Injury, Int. J. Care Injured 46 (2015) 773–774
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Editorial
Teamwork in trauma: Simply being part of a team is not enough!
Trauma teams are now ubiquitous in modern day trauma care. While the size and composition of the team will vary according to the size and capability of the institution, almost every well organised trauma receiving hospital will have a team of some sort attend the arrival of a patient with potentially life threatening injuries. So will the presence of a trauma team ensure that the patient is treated by a group of clinicians who display teamwork [1,2]? Not often is probably the answer. Teamwork requires that the team understands and displays all of the important characteristics described by Salas et al. [3] namely leadership, mutual performance monitoring, backup behaviour, adaptability and appropriate team orientation. Good teamwork requires that the team has an effective leader. All too often trauma teams have too many people trying to be the leader and occasionally no-one is the leader. Historically it was thought that the team leader by definition had to be the clinician with the most experience and knowledge but of course that is not the case. Team leadership is a role, like all the others within the trauma team, and any individual with a moderate amount of experience and training in the team leadership role can act in this position. This role may be delegated to a trainee under supervision so that their performance can be observed and mentorship provided. Of course for a member of the trauma team to effectively take the role of the team leader requires all the other members of the team to effectively fill their roles as well and for them not to encroach on the role of the leader. Mutual performance monitoring is another characteristic necessary for effective teamwork. This implies monitoring other team members’ performance and ensuring they are effectively coping with the role they have been allocated. Trauma is unpredictable and the actual knowledge and skills that an individual member of the team may be required to demonstrate in a given scenario hard to predict. It is not uncommon for members of the team to find themselves outside their areas of competence and in a well running team this is closely monitored by its members and appropriate backup provided. Effective backup behaviour should be a direct consequence of mutual performance monitoring. While this role may naturally fall to the team leader who should be most aware of the overall performance of the team, individual team members may occasionally have the personal or institutional resources to provide backup where it is required. An effective team demonstrates adaptability. More than most areas of clinical practice acute trauma presentations shift emphasis as more information becomes available about the likely injuries http://dx.doi.org/10.1016/j.injury.2015.02.014 0020–1383/ß 2015 Elsevier Ltd. All rights reserved.
and the patient demonstrates a response to treatment. Changing strategies in response to the changing clinical condition in a timely way is one of the hallmarks of an effective team. Finally, team orientation needs to be clearly focussed on the needs of the patient, not on competing personal or institutional priorities. Ensuring that time targets or bed availability demands are met at the expense of best patient care clearly is a failure of teamwork. If all these criteria are met the team will have a shared mental model of how the process of the resuscitation will work, will use effective closed loop communication, and will trust each other to do their jobs. So just being part of a trauma team will not ensure good teamwork is in place [1,4], nor that the patient will receive effective well coordinated care. Such teamwork may possibly occur by chance but it is much more likely the team will need to be trained to function in this way [1,5,6]. Historically, simple exposure to multiple learning experiences allowed learning in a ‘‘trial and error’’ format. This is no longer possible in many environments as exposure to the learning experience is episodic and occasional. Moreover, patients now expect to be treated by competent practitioners and that those in a learning role are well supervised. In this context it is inevitable that team and teamwork training are both required. While the former is the logistics of forming a team, being in the right place at the right time, and knowing where things are and how to use them, teamwork is the behavioural characteristics of the members of the team and ensuring that these characteristics are those which are known to facilitate the effective functioning of a team. Both team training and teamwork training are effectively delivered using some form of simulation as outlined by Weller et al. [5]. Team training is commonly undertaken in larger trauma hospitals in an in situ format. Mock trauma calls are made and the participants are expected to turn up promptly and be oriented to the environment in which acute trauma resuscitation is provided. Teamwork training is more complicated and usually requires some form of simulation together with an effective debrief. Amongst the requirements for various levels of certification in different jurisdictions around the world is the necessity to have a trauma team that responds to acute trauma presentations. However while the completeness of that team and it promptness in arriving is commonly reviewed in verification visits, at no point is its effectiveness assessed. Effective team behaviour requires teamwork and there is ample evidence that this can be developed and improved with appropriate training.
774
Editorial / Injury, Int. J. Care Injured 46 (2015) 773–774
As we seek to improve the effectiveness of our trauma care and the quality of our trauma outcomes, the delivery of acute trauma care in the first minutes and hours after presentation to hospital must come under the spotlight. Unless this care is delivered effectively the overall outcomes are likely to be compromised. Trauma teams are an accepted part of the acute trauma landscape, teams displaying effective teamwork are not. As we look for new ways of improving trauma care with better resuscitation strategies, new scanners, less invasive operations and better postoperative care, we need also to consider better functioning trauma teams, using contemporary simulation and behavioural training to ensure optimal teamwork.
References [1] Hughes KM, Benenson RS, Krichten AE, Clancy KD, Ryan JP, Hammond C. A crew resource management program tailored to trauma resuscitation improves team behavior and communication. J Am Coll Surg 2014;219:545–51.
[2] Bergs EAG, Rutten FLPA, Tadros T, Krijren P, Schipper IB. Communication during trauma resuscitation: do we know what is happening? Injury 2005;36:905–11. [3] Salas E, Sims D, Burke C. Is there a ‘‘Big Five’’ in teamwork? Small Group Res 2005;36:555–99. [4] Westli HK, Johnsen BH, Eid J, Rasten I, Brattebo G. Teamwork skills, shared mental models, and performance in simulated trauma teams: an independent group design. Scand J Trauma Resusc Emerg Med 2010;18:47. [5] Weller J, Boyd M, Cumin D. Teams, tribes and patient safety: overcoming barriers to effective teamwork in healthcare. Postgrad Med J 2014;90: 149–54. [6] Roberts NK, Williams RG, Schwind CJ, Sutyak JA, McDowell C, Griffen D, et al. The impact of brief team communication, leadership and team behaviour training on ad hoc team performance in trauma care settings. Am J Surg 2014;207:170–8.
Ian Civil E-mail address: [email protected] (I. Civil).
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Editorial
Teamwork in trauma: Simply being part of a team is not enough!
Trauma teams are now ubiquitous in modern day trauma care. While the size and composition of the team will vary according to the size and capability of the institution, almost every well organised trauma receiving hospital will have a team of some sort attend the arrival of a patient with potentially life threatening injuries. So will the presence of a trauma team ensure that the patient is treated by a group of clinicians who display teamwork [1,2]? Not often is probably the answer. Teamwork requires that the team understands and displays all of the important characteristics described by Salas et al. [3] namely leadership, mutual performance monitoring, backup behaviour, adaptability and appropriate team orientation. Good teamwork requires that the team has an effective leader. All too often trauma teams have too many people trying to be the leader and occasionally no-one is the leader. Historically it was thought that the team leader by definition had to be the clinician with the most experience and knowledge but of course that is not the case. Team leadership is a role, like all the others within the trauma team, and any individual with a moderate amount of experience and training in the team leadership role can act in this position. This role may be delegated to a trainee under supervision so that their performance can be observed and mentorship provided. Of course for a member of the trauma team to effectively take the role of the team leader requires all the other members of the team to effectively fill their roles as well and for them not to encroach on the role of the leader. Mutual performance monitoring is another characteristic necessary for effective teamwork. This implies monitoring other team members’ performance and ensuring they are effectively coping with the role they have been allocated. Trauma is unpredictable and the actual knowledge and skills that an individual member of the team may be required to demonstrate in a given scenario hard to predict. It is not uncommon for members of the team to find themselves outside their areas of competence and in a well running team this is closely monitored by its members and appropriate backup provided. Effective backup behaviour should be a direct consequence of mutual performance monitoring. While this role may naturally fall to the team leader who should be most aware of the overall performance of the team, individual team members may occasionally have the personal or institutional resources to provide backup where it is required. An effective team demonstrates adaptability. More than most areas of clinical practice acute trauma presentations shift emphasis as more information becomes available about the likely injuries http://dx.doi.org/10.1016/j.injury.2015.02.014 0020–1383/ß 2015 Elsevier Ltd. All rights reserved.
and the patient demonstrates a response to treatment. Changing strategies in response to the changing clinical condition in a timely way is one of the hallmarks of an effective team. Finally, team orientation needs to be clearly focussed on the needs of the patient, not on competing personal or institutional priorities. Ensuring that time targets or bed availability demands are met at the expense of best patient care clearly is a failure of teamwork. If all these criteria are met the team will have a shared mental model of how the process of the resuscitation will work, will use effective closed loop communication, and will trust each other to do their jobs. So just being part of a trauma team will not ensure good teamwork is in place [1,4], nor that the patient will receive effective well coordinated care. Such teamwork may possibly occur by chance but it is much more likely the team will need to be trained to function in this way [1,5,6]. Historically, simple exposure to multiple learning experiences allowed learning in a ‘‘trial and error’’ format. This is no longer possible in many environments as exposure to the learning experience is episodic and occasional. Moreover, patients now expect to be treated by competent practitioners and that those in a learning role are well supervised. In this context it is inevitable that team and teamwork training are both required. While the former is the logistics of forming a team, being in the right place at the right time, and knowing where things are and how to use them, teamwork is the behavioural characteristics of the members of the team and ensuring that these characteristics are those which are known to facilitate the effective functioning of a team. Both team training and teamwork training are effectively delivered using some form of simulation as outlined by Weller et al. [5]. Team training is commonly undertaken in larger trauma hospitals in an in situ format. Mock trauma calls are made and the participants are expected to turn up promptly and be oriented to the environment in which acute trauma resuscitation is provided. Teamwork training is more complicated and usually requires some form of simulation together with an effective debrief. Amongst the requirements for various levels of certification in different jurisdictions around the world is the necessity to have a trauma team that responds to acute trauma presentations. However while the completeness of that team and it promptness in arriving is commonly reviewed in verification visits, at no point is its effectiveness assessed. Effective team behaviour requires teamwork and there is ample evidence that this can be developed and improved with appropriate training.
774
Editorial / Injury, Int. J. Care Injured 46 (2015) 773–774
As we seek to improve the effectiveness of our trauma care and the quality of our trauma outcomes, the delivery of acute trauma care in the first minutes and hours after presentation to hospital must come under the spotlight. Unless this care is delivered effectively the overall outcomes are likely to be compromised. Trauma teams are an accepted part of the acute trauma landscape, teams displaying effective teamwork are not. As we look for new ways of improving trauma care with better resuscitation strategies, new scanners, less invasive operations and better postoperative care, we need also to consider better functioning trauma teams, using contemporary simulation and behavioural training to ensure optimal teamwork.
References [1] Hughes KM, Benenson RS, Krichten AE, Clancy KD, Ryan JP, Hammond C. A crew resource management program tailored to trauma resuscitation improves team behavior and communication. J Am Coll Surg 2014;219:545–51.
[2] Bergs EAG, Rutten FLPA, Tadros T, Krijren P, Schipper IB. Communication during trauma resuscitation: do we know what is happening? Injury 2005;36:905–11. [3] Salas E, Sims D, Burke C. Is there a ‘‘Big Five’’ in teamwork? Small Group Res 2005;36:555–99. [4] Westli HK, Johnsen BH, Eid J, Rasten I, Brattebo G. Teamwork skills, shared mental models, and performance in simulated trauma teams: an independent group design. Scand J Trauma Resusc Emerg Med 2010;18:47. [5] Weller J, Boyd M, Cumin D. Teams, tribes and patient safety: overcoming barriers to effective teamwork in healthcare. Postgrad Med J 2014;90: 149–54. [6] Roberts NK, Williams RG, Schwind CJ, Sutyak JA, McDowell C, Griffen D, et al. The impact of brief team communication, leadership and team behaviour training on ad hoc team performance in trauma care settings. Am J Surg 2014;207:170–8.
Ian Civil E-mail address: [email protected] (I. Civil).
