where injuries might be a high risk than usual. (P14)
In addition to the management of player performance, the application of a software, as P12 mentioned, could be highly significant for COVID-19 risk management. Such software could be utilised as a mechanism to assist in contact tracing processes within teams which can then aid decision making on return to play. The ability for support staff with responsibility for health and wellbeing to access continuous health monitoring and potentially an expanded version including COVID-19 symptom monitoring would be invaluable for protecting the whole team and support staff unit. Health monitoring where players can daily report their temperature and potentially other COVID-19 symptoms could trigger the order by medical support staff for a COVID-19 test and a temporary precautionary suspension of play until a negative result was returned. This would require players to be honest and transparent in their self-reporting for the benefit of the team and their support staff. Medical support staff with access to such ongoing health monitoring can thus assist in contributing to more informed decision making with management on RTP, participation in practice and competition. Medical support staff could also liaise between teams during competition to share such health data to ensure protection across a league though other playing levels of rugby may not be able to afford such as an advanced application, as P2 suggested, the frequent check points are also applied to make sure the ongoing monitoring:
So, there's check points in the air of starting the season, mid-season, and season off season. And that's checking in physically, mentally, socially results of contract decisions, those some points during the year. And then it's the ongoing monitoring. So, it's making sure day to day, week to week, that they’re physically, mentally, socially coping with being a professional rugby player. (P2)
While COVID-19 contact tracing processes  in a rugby setting may be considered extremely onerous by players it is essential that players buy into the process for the protection and care of the team as well as their own families and personal social networks outside of the rugby setting. It is of paramount importance that rugby players and all support staff keep track of all contacts that they are having on a continuous basis until the global pandemic is over and vaccines and treatments have been introduced to wider society. If a player or support staff comes in contact with a positive or presumptive positive case of COVID-19, that individual should immediately self-isolate from their team and undergo a test. Only when their test is returned as negative can they return to play or to actively support the team.
3.2 Players Health-and-Safety Awareness Improvement
Currently, there are various RTP guidelines published in sports research literature this year [2, 3]. that indicate a high level of health and safety awareness is the premise to ensure that players strictly follow those guidelines so that both players and staff can be protected from the risk of COVID-19.
3.2.1 Player Awareness Education
Awareness of the potential for COVID-19 to infect and impact all age groups is crucial to having the populace understand the disease. Many young people are under the impression that they cannot be infected or that if they are infected the symptoms will be mild and while 80% of global cases are asymptomatic or mild . The disease has an impact on all age groups regardless of how healthy individuals are at the time of infection. In Ireland, up to midnight on 24 June, 2020, the incidence of COVID-19 between 15 to 24 year olds was 1885 (7.42%), between 25 to 34 year olds is 4257 (16.76%) . Elite rugby players generally perform with a high level of fitness from a relatively young age which may mislead some players to be overly confident with their capability to withstand illness. The lack of health and wellbeing awareness amongst young players has been noticed by our interviewees:
Well, lots of players say it would be very common in an elite sports. The players take a lot of uh, sleeping tablets. So they play in high pressure games, often at night and they can't sleep. And but the, the culture in amongst our medical staff will be very against, that actually don't work and pay players get the addiction and they're not very good for your health. (P12)
Some, some players would be very, very committed to their own, uh individual and team welfare. And others, I would suspect probably put the result in the performance maybe about their own health and wellbeing on occasions. (P14)
The relevance of appropriate health focused education for players in order for them to recognise their own health and wellbeing is thus now of even greater importance due to COVID-19. Players and staff will need to be aware that their own health can impact others on their team, linked with the importance of open and honest reporting of their health / potential COVID-19 symptoms. Individual and collective health and wellbeing awareness level elevation as a result of COVID-19 has the potential to override the performance driven impetus that is embedded within rugby culture. Considering the pressures from peers and career as P7 and P2 described, it is challenging for young rugby players to have a sufficient awareness of their own welfare and how their own individual health status can impact their fellow teammates and support staff.
You know, um, they don't want to be seen to be the weak in… among their peers. They want to be seen to be as good or as healthy as the next guy. So from the point of view, how do they deal with it purely on peer pressure. (P7)
So how do you build in health and safety where you can actually you've got a one-year contract, you need to prove yourself on your injured for half of it and or the bulk of it and your that's ok. But yes, from an economic, from a sports perspective, they know if they do that come the end of the year, there won't be another contract. So, there's a big conflict there between what's actually going from a health and safety perspective. But what's goanna happen practically from the professional sports environment? They're really at odds. (P2)
Thus, player COVID-19 specific awareness education can reinforce the promotion of existing best practices. For instance, if players have ancillary concerns such as pressure from peers and contractual implications, they might not want to prioritise safety compliance behaviours which emphasises the importance of micromanagement to alleviate those concerns. The required behaviours (e.g. regular handwashing, covering mouth and nose with a tissue or sleeve during coughing/sneezing) need to be monitored intensively, assisted by a fair safety compliance incentive mechanism .
3.2.2 Player Reporting Awareness
Elite rugby players usually report unwell symptoms to their medical support staff for appropriate treatment motivated by curing the illness and injury in order to return to play as soon as possible.
the player has to be honest and open and frank with his superiors be they are the coach, are the doctor, or the physio that if he has an injury or if he has a difficulty with his site, or any other aspect of this physical wellbeing that he admits this and he explains to the professionals what the problem is to allow them to treat it…And a lot, and a lot of players are slow sometimes to admit that they have an injury in the hope that it might go away.... Well, their motivation for recovering from illness or injury is to play on the team. So therefore, they will immediately ensure that whatever treatment is required, whatever professional they have to see they will do that. Because they want to get back playing as quickly as possible. So it's fairly simple motivation. They just want to get back and be fit and be ready for selection for a team. But you know, it’s slightly different to somebody that's out of work and maybe doesn't like their job. (P7)
Thus, if the symptom of an injury or illness does not limit the player’s performance, the reporting awareness will be influenced by their understanding of the severity of the health consequence, as P12 mentioned:
And sometimes it's, I think under, getting their understanding of, do they understand how important it is that they're honest with medical staff about different injuries, their illnesses and their understanding of long term effects of doing certain things, like if they're taking sleeping medications, if they are taking anti-inflammatory because they can go to the pharmacy as same as you. (P12)
In the new norm of COVID-19 players could underestimate one of the many symptoms of the disease and either not disclose it to support staff for fear of being suspended from play or play on through ignorance of the disease without realising the impact it could have on their team and potentially an opposing team through infection. Education on COVID-19 should therefore focus not only on a thorough explanation of all potential symptoms of the disease but also on players’ understanding of the risks to themselves as well as teammates, support staff and opposition players and staff. Players should be educated that erring on the side of caution with potential symptoms could prevent a worst-case scenario of COVID-19 transmission throughout a team and their support staff, and in an extreme incidence cross infection to an opposing team following a competitive match.
As previously mentioned, open and honest health reporting will be necessary moving forward with COVID-19, however a players’ reporting behaviour may also be heavily influenced by the culture within their rugby team, as P8 denoted:
I think it's a culture thing. But I don't think anyone is ever going to say oh, we're not gonna talk if we get injured. We're not going to say if we don't feel ready to train or feel unwell. So I think just, their mutual respect for each other, and just building a culture and a team is the biggest factor. I don't think there's any, I don't think it’s a matter that would be in certain teams or squads. I get this. I get that. I think it's just an understanding that you can talk. It's okay to talk and that's changing massively. (P8)
According to the legislation in most developed countries, employees are responsible for their co-workers’ health-and-safety in their workplace. As players in parallel, reporting the unwellness is not only for their own individual sake, but also for protecting other players and staff from the potential risk during pandemic. Therefore, players will need become individual leaders and encourage each other to report all potential symptoms and their contact histories with confirmed or suspected COVID-19 cases, and if necessary may be required to undergo testing, self-isolation and suspension from play as an exercise in individual perseverance to benefit team integrity . A culture of transparency and honesty accompanied by an elevation of team unity in the face of COVID-19 (i.e. one for all and all for one) has the potential to ensure rugby teams get through the pandemic relatively unscathed.
3.2.3 RTP after Unwellness
RTP decisions are complex depending on type of sport, and often influenced by various factors as existing models suggest . A further consideration is that players’ anxiety may be elevated by a number of unanticipated facets of an extended period of modified training due to COVID-19 [35, 36], which might impact on injury risk when returning to play . In rugby, it is difficult to have a clear-cut procedure for players' RTP decision-making, be it an injury, illness or other symptoms. This is problematic because some participants thought it should be the responsibility of medical staff, some indicated that it was the player who actually made the decision, and some participants denoted it was a collaborative decision as clinical practitioners suggested .
The medic, the trained medical staff will make a decision that they are not allowed to participate… I think they're probably is a window where it's a collaboration with the, the player has some ownership to make a decision as long as I fully understand, yeah, and the risks associated with that and those risks are not really that severe. (P14)
Though medical decisions can largely ensure a player’s wellbeing, in the environment of a rugby organisation, the medical staff are usually the most conservative party among the stakeholders, as P3 said:
It’s like actually where’s the responsibility layer who has the ultimate saying what these players do and, you know, that’s that’s, that’s kind of… grey area like might be too idealistic to say that it always rests with the medical team because the medical team activity going to be pretty conservative and even if you look at, you know, some outcomes in certain areas where medical team are given full control of the topic and the outcome then, always, they don’t always do actually what the evidence says themselves. (P3)
After all, medical staff have the direct responsibility if a player’s health condition is getting worse because of RTP. For medical team’s view, ill or injured players had better not play until there is no risk of RTP for players health sake and medical team duty’s sake.
I’m fine to go, I wanna go back on blah blah…” Our medical staff would have seen something they know “No, you're not.” And they just don't like them, our medical staff. There's no question that if they think somebody’s off, nobody questions, not. And it’s, you know it's I think our medical staff are very well respected here in Ireland (P12)
So if there's any questions whatsoever, it's referring to the medical team and it's their responsibility. It’s not in the player’s hands to decide whether they play or not. It’s always taken out of their hands where are possible. (P8)
Coaching staff usually respected medical decisions despite the nature of some RTP decisions being disappointing for team morale or team effectiveness in competition, but the decisions are understood that fully recovery is the premise for players to participate in more competitions. As P5 explained:
I suppose when I look at health and safety in general, you know, that’s where coming… and I suppose I would have protocols, how we look at different injuries and plans to what happens, so that’s why we have traumatology training, in terms of dealing with them at pitch side situation.... Sometimes the players I had a game, earlier this season, where a player came to me and said ‘I don’t feel good, I need to come off’. So that’s generally the exception rather than the rule. That’s not the most common thing would happen. But in terms of the coaching staff, they’re happy for me to make the decision whether the player can continue or not. And I would generally tell them so like I said have a relationship with the player. You’re able to say, look, you know you’re not right, I know you’re not right. We know you’re for the team on the field, but you don’t have to be on the field, we can bring the player from the side-line who is fit. (P5)
The opinion of medical staff is undoubtedly important as they are the healthcare professional with the expertise including the short-term risk of performance detriment or re-injury, the consequences of infection, re-injury and other long-term health (and performance) risk for all players in the club. In light of COVID-19 the opinions of an informed and observant medical support staff are of even greater importance. The above quotes reinforce previous assertions regarding open and honest health reporting and an acceptance that micromanagement of their health will be a necessity moving forward. If a player does not to report an unwellness suffered and continue playing, medical staff would have no chance to provide in-time treatment, request appropriate testing, make recommendation on suspension from play or any other professional healthcare opinion on RTP which could have very serious consequences to the team as a whole unit in light of COVID-19. Players’ reporting awareness need to be evaluated and educated especially for infectious diseases such as COVID-19 and any injuries or illnesses that could have long-term health and wellbeing consequences to a player long after they have retired from the sport competitively.
3.3 Rugby’s Physical Contact Nature
Since professionalism, rugby has increasingly become more competitive with greater manifestation of aggressive physical interactions between the players . As the examples given by the interviewees:
I think in rugby we’re looking at lowing the level of the maximum tackle to nipple line. So again, that means that you know, people are tackling above it is too high. That’s a risk factor. (P5)
I think something like tackling technique can be worked on... Some people just don't have good tackling technique and maybe they do get hurt because of it. (P6)
The biggest challenge I suppose in the professional era is because the collisions and because the contact between players is now quite aggressive is and it's very strong and they collide and crash into each other so much, that is very important that the level of fitness and their mental approach. I mean a simple thing like to avoidance of a big dangerous tackles to move out of the way perhaps that, all of that is still in their brain, all impact on their personal safety. (P7)
Due to physical contact nature of rugby, players are exposed to a high risk of trauma resulting in abrasions and lacerations of skin. Infections can thus be spread from one player to another by direct contact via broken skin . Similarly, the nature of intense cardiovascular exercise induces greater production of sweat, greater exhalation and greater saliva production. Consequently, COVID-19 can have greater potential during training and competition to be transmitted by increased exposure to bodily fluids, particularly from water droplets as exhalent from the lungs. Given the level of intentional and incidental body contact and close quarters involved in rugby, there is an acceptance that these will be the last aspects of the sport to return to the field.