University of Groningen
Trauma leadership and ICU shift-handovers
Leenstra, Nico
DOI:
10.33612/diss.145055952
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Publication date: 2020
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Leenstra, N. (2020). Trauma leadership and ICU shift-handovers: Identification, observation and integration of key skills. University of Groningen. https://doi.org/10.33612/diss.145055952
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ap ter 2 – Id en ti fy in g tr au ma lea d e rs h ip s ki lls ABSTRACT
Introduction: Good leadership is essential for optimal trauma team performance, and targeted training of leadership skills is necessary to achieve such leadership proficiency. To address the need for a taxonomy of leadership skills that specifies the skill components to be learned and how to measure them across the five phases of trauma care, the authors developed the Taxonomy of Trauma Leadership Skills (TTLS).
Methods: Critical incident interviews were conducted with trauma team leaders and members from different specialties— emergency physicians, trauma surgeons, anesthesiologists, and emergency ward nurses—at three teaching hospitals in the Netherlands during January–June 2013. Data were iteratively analyzed for examples of excellent leadership skills at each phase of trauma care. Using the grounded theory approach, elements of excellent leadership skills were identified and classified. Elements and behavioral markers were sorted and categorized using multiple raters. In a two-round verification process in late 2013, the taxonomy was reviewed and rated by trauma team leaders and members from the multiple specialties for its coverage of essential items. Results: Data were gathered from 28 interviews and 14 raters. The TTLS details five skill categories (information coordination, decision making, action coordination, communication management, and coaching and team development) and 37 skill elements. The skill elements are captured by 67 behavioral markers. The three-level taxonomy is presented according to five phases of trauma care.
Discussion: The TTLS provides a framework for teaching, learning, and assessing team leadership skills in trauma care and other complex, acute care situations.
Published as:
Leenstra NF, Jung OC, Johnson A, Wendt KW, Tulleken JE. Taxonomy of trauma leadership skills: a framework for leadership training and assessment. Academic Medicine, 2016;91:272-81.
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INTRODUCTION
The designated trauma team leader is a key member of the multidisciplinary acute trauma care team. This individual, who is often a trauma surgeon or emergency physician,1,2 holds a coordinating, supervising role and a central position in team
communication.3 Depending on local context, with regard to the patient provided,
the trauma team leader can play either a hands-on role (i.e., performing examinations and medical interventions) or a hands-off role (i.e., acting as the designated leader, delegating examinations and medical interventions). The ad hoc trauma team generally consists of an anesthesiologist, nurse anesthetist, emergency physician or surgical resident, emergency ward nurses, a neurologist, and a radiologist, all of whom are on call. Other professionals may join in as consultants.
Coordinative skills and other facets of “good” leadership have been found to be essential for optimal clinical team performance.4–6 Conversely, poor leadership
has been identified as a potential threat to patient safety.7 Not surprisingly, then,
trauma courses, such as Advanced Trauma Life Support,8 have given increased
attention to non-technical aspects of team members’ performance in recent years. Simulation-based training has emerged to specifically train team and leadership skills, with the intent of taking the practice of leadership skills beyond role modeling or informal feedback into deliberate practice.5,9 However, to the best of
our knowledge, there is no skills taxonomy for trauma team leader education or assessment that offers the degree of practical guidance needed for the deliberate practice of leadership skills.
Important non-technical skill areas of the trauma team leader have been identified, including prioritizing and directing team activities, distributing tasks, monitoring the environment,10,11 teaching,10 supporting team members, and
encouraging an open team climate.3,12 Yet, the identification of these skill areas
has not always been accompanied by the identification of their component skills and the observable, measurable behaviors with which the skills can be trained or assessed. For leadership in resuscitation teams,13,14 some recommendations have
been made regarding measurable behaviors such as querying the team for observations, sharing information, periodically reviewing data with the team, and clearly announcing actions.13 In most studies of leadership in trauma medicine
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leaders,10 leadership was distributed among team members,11 or the team leaders
were operating within the highly protocolized setting of resuscitation.13,14 Thus,
although many aspects of leadership identified in these studies applied to the hands-on involved team leader, it is not clear whether the hands-off, designated trauma team leader would show a different pattern of behavior.
Educational tools that have proven to be effective in developing non-technical skills in clinical settings are often based on behavioral markers.15–19
Behavioral marker systems typically present skills at three levels of abstraction--skill category, abstraction--skill elements, and behavioral markers illustrating excellent or poor skill utilization--and may address either individual or team performance. In trauma care, the modified nontechnical skills scale for trauma (T-NOTECHS) has been used effectively for the training, observation, and assessment of teamwork skills.19 Although the T-NOTECHS contains the category “leadership,” it does not
detail the skill elements and behavioral markers that are needed for targeted leadership training.
Trauma care has five distinct phases: briefing, handover, patient handling, transfer to follow-up care, and debriefing (see Chart 1; adapted from Fernandez et al’s20 three phases for emergency care). Because the goals, tasks, and actors
change within these phases, it can be expected that the non-technical skills used by the trauma team leader will change as well. Given the different leadership demands across the phases, it is surprising that existing taxonomies have not explicitly addressed the skills required in different phases.
To address the need for a taxonomy that can be used to train and assess leadership skills of the hands-off designated trauma team leader in the different phases of trauma care, we aimed to identify key leadership skills and the behavioral markers by which they can be taught and assessed, and to structure these skills according to phase. We developed a taxonomy based upon interviews with trauma team members who can be trauma team leaders or who work with them, and trauma team leaders participated in the verification phase of development. The resulting Taxonomy of Trauma Leadership Skills (TTLS), presented in this report, reflects trauma team leaders’ and members’ conceptions of excellent leadership performance by the trauma team leader.
Chart 1. Trauma team activities in the five phases of trauma care
Planning phases Action phase Reflection phase
Briefing Patient handling Transfer to follow-up care
The team assembles, and members greet each other. The case is analyzed given the available information, and an initial strategy is discussed.
The team monitors progress, the patient, and the
environment, communicating about
diagnostic information, strategy, and coordination, and providing each other assistance in order to effectively diagnose the patient’s injuries, provide initial treatment, and prepare the patient for follow-up care.
Members of the team transfer the patient to follow-up care. They discuss patient
information, the traumatic event and diagnostic information, treatment information, awareness of risks and recommendations for further care.
Handover Debriefing
The team receives patient information, details on traumatic mechanism, injuries sustained, signs and trends, and the treatment given so far from the ambulance crew. Requests for additional details or clarifications are made.
The team reflects on their performance, and identifies strengths and weaknesses for future performance.
METHOD Study setting
The study was conducted in the Netherlands in 2013–2014 at three teaching hospitals: one university medical center (with 1,218 admissions at the trauma department within 24 hours in 2012, of which 203 were rated > 15 on the Injury Severity Score [ISS]21) and two general district teaching hospitals (1,227
admissions with 25 rated >15 on ISS and 1,014 admissions with 32 rated > 15 on the ISS, respectively). At all three sites, surgeons and emergency physicians, including residents, can serve as the trauma team leader, which is similar to trauma care in the United States and elsewhere in Europe. When a resident acts as trauma team leader, a consultant surgeon supervises the resident’s performance (cf. Klein et al10).
Study design
We used a combination of elements from the grounded theory approach22 and
elements from quantitative study designs to identify the leadership behaviors and nontechnical skills of hands-off trauma team leaders that ensure effective trauma
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care and patient safety for each phase of trauma care. The study consisted of three parts:
1. Critical incident interviews with a focus on excellent leadership performance and identification of skill categories. Following the grounded theory approach, interviews were inductively coded, and codes were sorted into categories based on insights that emerged during analysis.22 In
addition, a collaborative sorting procedure was developed for the purpose of determining whether any overlap or ambiguity was present within the definitions of categories.
2. Identification of the skill elements and behavioral markers from the categories identified in part 1, followed by classification of the skill elements according to the five phases of trauma care.
3. Verification of the taxonomy. Members of the different professional groups who participate in trauma care reviewed drafts of the TTLS to indicate the relative importance of the skills. The data were used to remove less relevant skills, thus improving the taxonomy’s practicality for future use in training or assessments.
Interviews
Participants. Surgeons, emergency physicians, anesthesiologists, and emergency ward nurses (trauma experience ≥1 year) were included in the interviews to limit bias due to professional perspective and to develop an educational model supported both by trauma team leaders and by those who work with them. Nurses were included depending on their availability on the days the interviewer was present. Medical staff participated on the basis of responding to an e-mailed invitation outlining the study purpose and interview process. We aimed to include at least two participants from each professional group, from each study site, to ensure generalizability, but we added participants only until the interviews failed to add new insights into leadership behavior.
Participation was voluntary and could be withdrawn at any point. Informed consent was obtained. Ethics approval was waived by the institutional review board of the University Medical Center Groningen.
Interview protocol. All interviews were conducted during January–June 2013 by the first author (N.F.L.), who observed 12 hours of trauma team training and 8 hours of actual trauma care prior to developing the interview protocol. After
the first two interviews, minor adjustments were made in the wording and question order of the interview protocol.
The interview consisted of three parts: exploration of general views on trauma team leadership, analysis of a critical incident of excellent leadership performance, and recommendations for improvement with regard to leadership. Questions were open-ended.
Interviews took place in person and lasted 40-60 minutes. All interviews were tape-recorded and were later transcribed verbatim. Interview transcripts were de-identified prior to analysis.
For the critical incident section of the interview, participants were first asked to summarize a complex or urgent case in which they perceived leadership as especially good. Additional questions were asked about each phase of that case. (For the interview protocol, see appendix 1 at the end of this chapter). The questions were adapted from earlier interview studies.15,18
Identification of skill categories
Interview transcripts were analyzed by the first author (N.F.L.), following a grounded theory approach22 given the method’s iterative approach to gathering
insights and model building.23 ATLAS.ti version 5.2 (Scientific Software
Development GmbH, Berlin, Germany) was used for the coding and analysis of interview data.
Interview segments about leadership behavior were coded by the first author by paraphrasing them line-by-line, and notes across interviews and links with existing literature were documented. Additional coding related the segments to the correct phase of trauma care. These steps were repeated after every two to three interviews, in order to allow insights in key skill areas to develop.22
Inter-rater reliability was tested with an independent second Inter-rater by calculating the percentage of identically coded segments for the first three interviews. The second rater and first author reached consensus on how to complete the further coding of all interviews.
After all interviews were coded, provisional categories were defined and similar codes were reworded into one code by the first author (N.F.L.). Four human factors experts (the second author [O.C.J.], a crew resource management [CRM] instructor; the third author (A.J.), a psychologist; an additional CRM instructor; and a medical education advisor) with varied experience in evaluating
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nonmedical competencies in health care provided feedback on the categories and sorted the codes into the categories. Ambiguously sorted codes (i.e., codes sorted differently from the first author by two or more raters) were identified. Based on the expert feedback, these categories were redefined or codes were replaced. Inter-rater agreement of each expert and the first author was analyzed.
Because the different participant groups were included in the interviews to ensure diverse input rather than to create different versions of the taxonomy, the interview transcripts were not analyzed specifically for differences between groups.
Identification of skill elements and behavioral markers
Each categorized code was further classified as being a skill element or a behavioral marker.15,18,23,24 The skill elements and behavioral markers were then
sorted into the five phases of trauma care. Interview transcripts were re-read to ensure that there were no misinterpretations. The number of interview participants describing each of the skills was counted.
Taxonomy verification
To verify that the TTLS was a consistent reflection of the views of trauma team leaders and members, the interview participants as well as additional staff surgeons and anesthesiologists of the three hospitals were invited to review the first version of the taxonomy. During November–December 2013, they were invited by e-mail to rate each skill element for relevance to “excellent” leadership using a 5-point Likert-scale (1 = very irrelevant to 5 = very relevant). They were also asked to provide written comments regarding omissions or ambiguous phrasing. Surveys were administered and returned as Microsoft Word forms by e-mail.
The criterion for inclusion of a skill element in the taxonomy was 75% or more of ratings of relevant or very relevant (4 or 5). The first author (N.F.L.) and three of the raters--emergency physicians from one hospital--discussed the comments and the skills that did not meet the inclusion criterion. The first author then revised those skill elements that were ambiguous and added additional skill elements. During January–February 2014, respondents were then asked to rate the skill elements added or revised, as well as to re-rate the skill elements originally rated as less relevant (i.e., rated 1, 2, or 3); average ratings from the first
round were provided. Skill elements were excluded from the TTLS if they again did not meet the inclusion criterion.
RESULTS
Interview participants
After 28 interviews were conducted, the decision was made to stop data collection as the analysis of interviews no longer resulted in unique codes. The 28 interview participants included five surgeons, three surgical residents, eight emergency physicians, one resident emergency physician, one anesthesiologist, two anesthesiology residents, and eight emergency nurses. The general view expressed in the interviews was that a hands-off trauma team leader is the most effective leader, as hands-on engagement by the trauma team leader results in the loss of the overview of the situation.
Identification of skill categories
The coding of the 28 interviews resulted in 744 original codes, which were collapsed into 103 unique codes by removing redundancy. Table 1 illustrates how interview segments were coded. Coding was considered reliable, as 167 (70.5%) of the 237 data segments in the first three interviews were coded identically by a second rater.
Sorting the 103 codes according to the skill areas identified in the notes made during the analysis of the interviews resulted in the initial adoption of eight skill categories: information management, action management, decision making, situation monitoring, evaluation, communication management, coaching, and encouraging team climate. The independent sorting of the codes by the four human factors experts resulted in a moderate inter-rater agreement with the first author (Cohen’s Kappa = .45–.53). Based on the sorts and the experts’ feedback, some overlap of categories became evident. In particular, codes that were sorted into the situation monitoring category were approximately equally likely to be sorted into the action management category; the same was true for the evaluation category with respect to the information management and decision making categories. The eight provisional categories were collapsed into five definitive
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Table 1. Sample trauma team member interview segments, codes/behavioral markers, and resulting
skill elements, by phase of the trauma care process
Phase Sample interview segmentc
(participant type, hospital)
Code/behavioral
marker Skill element
Briefing I think it is important to discuss a
strategy in advance. “This has happened, and the patient will probably have these and these injuries.” So you can talk with the anesthesia crew: “You’ll probably need to do this and this since the patient has facial damage and still needs to be intubated.” (Surgeon, H3) Informs the team on the information that has come in Walks through probable upcoming tasks Exchanging pre-hospital information Discussing strategy and tasks
Handover It is the resident’s [team leader’s]
responsibility to clarify if necessary, or to summarize the handover. I had heard some information in the pre-hospital information, which I did not hear in the handover, so I asked. (Emergency physician, H1)
Asks the ambulance crew questions to clarify unclear information
Collecting patient information (as central contact)
Patient handling
The team leader plays an important role in translating blood pressure 93 over 47 into “the patient is in shock, it is bad and probably caused by this and this.” The team leader is the central computer that synthesizes information, but also exchanges this with the team. (Surgeon, H2)
Translates findings into assessment and explanation Communicates understanding of an urgent situation Communicating findings/assessment Transfer to follow-up care
The patient was known with a cardiac history. On impact the steering wheel connected heavily into his chest. I recommended [to the intensivist to whom the patient was handed over] a repeat of an ECG and a new lab looking at the cardiac enzymes. (Emergency physician, H2)
Provides recommendations and rationale
Exchanging
thoughts for care plan
Highlighting safety
concerns
Debriefing Afterwards you need to get back to how things went. You can’t change what happened, but you can discuss it for the next time, try to understand it. Ask others “How did you experience the case?” (Surgeon, H1)
Discusses what
happened
Asks for others’
perceptions
Exchanging perceptions and understanding
categories: information coordination, decision making, action coordination, communication management, and coaching and team development (see Table 2 for definitions). The first author resorted the codes into these five categories, and inter-rater agreement with a fifth expert (a CRM instructor) was found to be good (Cohen’s Kappa = .71).
Table 2. Taxonomy of Trauma Leadership Skills: skill categories, definitions, and basis in the literature
Skill category Definition Relevant non-technical and
leadership categories in the literature
Information coordination
Communication and behaviors aimed at collecting, sharing, understanding, and reviewing patient information in order to reach a shared awareness and understanding of the situation.
Information coordination43
Situation awareness15,18,19,23
Exchanging information15,18
Information gathering11,44
Managing resources33
Communication and coordination33
Decision making Communication and behaviors aimed at making and reviewing strategy choices in a way that allows for the team’s input, verification, and consent. Decision making is intertwined with information coordination.
Decision making15,18,19,23,33,44
Reporting and critiquing plans11
Provide strategic direction10
Flexible communication strategies
Action coordination
Communication and behaviors aimed at enhancing efficiency and direction, through both explicitly coordinating joint actions and enhancing mutual anticipation. Action coordination43 Maintaining standards33 Task/Resource management15,18,23,33,44 Coordinating activities15,18 Strategic planning10,11
Directing and enabling33
Communication and coordination33
Communication management
Communication and behaviors aimed at preventing breakdowns in team communication by applying standards of “closed loop communication,” creating proper communication circumstances, structuring discussions, and timing messages.
Closed loop communication45
Call-outs45
Flexible communication strategies36
Coaching and team development
Communication and behaviors aimed at supporting and developing others, evaluating performance, and enhancing conditional requirements for cooperation and standards of patient safety.
Supporting others18,23,33
Establish team norms,
teambuilding15,23,44
Coaching, guiding, teaching10,11,,33,46
Empowering leadership46
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Identification of skill elements and behavioral markers
The 103 codes were classified into 38 representative skill elements and 65 behavioral markers, and the behavioral markers were grouped under corresponding skill elements. The interviews were re-read at this stage but no new elements were identified. The skill elements and corresponding behavioral markers were grouped according to phase of trauma care (see Table 3) for presentation to trauma team professionals for verification.
Table 3. Ratings and Endorsement by Trauma Team Members and Leaders (n = 14) of the Relevance
of the Skill Elements, Identified in 28 Interviews, to Excellent Trauma Leadership, by Phase of Trauma Care and Skill Category
Relevance to excellent leadership
Phase and
category Skill elementa
Identified in no. (%) of interviewsb Endorsement %c Rating, mean (SD)d Briefing IC Exchanging pre-hospital information 23 (82) 100 4.71 (.47)
DM Discussing strategy and tasks 24 (86) 100 4.57 (.51)
AC Discussing preparations 13 (46) 58; 100 4.21 (.89);
4.50 (.52)
CTD Setting positive team climate 16 (57) 86 4.46 (.78)
Handover
IC Collecting patient information
as central contact
19 (68) 100 4.93 (.27)
Checking for differences in pre-hospital information and handover
4 (14) 58; 58 4.21 (.89);
3.75 (.75)
DM Confirming initial plans at end
of handover
7 (25) 86 4.07 (.83)
AC Coordinating continuity of care
during handover 21 (75) 75 4.08 (.79) CM Handling handover communication environment 21 (75) 83 4.42 (.79) Patient handling
IC Collecting patient information 27 (96) 100 4.78 (.43)
Discussing findings/assessment 27 (96) 69; 100 4.08 (1.04); 4.75 (.45) Communicating findings/assessment 28 (100) 100 4.71 (.47) Table continues
Table 3 continued
DM Considering options 23 (82) 93 4.71 (.61)
Selecting and communicating option
25 (89) 86 4.07 (.83)
Reviewing decisions 21 (75) 93 4.71 (.61)
AC Planning and prioritizing care 19 (68) 100 4.93 (.27)
Monitoring actions/protocol adherence
28 (100) 100 4.71 (.47)
Updating about progress 27 (96) 100 4.67 (.49)
Providing action/correction instructions
27 (96) 93 4.64 (.63)
Anticipating/responding members’ task needs
18 (64) 75 4.00 (.74) CM Handling communication environment 16 (57) 93 4.57 ( .65) Applying communication standards 23 (82) 79 4.21 (.97) Structuring discussions 6 (21) 83 4.33 (.78)
CTD Recognizing limits of own
competence — 86 4.50 (.52) Supporting/coaching/educating others 18 (64) 86 4.07 (.07) Stimulating concern reporting/speaking up 15 (53) 86 4.29 (.91) Stimulating positive cooperative atmosphere 24 (86) 93 4.57 (.65) Managing workload 3 (11) 75 4.08 (.79)
Transfer to follow-up care
IC Presenting case assessment and
rationale
3 (11) 100 4.71 (.47)
Highlighting concerns 1 (4) 100 4.50 (.52)
DM Discussing admission to
follow-up care
6 (21) 86 4.07 (.83)
AC Coordinating continuity of care
during handover
21 (75) 75 4.08 (.79)
Exchanging thoughts for care plan
1 (4) 100 4.50 (.52)
Debriefing
IC Exchanging perceptions and
understanding 1 (4) 93 4.08 (.64) AC Organizing debriefing 1 (4) 86 4.07 (.83) Presiding debriefing 3 (11) 64; 64 3.86 (.95); 3.81 (.98) CTD Evaluating performance 14 (50) 93 4.43 (.83)
Discussing team climate issues 10 (36) 93 4.43 (.65)
Providing/receiving feedback 13 (46) 93 4.29 (.61)
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Abbreviations: IC indicates information coordination; DM, decision making; AC, action coordination; CM, communication management; CTD, coaching and team development; SD, standard deviation.
aSkillelements are translated from the original Dutch. One element (“recognizing limits of own
competence”) was not identified in the interviews; it was added after the first round of the verification process. The elements in italics were excluded after the second round of ratings because they did not reach the 75% endorsement criterion for inclusion.
bTwo percentages and two means and standard deviations are displayed for elements that were rated
in both the first and second rounds of the taxonomy verification process (see Method).
cEndorsement % represents the percentage of the 14 trauma team leaders and team members (from
the three study hospitals) who rated the element as relevant (4) or very relevant (5) to excellent leadership during the first round, and in some instances second round, of the verification process in 2013.
dRatings used a 5-point Likert-scale, ranging from 1 = very irrelevant to 5 = very relevant to excellent
leadership.
Taxonomy verification
Fourteen trauma team leaders and members (four surgeons, five emergency physicians, one emergency nurse, and four anesthesiologists) participated in the verification of the taxonomy. (Ten of them had also participated in the interviews.) In the first round, they endorsed 34 of the 38 skill elements as relevant for “excellent” leadership (see Table 3). Based on their suggestions, two behavioral markers (“prioritizes information needs” and “makes a final call under pressure and provides brief rationale”) and one skill element (“recognizing limits of own competence”) were added for rating in round 2. In the second round, only 2 of the 4 skill elements for which consensus was not reached initially (“checking for differences in pre-hospital information and handover” and “presiding debriefing”) again failed to reach the criterion for inclusion and were removed. The final taxonomy included 37 skill elements and 67 behavioral markers.
Appendix 2 at the end of this chapter presents the definitive TTLS, with skill elements and their behavioral markers organized by skill category and phase of trauma care.
DISCUSSION
This report outlines the development of the TTLS, a taxonomy of the trauma team leader’s non-technical skills. A grounded theory approach and additional quantitative methods were used to identify skill elements and behavioral markers
for the skill categories of information coordination, decision making, action coordination, communication management, and coaching and team development. The foundation of data acquired from surgeons, emergency physicians, anesthesiologists, and emergency ward nurses, the unique organization of skill categories and skill elements, and the density of the behavioral markers across the five phases of trauma care situate the TTLS to contribute to the training and assessment of leadership skills.
Our emphasis on leadership as a function of phase of care is consistent with the views of Fernandez et al,20 who observed that leadership is required from
planning to debriefing, in order to continuously support team performance. In this respect, the TTLS differs from previous taxonomies, such as the Surgeons’ Leadership Inventory,25 which make no explicit distinction between different
phases of performance. Although Xiao et al11 looked at how characteristics of the
situation (e.g., someone entering the room) trigger the use of different leadership behaviors in trauma teams, their study was restricted to the action phase of trauma care. The importance of continuous leadership can be observed in the effects of team communication during briefings and debriefings on subsequent team performance in the operating theater26–28 or the intensive care unit,29 as well
as in the effects of team communication during patient handovers on subsequent care.30–32 Previous taxonomies, such as T-NOTECHS, also acknowledge the trauma
team leader’s tasks in briefing and debriefing by including elements such as “briefs the team prior to patient arrival.”19 Our taxonomy, the TTLS, provides a
necessary additional level of detail regarding how the trauma team leader should perform these tasks.
Prior to this study, it was not clear to what extent leadership skills identified in studies on resuscitation, hands-on, or distributed leadership would also apply to the leadership provided by a hands-off, designated TTL. Some of the skill categories we identified for excellent leadership by the hands-off trauma team leader (i.e., decision making, action coordination, and coaching and team development) resemble the leadership skill categories previously attributed to hands-on trauma team leadership (i.e., providing strategic direction, monitoring, and teaching).10 Furthermore, by identifying the skill elements and behavioral
markers for those skill categories, we provided concrete and observable behaviors that can be taught in leadership training. In addition, our respondents identified information coordination as an important skill category, just as it has been
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previously identified for the hands-off resuscitation leader.13 Also, we found a skill
element for handling the communication environment--a skill element that has not previously been associated with trauma leadership. It remains unclear whether information coordination and handling the communication environment can be attributed exclusively to the team leader’s position. For instance, surgeons in the operating theater apply information sharing as a strategy, as well.25
Notable in our findings is that in addition to task-structuring skills, we found coaching and team development skills to be associated with effectiveness and safety. That is, the trauma team leader needs to be clear and assertive in delegating tasks and making decisions while, at the same time, inviting and constructively incorporating team members’ input and enhancing their individual performance. In previous studies, the skills for structuring care and the skills for promoting a healthy team environment have been identified as closely related.12,33–35 For instance, dissatisfaction of team members and withdrawal of
team members’ input are more likely when autonomy and expertise are not recognized properly by team leaders12,34; in contrast, encouraging behaviors tend
to improve team members’ performance.35 The absence of power barriers makes
speaking up and collaborative understanding more likely, which in turn enhances flexibility, error prevention, and recovery from errors.12 Consequently, trauma
team leaders use coercive, educational, discussing, and negotiating strategies in building consensus within the team.36 The TTLS’s integration of team
development and coaching skills with task-structuring skills is therefore in line with recommendations to emphasize the team leader’s role in promoting team collaboration.6
The TTLS was developed for use in the training and assessment of any physician in the role of trauma team leader. By including multiple professional groups in the development of the TTLS, we aimed to limit bias due to professional perspective. Although we did not explicitly compare the interview data across the different professional groups, no consistent differences between specialties emerged during the analysis of the interview transcripts. This may seem surprising, as previous studies have shown that physicians and nurses hold different expectations of working together.37 Two reasons our data did not show
such differences may be our focus on excellent leadership and the accessibility of simulation-based team training at the study sites. Both our study focus and the fact that many participants had been exposed to training intended to enhance
awareness of human performance limitations and consequent patient safety needs may have made the participating nurses and doctors aware of the expectations for the trauma team leader. Further, the grounded theory approach used in this study called for the active and creative engagement of researchers in the interpretation of the data.38 Although the mix of professionals participating in the development
and verification of the taxonomy limited bias due to professional perspective, one limitation of the study may be that most of the participants involved in the verification phase had also been involved in the interview phase. This way, the verification therefore served as an important check of whether the taxonomy reflected the interviews, but may have provided less evidence for the taxonomy’s generalizability outside this group. Involving psychologists and medical educators in the development of the TTLS allowed us to create a taxonomy that can be easily understood and consistently interpreted. Therefore, we believe the TTLS provides a strong starting point for further verification of the generalizability of skill elements across trauma departments.
The TTLS has practical relevance: It provides stakeholders a framework for discussing and improving leadership and specifies the behavioral markers that illustrate the desired performance. Using such guidelines, trainees can identify skill categories or elements in which they are lacking and choose particular behaviors to model. In turn, the TTLS provides trauma teams and supervisors with a framework that can be used to focus feedback effectively. Within simulation-based team training in particular, the skill elements and behavioral markers can be used to design triggering events in the scenarios to practice targeted skills.39,40 Because team training should also focus on briefings,
handovers, and debriefings, the TTLS’s embedding of skills in the five phases of trauma care can be particularly helpful. Although the TTLS was developed for the trauma care setting, the leadership skills it describes may extend to any clinical setting that involves critical, complex situations.
Our focus in this study was on non-technical skills, yet we propose that the trauma team leader’s effective and timely utilization of non-technical skills cannot occur without a good understanding of major traumatic injuries and of trauma care procedures and standards. However, given the multidisciplinary nature of the trauma team, the team leader does not have to be expert in all procedures. Although technical performance and perceptions of leadership have previously been found to be correlated,35,41 it has not yet been determined to what extent
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expertise in non-technical skills can compensate for lack of or lower levels of expertise in clinical skills, and vice versa.
As described above, our goal was to create a taxonomy that provides skill elements and their behavioral markers. The TTLS can leverage the development of objectives for training programs, and provides a structure for the development of assessment tools that enable objective assessment and delivery of structured feedback.42 Because the TTLS provides a structure for rating trauma team leader
performance across the phases of care, it can be used to study the frequency or timing of skills demonstrated during specific events, such as rapidly evolving emergencies, thus improving the understanding of adaptive leadership. As a step toward developing such assessment tools, work is underway to test whether the skill elements from the TTLS can be observed objectively, and whether the behavioral markers can be used to assess leadership performance validly.
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ap ter 2 – Id en ti fy in g tr au ma lea d e rs h ip s ki lls APPENDIX 1 Interview protocol
Part 1: General views on leadership
1. In trauma care, what is/are the main function(s) of the team leader to you?
2. What are the skills you expect of a team leader? (leave open to include both technical and
non-technical skills)
3. Are there different leadership styles? If yes, is there a leadership style you prefer?
4. What is your stance in hands-on or hands-off involvement
Part 2: Critical incident with excellent leadership performance
1. Could you describe a case you were involved in as either a team member or as team leader
yourself, of which you feel that leadership performance was excellent in terms of effectiveness and patient safety. Briefly explain why it was excellent.
2. What did the team leader and the team do prior to patient arrival?
3. How was the handover situated? What did the team leader do during the handover?
4. After the handover was finished, what did the team leader do first?
5. How did the team leader contribute to the progress of the patient handling?
6. When and how was communicated about the tasks by team leader and team members?
7. How was information being shared? How was case understanding developed? How did the
team leader contribute to this?
8. How were decisions being made and communicated?
9. What made the cooperation between the team and the team leader so excellent?
10. How was the patient handling finalized?
11. How was the patient handed over? What did the team leader do during the handover? 12. Was there a debriefing? [if not, what do you expect of the team leader in a debriefing?] Additional questions were asked to explore case-specific events.
Part 3: General recommendations for improvement
13. Do you have any recommendations for trauma team leadership that we have not yet discussed during this interview?
APPENDIX 2
Taxonomy of Trauma Leadership Skills (TTLS): skill elements and behavioral markers by the five
phases of trauma carea
Planning Phases Briefing
Skill category Skill element Selected behavioral marker(s)
Information coordination
Exchanging pre-hospital information
Informs members on patient, mechanism,
injuries.
Searches patient history in database.
Decision making Discussing strategy and
tasks
Walks through probable upcoming tasks.
Discusses a contingency planning (“who
does what if”). Action
coordination
Discussing preparations Asks nurse to order blood products.
Coaching and team development
Setting positive team climate
Becomes familar with team
(names/functions/experience).
Sets expectations of concern reporting.
Handover
Skill category Skill element Behavioral marker
Information coordination
Collecting patient information as central contact
Provides room for team’s additional
questions.
Asks ambulance crew to clarify
unclear/incomplete information.
Decision making Confirming initial plans
at end of handover
Summarizes major safety concerns.
Confirms plans made in briefing and
repeats first actions. Action
coordination
Coordinating continuity of care during handover
Verifies whether actions need to be started/taken over immediately at arrival. Communication
management
Handling handover communication environment
Limits communication that is not related to
handover.
Limits patient handling during handover -
if not immediately required - to enhance team’s attention to information.
ap ter 2 – Id en ti fy in g tr au ma lea d e rs h ip s ki lls Appendix 2 continued Action Phase Patient handling
Skill category Skill element Behavioral marker
Information coordination
Collecting patient information
Prioritizes information needs.
Receives reports from physical
examination, displays, and lab results. Discussing
findings/assessment
Discusses interpretation of CT scan with
radiologist.
Reviews information to prevent blind
spots. Communicating
findings/assessment
Communicates findings and observations
Communicates changes and trends in
patient conditions and their implications.
Shares own understanding of the situation
Communicates explanation of low blood
pressure.
Communicates anticipation of a likely
complication.
Decision making Considering options Considers the risks and benefits of
different options
Assesses action priorities with respect to
urgency of the situation
Invites team members’ input when making
a difficult decision. Selecting and
communicating option
Makes a final call under pressure, and provides brief rationale.
Reviewing decisions Reviews working diagnosis in light of new
findings.
Aborts current course in light of patient’s
rapid deterioration.
Reviews success of interventions.
Action coordination
Planning & prioritizing care
Communicates care priorities after primary survey.
Monitoring actions/protocol adherence
Views if actions are appropriate given the
progress in protocol.
Monitors if the actions being performed
meet quality standards.
Appendix 2 continued
Updating about progress Summarizes the actions taken so far and
what is up next.
Asks team member to update when tasks
are performed.
Informs other team members about
difficult intubation being performed. Providing instructions
and corrections
Instructs a specific member when to
perform an action.
Provides brief instructions to improve
team members’ technical performance. Anticipating members’
task needs
Relieves anaesthetist from head
stabilization by re-assigning this task.
Anticipates when team members will need
equipment Handling suggestions
constructively
Responds to members’ task
suggestions/alternatives.
Checks with team if actions are complete
Communication management
Handling communication
environment
Matches timing of a résumé with a period of lower workload.
Draws entire team’s attention to important
messages. Applying communication
standards
Confirms the receipt of new information or requests.
Structuring discussions Collects team members’ perspectives
efficiently.
Summarizes different viewpoints and
explains conclusion. Coaching and team development Recognizing limits of own competence
Asks an experienced team member or attending for help in a novel or complex situation. Supporting and
educating others
Guides a less experienced team member with guiding questions in a difficult procedure.
Managing workload Recognizes overloaded team members and
re-delegates tasks. Stimulating concern
reporting
Responds appreciatively/constructively when team member points out concern.
Stimulating positive cooperative atmosphere
Matches assertiveness and authority with urgency and team experience.
ap ter 2 – Id en ti fy in g tr au ma lea d e rs h ip s ki lls Appendix 2 continued. Reflection phases Transfer to follow-up care
Skill category Skill element Behavioral marker
Information coordination
Presenting case assessment and rationale
Provides clear information, summarizing the mechanism, findings and assessment, and treatment given so far.
Highlighting concerns Closes the handover with the primary
concerns
Decision making Discussing admission to
follow-up care (prior to handover)
Calls the ICU, OR, or ward in advance to discuss admission with initial description of patient condition.
Action coordination
Coordinating continuity of care during handover
Makes sure patient is installed and connected prior to handover.
Exchanging thoughts on care plan
Provides recommendations and confirms priorities.
Debriefing
Skill category Skill element Behavioral marker
Information coordination
Exchanging perceptions and understanding
Discusses what happened, asks for
others’ perceptions.
Explores the reasons for ambiguous
understanding of the case amongst team members, or dissatisfaction with decisions.
Action coordination Organizing debriefing Checks with team members for best time and
place to debrief. Coaching and team
development
Evaluating performance Discusses what went well and what could
be improved.
Stimulates analysis of why things
happened the way they did. Discussing team climate
issues
Reflects on how discussions were handled, explains directness.
Providing and receiving feedback
Discusses improvement needs aand
solutions.
Invites constructive feedback on
leadership behaviors.
aFor definitions of the five phases of trauma care, see Chart 1. For definitions of the skill categories, see
