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Negotiated knowledge positions: communication in trauma teams
Umeå University, Faculty of Medicine, Department of Nursing. Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.ORCID iD: 0000-0003-0680-9962
2015 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background Within trauma teams, effective communication is necessary to ensure safe and secure care of the patient. Deficiencies in communication are one of the most important factors leading to patient harm. Time is an essential factor for rapid and efficient disposal of trauma teams to increase patients’ survival and prevent morbidity. Trauma team training plays an important role in improving the team’s performance, while the leader of the trauma team faces the challenge of coordinating and optimizing this performance.

Aim The overall aim of this thesis was to analyse how members of trauma teams communicated verbally and non-verbally during trauma team training in emergency settings, and how the leaders were positioned or positioned themselves in relation to other team members. The aim was also to investigate the use of a communication tool, closed-loop communication, and the time taken to make a decision to go to surgery in relation to specific factors in the team as well as the leader’s position.

Methods Eighteen trauma teams were audio and video recorded and analysed during regular in situ training in the emergency room at a hospital in northern Sweden. Each team consisted of six participants: two physicians, two nurses, and two enrolled nurses, giving a total of 108 participants. In Study I, the communication between the team members was analysed using a method inspired by discourse psychology and Strauss’ concept of “negotiated orders”. In Study II, the communication in the teams was categorized and quantified into “call-outs” and “closed-loop communication”. The analysis included the team members’ background data and results from Study I concerning the leader’s position in the team. Poisson regression analyses were performed to assess closed-loop communication (outcome variable) in relation to background data and leadership style (independent exploratory variables). In Study III, quantitative content analysis was used to categorize and organize the team members’ positions and the leaders’ non-verbal communication in the video-recorded material. Time sequences of leaders’ non-verbal communications in terms of gaze direction, speech time, and gestures were identified separately to the level of seconds and presented as proportions (%) of the total training time. The leaders’ vocal nuances were also categorized. The analysis in Study IV was based on the team members’ background data, the results from Study I concerning the leader’s position in the team, and the categorization and quantification of team communication from Study II. Cox proportional hazard regression was performed to assess the time taken to make a decision to go to surgery (outcome variable) in relation to background data, the leader’s position, and closed-loop communication (independent variables).

Results The findings in Study I showed that team leaders used coercive, educational, discussing, and negotiating repertoires to convey knowledge and create common goals of priorities in work. The repertoires were used flexibly and changed depending on the urgency of the situation and the interaction between the team members. When using these repertoires, the team leaders were positioned or positioned themselves in either an authoritarian or an egalitarian position. Study II showed that closed-loop communication was used to a limited extent during the trauma team training. Call-out was more frequently used by team members with eleven or more years in the profession and experience of trauma within the past year, compared with team members with no such experience. Scandinavian origin, an egalitarian team leader and previous experience of two or more structured trauma courses were associated with more frequent use of closed-loop communication compared to those with no such origin, leader style, or experience. Study III showed that team leaders who gained control over the “inner circle” used gaze direction, vocal nuances, verbal commands, and gestures to solidify their verbal messages. Leaders who spoke in a hesitant voice or were silent expressed ambiguity in their non-verbal communication, and other team members took over the leader's tasks. Study IV showed that the team leader’s closed-loop communication was important for making the decision to go to surgery. In 8 of 16 teams, decisions on surgery were taken within the timeframe of the trauma team training. Call-outs and closed-loop communication initiated by the team members were significantly associated with a lack of decision to go to surgery.

Conclusions The leaders used different repertoires to convey and gain knowledge in order to create common goal in the teams. These repertoires were both verbal and non-verbal, and flexible. They shifted depending on the urgency of the situation and the interaction within the team. Depending on the chosen repertoire, the leaders were positioned or positioned themselves as egalitarian and/or authoritarian leaders. In urgent situations, the leaders used closed-loop communication as part of a coercive repertoire, and called out commands and directed requests to specific team members. This repertoire was important for making the decision to go to surgery; the more closed-loop communication initiated by the leader, the more likely that the team would make a decision to go to surgery. Problems arose if the leaders were positioned or positioned themselves as either an authoritarian or an egalitarian leader. The leaders needed to be flexible and use different repertories in order to move the teamwork forward. It was notable that higher numbers of call-outs and closed-loop communication initiated by the team members decreased the probability of making the decision to go to surgery.

Place, publisher, year, edition, pages
Umeå: Umeå universitet , 2015. , 79 p.
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 1733
Keyword [en]
communication, discourse psychology, ideological dilemma, interpretative repertoires, leadership, non-verbal communication, position, power, team work, time, trauma team, trauma team training, silence
National Category
Nursing
Identifiers
URN: urn:nbn:se:umu:diva-108251ISBN: 978-91-7601-298-7 (print)OAI: oai:DiVA.org:umu-108251DiVA: diva2:851768
Public defence
2015-10-02, Vårdvetarhusets Aula, Umeå universitet, Umeå, 09:00 (Swedish)
Opponent
Supervisors
Available from: 2015-09-11 Created: 2015-09-07 Last updated: 2016-03-16Bibliographically approved
List of papers
1. Flexible knowledge repertoires: Communication by leaders in trauma teams
Open this publication in new window or tab >>Flexible knowledge repertoires: Communication by leaders in trauma teams
2012 (English)In: Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, ISSN 1757-7241, E-ISSN 1757-7241, Vol. 20, no 1, 44- p.Article in journal (Refereed) Published
Abstract [en]

Background: In emergency situations, it is important for the trauma team to efficiently communicate their observations and assessments. One common communication strategy is “closed-loop communication”, which can be described as a transmission model in which feedback is of great importance. The role of the leader is to create a shared goal in order to achieve consensus in the work for the safety of the patient. The purpose of this study was to analyze how formal leaders communicate knowledge, create consensus, and position themselves in relation to others in the team.

Methods: Sixteen trauma teams were audio- and video-recorded during high fidelity training in an emergency department. Each team consisted of six members: one surgeon or emergency physician (the designated team leader), one anaesthesiologist, one nurse anaesthetist, one enrolled nurse from the theatre ward, one registered nurse and one enrolled nurse from the emergency department (ED). The communication was transcribed and analyzed, inspired by discourse psychology and Strauss’ concept of “negotiated order”. The data were organized and coded in NVivo 9.

Results: The findings suggest that leaders use coercive, educational, discussing and negotiating strategies to work things through. The leaders in this study used different repertoires to convey their knowledge to the team, in order to create a common goal of the priorities of the work. Changes in repertoires were dependent on the urgency of the situation and the interaction between team members. When using these repertoires, the leaders positioned themselves in different ways, either on an authoritarian or a more egalitarian level.

Conclusion: This study indicates that communication in trauma teams is complex and consists of more than just transferring messages quickly. It also concerns what the leaders express, and even more importantly, how they speak to and involve other team members.

Place, publisher, year, edition, pages
BioMed Central, 2012
Keyword
Leadership, Communication, Teamwork, Simulation, Discourse psychology
National Category
Nursing
Identifiers
urn:nbn:se:umu:diva-57874 (URN)10.1186/1757-7241-20-44 (DOI)000311410400001 ()22747848 (PubMedID)
Note

This study was supported in part by the Laerdal Foundation, Nordic Safety and Security, a project sponsored by the EU regional funds and the County Council of Västerbotten (grant number VLL-154071).

Available from: 2012-08-20 Created: 2012-08-20 Last updated: 2017-12-07Bibliographically approved
2. Communication in interdisciplinary teams: Exploring closed-loop communication during in situ trauma team training
Open this publication in new window or tab >>Communication in interdisciplinary teams: Exploring closed-loop communication during in situ trauma team training
Show others...
2013 (English)In: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 3, no 10, e003525- p.Article in journal (Refereed) Published
Abstract [en]

Objectives: Investigate the use of call-out (CO) and closed-loop communication (CLC) during a simulated emergency situation, and its relation to profession, age, gender, ethnicity, years in profession, educational experience, work experience and leadership style.

Design: Exploratory study.

Setting: In situ simulator-based interdisciplinary team training using trauma cases at an emergency department.

Participants: The result was based on 16 trauma teams with a total of 96 participants. Each team consisted of two physicians, two registered nurses and two enrolled nurses, identical to a standard trauma team.

Results: The results in this study showed that the use of CO and CLC in trauma teams was limited, with an average of 20 CO and 2.8 CLC/team. Previous participation in trauma team training did not increase the frequency of use of CLC while ≥2 structured trauma courses correlated with increased use of CLC (risk ratio (RR) 3.17, CI 1.22 to 8.24). All professions in the trauma team were observed to initiate and terminate CLC (except for the enrolled nurse from the operation theatre). The frequency of team members’ use of CLC increased significantly with an egalitarian leadership style (RR 1.14, CI 1.04 to 1.26).

Conclusions: This study showed that despite focus on the importance of communication in terms of CO and CLC, the difficulty in achieving safe and reliable verbal communication within the interdisciplinary team remained. This finding indicates the need for validated training models combined with further implementation studies.

Place, publisher, year, edition, pages
BMJ Publishing Group, 2013
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:umu:diva-81936 (URN)10.1136/bmjopen-2013-003525 (DOI)
Available from: 2013-10-23 Created: 2013-10-23 Last updated: 2017-12-06Bibliographically approved
3. Trauma team leaders' non-verbal communication: video registration during trauma team training
Open this publication in new window or tab >>Trauma team leaders' non-verbal communication: video registration during trauma team training
2016 (English)In: Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, ISSN 1757-7241, E-ISSN 1757-7241, Vol. 24, 37Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: There is widespread consensus on the importance of safe and secure communication in healthcare, especially in trauma care where time is a limiting factor. Although non-verbal communication has an impact on communication between individuals, there is only limited knowledge of how trauma team leaders communicate. The purpose of this study was to investigate how trauma team members are positioned in the emergency room, and how leaders communicate in terms of gaze direction, vocal nuances, and gestures during trauma team training.

METHODS: Eighteen trauma teams were audio and video recorded during trauma team training in the emergency department of a hospital in northern Sweden. Quantitative content analysis was used to categorize the team members' positions and the leaders' non-verbal communication: gaze direction, vocal nuances, and gestures. The quantitative data were interpreted in relation to the specific context. Time sequences of the leaders' gaze direction, speech time, and gestures were identified separately and registered as time (seconds) and proportions (%) of the total training time.

RESULTS: The team leaders who gained control over the most important area in the emergency room, the "inner circle", positioned themselves as heads over the team, using gaze direction, gestures, vocal nuances, and verbal commands that solidified their verbal message. Changes in position required both attention and collaboration. Leaders who spoke in a hesitant voice, or were silent, expressed ambiguity in their non-verbal communication: and other team members took over the leader's tasks.

DISCUSSION:

In teams where the leader had control over the inner circle, the members seemed to have an awareness of each other's roles and tasks, knowing when in time and where in space these tasks needed to be executed. Deviations in the leaders' communication increased the ambiguity in the communication, which had consequences for the teamwork. Communication cannot be taken for granted; it needs to be practiced regularly just as technical skills need to be trained. Simulation training provides healthcare professionals the opportunity to put both verbal and non-verbal communication in focus, in order to improve patient safety.

CONCLUSIONS: Non-verbal communication plays a decisive role in the interaction between the trauma team members, and so both verbal and non-verbal communication should be in focus in trauma team training. This is even more important for inexperienced leaders, since vague non-verbal communication reinforces ambiguity and can lead to errors.

Place, publisher, year, edition, pages
BioMed Central, 2016
Keyword
Communication, Coordination, Leadership, Non-verbal communication, Time, Trauma team, Trauma team training
National Category
Anesthesiology and Intensive Care Nursing
Identifiers
urn:nbn:se:umu:diva-108083 (URN)10.1186/s13049-016-0230-7 (DOI)000372795600002 ()27015914 (PubMedID)
Available from: 2015-09-03 Created: 2015-09-03 Last updated: 2017-12-04Bibliographically approved
4. Trauma teams and time to early management during in situ trauma team training
Open this publication in new window or tab >>Trauma teams and time to early management during in situ trauma team training
Show others...
2016 (English)In: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 6, no 1, e009911Article in journal (Refereed) Published
Abstract [en]

OBJECTIVES: To investigate the association between the time taken to make a decision to go to surgery and gender, ethnicity, years in profession, experience of trauma team training, experience of structured trauma courses and trauma in the trauma team, as well as use of closed-loop communication and leadership styles during trauma team training.

DESIGN: In situ trauma team training. The patient simulator was preprogrammed to represent a severely injured patient (injury severity score: 25) suffering from hypovolemia due to external trauma.

SETTING: An emergency room in an urban Scandinavian level one trauma centre.

PARTICIPANTS: A total of 96 participants were divided into 16 trauma teams. Each team consisted of six team members: one surgeon/emergency physician (designated team leader), one anaesthesiologist, one registered nurse anaesthetist, one registered nurse from the emergency department, one enrolled nurse from the emergency department and one enrolled nurse from the operating theatre.

PRIMARY OUTCOME: HRs with CIs (95% CI) for the time taken to make a decision to go to surgery was computed from a Cox proportional hazards model.

RESULTS: Three variables remained significant in the final model. Closed-loop communication initiated by the team leader increased the chance of a decision to go to surgery (HR: 3.88; CI 1.02 to 14.69). Only 8 of the 16 teams made the decision to go to surgery within the timeframe of the trauma team training. Conversely, call-outs and closed-loop communication initiated by the team members significantly decreased the chance of a decision to go to surgery, (HR: 0.82; CI 0.71 to 0.96, and HR: 0.23; CI 0.08 to 0.71, respectively).

CONCLUSIONS: Closed-loop communication initiated by the leader appears to be beneficial for teamwork. In contrast, a high number of call-outs and closed-loop communication initiated by team members might lead to a communication overload.

Keyword
Accident & Emergency Medicin, Anaesthetics, Medical Education & Training, Trauma Management
National Category
Nursing Anesthesiology and Intensive Care
Identifiers
urn:nbn:se:umu:diva-115215 (URN)10.1136/bmjopen-2015-009911 (DOI)000369993900144 ()26826152 (PubMedID)
Note

Originally included in thesis in submitted form.

Available from: 2016-02-01 Created: 2016-02-01 Last updated: 2017-11-30Bibliographically approved

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