Accepted Manuscript Title: The effect of a nurse team leader on communication and leadership in major trauma resuscitations☆ Author: Alana Clements, Kate Curtis, Leanne Horvat, Ramon Z. Shaban PII: DOI: Reference:
S1755-599X(14)00030-5 http://dx.doi.org/doi:10.1016/j.ienj.2014.04.004 IENJ 347
To appear in:
International Emergency Nursing
Received date: Revised date: Accepted date:
11-9-2013 13-1-2014 30-4-2014
Please cite this article as: Alana Clements, Kate Curtis, Leanne Horvat, Ramon Z. Shaban, The effect of a nurse team leader on communication and leadership in major trauma resuscitations☆, International Emergency Nursing (2014), http://dx.doi.org/doi:10.1016/j.ienj.2014.04.004. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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Title: The effect of a nurse team leader on communication and leadership in major
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trauma resuscitations
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Authors
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Alana Clements RN, MEmergNurs1,Kate Curtis RN, PhD1-4, Leanne Horvat RN
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MN(NursPrac)5 and Ramon Z. Shaban6 RN, PhD,
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AC, KC, and LH conceived and designed the study. AC, KC developed the study protocol, designed and tested the study instruments. AC, KC & LH supervised data collection. RS analysed the data All authors prepared and approved the manuscript
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Author affiliations
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1. Trauma Service, St George Hospital, NSW Australia
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2. Sydney Nursing School, University of Sydney, Australia
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3. The George Institute for Global Health
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4. St George Clinical School, Faculty of Medicine, University of NSW
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5. South Eastern Sydney Local Health District
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6. Centre for Health Practice Innovation, School of Nursing and Midwifery,
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Griffith Health Institute, Griffith University
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Corresponding author
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Alana Clements
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Phone: 02 9947 9865 Fax: 02 9947 9879
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Email: [email protected]
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Acknowledgement
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The authors acknowledge Kerri Holzhauser for her assistance with survey design and preliminary analyses and Pauline Calleja for sharing her trauma medical record audit.
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Abstract
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Background: Effective assessment and resuscitation of trauma patients requires an
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organised, multidisciplinary team. Literature evaluating leadership roles of nurses in
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trauma resuscitation and their effect on team performance is scarce.
35 36
Aim: To assess the effect of allocating the most senior nurse as team leader of trauma
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patient assessment and resuscitation on communication, documentation and
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perceptions of leadership within an Australian emergency department.
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Methods: The study design was a pre-post-test survey of emergency nursing staff
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(working at resuscitation room level) perceptions of leadership, communication, and
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documentation before and after the implementation of a nurse leader role. Patient
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records were audited focusing on initial resuscitation assessment, treatment, and
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nursing clinical entry. Descriptive statistical analyses were performed.
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Results: Communication trended towards improvement. All (100%) respondents post-
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test stated they had a good to excellent understanding of their role, compared to
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93.2% pre-study. A decrease (58.1% to 12.5%) in ‘intimidating personality’ as a
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negative aspect of communication. Nursing leadership had a 6.7% increase in the
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proportion of those who reported nursing leadership to be good to excellent. Accuracy
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of clinical documentation improved (p = 0.025).
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Conclusion: Trauma nurse team leaders improve some aspects of communication and
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leadership. Development of trauma nurse leaders should be encouraged within trauma
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team training programs.
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Key words: Trauma; leadership; resuscitation; nursing; emergency; communication
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INTRODUCTION
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Traumatic injury accounts for 11% of global mortality and is a leading cause of
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disability1. Trauma affects society on a physical, psychological and economical level2,
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and in Australia injuries are one of the most costly disease groups3.
63 64
Quality trauma care required an integrated and resourced trauma system. The aim of a
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trauma system is to facilitate the timely treatment of severely injured patients where
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resources are available for their optimal management and rehabilitation. Trauma
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systems have significantly reduced trauma patient mortality in Australia4,5 and
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internationally6,7.
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Once the trauma patient has arrived at the trauma centre, in-hospital trauma systems,
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such as trauma teams, are activated and facilitate systematic clinical assessment and
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ongoing patient care8,9. Quality and effective initial assessment and resuscitation of
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trauma patients [requires a multidisciplinary trauma team led by medical and nursing
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staff10,11. Adopting a structured team-based approach to trauma care in resuscitation
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allows for simultaneous inputs to address the need for rapid resuscitation, stabilisation
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and to prioritise ongoing patient care11.
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Leadership, documentation12 and communication are an integral part of trauma team
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success in major trauma resuscitation13. As a matter of course, the assessment and
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resuscitation of trauma patients at the study site is initially managed by emergency
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physicians. A senior nurse with resuscitation and training experience is allocated to
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each emergency department (ED) resuscitation room for the shift, and others attend
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and assist when required for a resuscitation, such as a major trauma. When a trauma
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call is activated, nurses are allocated to either the airway, breathing and circulation or
5 Page 4 of 18
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scribe roles. The resuscitation nurse was traditionally assigned the role of airway
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nurse. The airway nurse’s ability to maintain a comprehensive overview of their
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patients’ treatment and understanding of the definitive care plan, which they were
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expected to contribute to, as well as provide a comprehensive clinical handover to
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other clinicians can be difficult when focussed on particular tasks, such as airway
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management. Anecdotally, this lack of awareness of the patient process and plan
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created frustration among the nursing staff and could potentially inhibit patient care.
90
There was also no formal nursing team leader, which would delegate nursing roles
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and interventions in conjunction with the medical team leader.
92 93
Nurses are integral to trauma and resuscitation in the ED, and their contribution
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through quality clinical care in addition to effective communication, leadership, and
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team work ultimately enables quality patient outcomes14. However, literature
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evaluating the role allocation of nurses in trauma resuscitation and their effect on
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team performance is scarce. We hypothesised that allocating the most senior nurse as
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scribe and enhancing the role to include nursing leadership would improve nursing
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documentation, awareness of the patient’s clinical condition, ongoing patient
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management plans by facilitating prioritisation of nursing intervention and overall
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effective communication among team members. This role would see the medical
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trauma team leader and the nurse team leader work collaboratively in major trauma
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resuscitations.
104 105
AIM
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To assess the effect of allocating the most senior nurse as nurse team leader and scribe
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on effective communication, documentation, and perceptions of leadership in major
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trauma resuscitations.
109 110
METHODS
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A pre—post test design was used employing survey and audit methods. The study
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was conducted from March 2011 (pre-test), implementation (April – May 2011) to
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July 2011(post-test) at [Anonymised] a major trauma centre in [Anonymised],
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Australia. The [Anonymised] is the fourth busiest in the [Anonymised] and treated
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66507 patients in 2012. Over 1700 trauma patients presented in 2012, and of those
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over 350 were severely injured (injury severity score > 12) are admitted annually.
117 118
Data Collection Tools
119
Two tools were developed to test the hypothesis. A staff survey to determine
120
perceptions of leadership, effective communication and awareness of patient plan and
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a medical record audit form to determine the quality of the documentation.
122 123
The survey was developed using an expert group of four trauma and emergency
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resuscitation nurse clinicians and nurse academics. Survey questions were developed
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using the expert group consensus and were based on key positive and negative
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leadership concepts described in the literature, such as decision making, instruction,
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effective communication, intimidation, knowledge, and initiation of treatment10,15.
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These themes were identified from a formal literature review around nursing
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leadership and resuscitation14. The survey had ten questions using a variety of
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response formats: likert scale, checklist, and open-ended questioning (Table 1). For
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example;
132 133
“When you are the resuscitation nurse in a major trauma how aware are you of the
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injuries?”
135 136
Participants were able to provide written comment after each question. The survey
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was piloted by five clinicians for feedback on usability and content validity. Survey
138
results were compared pre and post implementation of the nurse team leader role.
139 140
Patient medical records underwent a retrospective documentation audit using a
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modification of a validated tool to compare completeness and detail of nursing
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documentation12. The audit tool enabled data extraction from three aspects of the
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trauma resuscitation episode of care. These were; 1) initial resuscitation assessment
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and patient demographics (such as mechanism of injury, vital signs, demographics
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and medical history), 2) resuscitation treatment (e.g. medication/intravenous fluid
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administration, investigations and interventions) and 3) the clinical nursing entry (that
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describes a summary of the patient assessment, patient progress and management
148
plan). All these components were reviewed as being complete or incomplete,
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including the nursing entry which was assessed for clarification of the patient
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assessment, progress and plan which are integral components of trauma patient care
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documentation.
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Participants
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Following ethics approval, all emergency nursing staff working at resuscitation room
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level were invited to participate in the study (pre n=57, post n=52). The survey was
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limited to nursing staff as this was a nursing role change, nurses are the consistent
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workforce in the ED, and the intent of the role change was to improve nursing
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communication.
159 160
Data Collection Process
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A survey was placed in their staff pigeonhole/mailbox before the implementation of
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the new role. The pre-survey was available for staff completion two months before the
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trauma nurse leader role was implemented. An introduction letter explained the
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purpose, anonymity, voluntary nature and dissemination intent of the research. A
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survey box was placed in the ED staffroom for completed survey forms. The surveys
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were collected regularly during the two month period.
167 168
The medical records for audit were identified using the [Anonymised] trauma
169
database. Trauma data is collected prospectively on all trauma patient presentations
170
and includes demographics, length of stay, injury severity score (ISS) and
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complications. This database enabled the identification of patients that were classified
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as a major trauma (ISS >12) and received a trauma team activation.
173 174
Role implementation
175
A process of engagement and consultation with the ED and trauma service nursing
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and medical consultants resulted in the formalisation of a nurse trauma team leader
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role. The senior nurse role became scribe and nurse team leader for trauma and
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resuscitation. The scribe component of the role ensured the nurse leader had a
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comprehensive, real time overview of patient care. The leadership component of the
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role then enabled the nurse leader to work in conjunction with the medical team
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leader, prioritise nursing interventions and facilitate effective team communication.
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While the medical team leader has overarching responsibility, the medical and nurse
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team leaders work collaboratively. Education was provided to nurses working at
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resuscitation level over a two month period on the roles and responsibilities of being a
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nurse team leader. This education included leadership skills, clinical care, conflict
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management, and graded assertiveness by formal and informal education methods,
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regular in-service and mentoring during a resuscitation. Prior to the implementation of
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the new role, resuscitation nursing staff completed an in-service on the definition,
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purpose and responsibilities involved in the role. During the implementation, the
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trauma and emergency nurse consultants and educators mentored nurses in their new
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role by using a shadow strategy during a major trauma resuscitation to provide expert
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advice and guidance.
193 194
Data Analysis
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The data were obtained in a de-identified form and only aggregate data is reported.
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Data were entered into excel and imported into SPSS Version 20.016for analysis.
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Analysis of the survey results was restricted due to the small variable cell sizes. Due
198
to the confidential and non-identifiable nature of data, it is not known if the same
199
participants completed the pre and post questionnaires, although it is likely that a
200
proportion did. For this reason it has been assumed that data samples are matched,
201
dependent data and a pre-post analysis was conducted. All binary (yes/no) data were
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analysed using McNemar’s chi square analysis. Ordinal data were analysed using the
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Wilcoxon signed-rank test. Medical Record documentation audits used independent
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samples and were analysed using Chi-square analysis.
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RESULTS
208 209
Survey
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In this study, 31 (55%) nurses completed the pre-test survey and 24 the post-test
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survey (48%). Communication trended towards improvement with the nursing team
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leader role implementation. There were 73% (pre) compared to 80% (post) felt that
213
overall communication was good to excellent, and the incidence of very good to
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excellent nursing communication increased from 58.6% (pre) to 68.2% (post). All
215
respondents post-test stated they had a good to excellent understanding of their role,
216
compared to 93.2% prior. Post intervention there was a decrease in ‘intimidating
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personality’ as a negative aspect of communication and leadership in major trauma
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resuscitation, from 58.1% (n = 18) to 12.5% (n = 3) and a decrease in ’no team
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member identification’ (from 58% to 42%).
220 221
Nursing leadership improved post implementation of the nurse team leader role. There
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was a 6.8% decrease in respondents who felt nursing leadership was poor/average and
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a 6.7% increase in the proportion of those who felt nursing leadership was good to
224
excellent. One participant recorded on their survey responses when asked how aware
225
they were of the patients’ injuries and plan: “In the leadership and/or scribe role I am
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very aware. As the airway nurse - variably - as you can get tunnel vision in the role
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or[only] just hear due to softly spoken voices or just general noise”. Another nurse
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commented that knowledge of the patient’s injury and condition improved with a
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nurse leader in charge of the trauma and resuscitation:“The primary nurse knows
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about the patient’s injuries and treatment plan properly”
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Prior to the nurse team leader role, respondents noted that communication was poor
233
and problematic. As one respondent noted:“Often there is simply too much noise and
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therefore poor communication and interaction. We all need clear direction on any
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given resus[citation] and effective communication” Participant A
236 237
Medical Records Audit
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There was an improvement in the recording of the first blood pressure being
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performed manually rather than with an automated device (χ²(1) = 6.765, p = 0.009).
240
The clinical nursing entry that describes a summary of the patient assessment, patient
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progress and plan was improved in terms of the accuracy of injuries (χ²(1) = 5.00, p =
242
0.025). No other significant changes were seen (Table 2).
243 244
Discussion
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The results of this study reinforce the evidence that nurses contribute to the effective
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communication and functioning of the trauma team. The introduction of a nurse team
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leader improved perceptions of nursing leadership in our ED. The leadership role
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required the nurse to oversee the trauma resuscitation in conjunction with the medical
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team leader. The “overseeing” concept enables the leader to compile a structured team
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which is known to work more harmoniously and perform the tasks of resuscitation
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more effectively.15 Leadership along with competence, communication and the status
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of the patient influence the culture of the trauma team10. Wurster et al17 suggests that
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advanced autonomous trauma nurses who are able to identify and resolve issues in the 12 Page 11 of 18
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trauma room improve team performance for trauma patients, enhance group cohesion,
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communication and documentation. The development of trauma nurse team leaders
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should be encouraged within trauma team training programs.
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The allocation of an experienced emergency nurse to this role is supported by
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Cudmore18 who reports that nurses working with trauma patients are most confident
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when they have more than two years trauma experience. Experience, confidence and
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knowledge within the resuscitation team environment are assisted by targeted team
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training and contribute to the development of leadership skills19. Capella13
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demonstrated that trauma team training significantly improves team performance and
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efficacy of patient care, although the contribution of the nurse was not examined
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independently. Team dynamics are subject to constant change in relation to human
265
factors such as personalities, experience and communication skills which impedes
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robust investigation into individual roles. Further, as is typical in any ED, a wide
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variety of patient presentations and injuries can affect a team’s performance which
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results in study design complexities20
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Verbal and written communication directly relate to patient outcomes21. The main
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issues around trauma care communication processes include a lack of clarity during
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clinical handovers including missing or inaccurate information given and poorly
272
documented care12. The implementation of a nurse team leader improved verbal
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communication in major trauma resuscitations in our ED and to a lesser degree
274
written communication. This study could be explained by the small sample size, the
275
pre-existing high quality of documentation, patient stability or a lack of resources
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equating to time constraints and the nurse prioritising verbal communication and
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patient care above written documentation, all of which are known barriers22. An
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increase in nurse patient ratios may go some way to address this23, although the onus
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remains on nurses to be proactive in ascertaining and communicating information
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regarding patient care24. For example, these findings are applicable to other
281
resuscitation contexts, for example a rapid response nurse. A rapid response nurse is a
282
member of a team who responds to deteriorating patients outside of the ED or ICU
283
environment has been shown to be effective in leadership, improving team dynamics, the
284
identification of patient deterioration, improving patient outcomes and communication25,26.
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The trauma leadership role could be further enhanced by extending the leadership role
286
past the ED to the inpatient setting. Fecura27 demonstrated that trauma nurse
287
coordinators in the military setting showed improved performance in trauma care by
288
improving patient care processes, policy refinements, and clinical practice guidelines
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implementation. The military setting and trauma case management model is known to
290
reduce inpatient complication rates while improving communication28.
291
This study was limited by the small sample size necessitated by a single site and
292
specific population. Further research is required to evaluate this role with the medical
293
team members and its effect on patient outcomes.
294 295
Conclusion
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Trauma nurse team leaders improve leadership and communication in trauma
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resuscitations. The knowledge, trauma experience and assertiveness of senior nurses
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contribute to the effective functioning of the trauma team. The development of trauma
299
nurse leaders should be encouraged within trauma team training programs.
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Table 1: Perceptions of leadership and communication in major trauma survey results¹
Question
Pre (n = 31)
Post (n = 24)
n (%)
n (%)
(n = 31)
(n = 24)
2 (6.5)
0 (0)
29 (93.5)
24 (100.0)
(n = 29)
(n = 21)
Poor/average
13 (44.8)
8 (38.1)
Good/very good/excellent
16 (55.2)
13 (61.9)
I understand what my role is during a major trauma resuscitation? Poor/average Good/very good/excellent
How well do you think nurses lead an after hours major trauma resuscitation in the traumas you have been involved in?
16 Page 15 of 18
(n = 31)
(n = 23)
Never/rarely/sometimes
2 (6.5)
0 (0.0)
Most of the time/Always
29 (93.5)
23 (100.0)
(n = 30)
(n = 20)
Poor/average
8 (26.7)
4 (20.0)
Good/very good/excellent
22 (73.3)
16 (80.0)
Intimidating personality
18 (58.1)
3 (12.5)
No identification team member
18 (58.1)
10 (41.7)
Unclear instructions
16 (51.6)
19 (79.2)
No documentation
11 (35.5)
10 (41.7)
Language barrier
3 (9.7)
3 (12.5)
Workload
10 (32.3)
11 (45.8)
Absent verbal patient plan
19 (61.3)
17 (70.8)
Approachable personality
20 (64.5)
18 (75.0)
Clear instructions
23 (74.2)
18 (75.0)
Verbal patient plan
19 (61.3)
14 (58.3)
Audible instruction
20 (64.5)
17 (70.8)
Defined team leader
20 (64.5)
18 (75.0)
Identification of team members
16 (51.6)
10 (41.7)
Clear documentation
22 (71.0)
13 (54.2)
When you are the resuscitation nurse in a major trauma how aware are you of the injuries?
How do you rate the overall level of verbal communication regarding the patient management plan and progress between all members of the trauma team in a major trauma resuscitation?
Of the choices below what do you feel are negative aspects of communication that occur in a major trauma resuscitations you have been involved in?
Of the choices below what do you feel are positive aspects of communication in a major trauma resuscitation?
17 Page 16 of 18
(n = 29)
(n = 22)
0 (0)
0 (0)
1 (3.5)
2 (9.1)
Good
11 (37.9)
5 (22.7)
Very good
11 (37.9)
11 (50.0)
Excellent
6 (20.7)
4 (18.2)
How do you rate the overall level of communication between nursing staff in a after hours major trauma resuscitations you have been involved in? Poor Average
382 383 384 385
¹ Cell sizes were too small (n < 5) to perform McNemar’s Chi square or Wilcoxin singed-rank tests on the majority of items. No significant relationships were seen for those items containing larger cell sizes.
18 Page 17 of 18
386 387
Table 2: Documentation quality pre and post nurse leader role implementation Trauma Admission Sheet (answer of yes to the following:)
Pre n (%)¹ (n = 40)
Post n (%)¹ (n = 40)
Sig (p)
a) MOI
40 (100.0)
39 (97.5)
*
b) MOI specifics (eg height of fall, speed of MVC)
37 (92.5)
37 (92.5)
*
c) Ambulance treatment
37 (92.5)
33 (82.5)
*
d) Initial obs (complete)
36 (90.0)
37 (92.5)
*
e) Initial BP manual
8 (20.0)
19 (47.5)
.009
f) 15 minute obs per protocol for 1st hour
30 (78.9)
27 (69.2)
.331
g) 1st hourly temperature
18 (47.4)
22 (56.4)
.427
h) Patient details – name, age, DOB
40 (100.0)
38 (95.0)
*
i) Patient med history
36 (90.0)
33 (82.5)
*
a) Allergies
30 (90.9)
30 (93.8)
*
b) IV access identification
29 (87.9)
33 (97.1)
*
c) Medication charted
32 (100.0)
33 (100.0)
*
d) Fluids charted
28 (96.6)
26 (92.9)
*
e) Investigations documented
19 (59.4)
18 (52.9)
.599
f) Chart singed by MO
11 (33.3)
17 (50.0)
.167
a) MOI
36 (90.0)
37 (92.5)
*
b) Primary survey findings
34 (85.0)
33 (82.5)
.762
c) Injuries
15 (37.5)
25 (62.5)
.025
d) Investigations
34 (85.0)
31 (77.5)
.390
e) Interventions
33 (82.5)
36 (94.7)
*
f) Patient plan
34 (85.0)
30 (75.0)
.264
Resuscitation Flow Chart
Clinical Notes – Nursing Entry
388 389 390 391
¹ Percentages are based on numbers of responders * Cell sizes were too small (n < 5) to perform analyses on these items.
19 Page 18 of 18
S1755-599X(14)00030-5 http://dx.doi.org/doi:10.1016/j.ienj.2014.04.004 IENJ 347
To appear in:
International Emergency Nursing
Received date: Revised date: Accepted date:
11-9-2013 13-1-2014 30-4-2014
Please cite this article as: Alana Clements, Kate Curtis, Leanne Horvat, Ramon Z. Shaban, The effect of a nurse team leader on communication and leadership in major trauma resuscitations☆, International Emergency Nursing (2014), http://dx.doi.org/doi:10.1016/j.ienj.2014.04.004. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
1
Title: The effect of a nurse team leader on communication and leadership in major
2
trauma resuscitations
3
Authors
4
Alana Clements RN, MEmergNurs1,Kate Curtis RN, PhD1-4, Leanne Horvat RN
5
MN(NursPrac)5 and Ramon Z. Shaban6 RN, PhD,
6 7 8 9 10
AC, KC, and LH conceived and designed the study. AC, KC developed the study protocol, designed and tested the study instruments. AC, KC & LH supervised data collection. RS analysed the data All authors prepared and approved the manuscript
11 12
Author affiliations
13 14
1. Trauma Service, St George Hospital, NSW Australia
15
2. Sydney Nursing School, University of Sydney, Australia
16
3. The George Institute for Global Health
17
4. St George Clinical School, Faculty of Medicine, University of NSW
18
5. South Eastern Sydney Local Health District
19
6. Centre for Health Practice Innovation, School of Nursing and Midwifery,
20
Griffith Health Institute, Griffith University
21 22
Corresponding author
23
Alana Clements
24
Phone: 02 9947 9865 Fax: 02 9947 9879
25
Email: [email protected]
26 27
Acknowledgement
28 29 30
The authors acknowledge Kerri Holzhauser for her assistance with survey design and preliminary analyses and Pauline Calleja for sharing her trauma medical record audit.
31
Abstract
2 Page 1 of 18
32
Background: Effective assessment and resuscitation of trauma patients requires an
33
organised, multidisciplinary team. Literature evaluating leadership roles of nurses in
34
trauma resuscitation and their effect on team performance is scarce.
35 36
Aim: To assess the effect of allocating the most senior nurse as team leader of trauma
37
patient assessment and resuscitation on communication, documentation and
38
perceptions of leadership within an Australian emergency department.
39 40
Methods: The study design was a pre-post-test survey of emergency nursing staff
41
(working at resuscitation room level) perceptions of leadership, communication, and
42
documentation before and after the implementation of a nurse leader role. Patient
43
records were audited focusing on initial resuscitation assessment, treatment, and
44
nursing clinical entry. Descriptive statistical analyses were performed.
45 46
Results: Communication trended towards improvement. All (100%) respondents post-
47
test stated they had a good to excellent understanding of their role, compared to
48
93.2% pre-study. A decrease (58.1% to 12.5%) in ‘intimidating personality’ as a
49
negative aspect of communication. Nursing leadership had a 6.7% increase in the
50
proportion of those who reported nursing leadership to be good to excellent. Accuracy
51
of clinical documentation improved (p = 0.025).
52 53
Conclusion: Trauma nurse team leaders improve some aspects of communication and
54
leadership. Development of trauma nurse leaders should be encouraged within trauma
55
team training programs.
56
3 Page 2 of 18
57
Key words: Trauma; leadership; resuscitation; nursing; emergency; communication
58
4 Page 3 of 18
59
INTRODUCTION
60
Traumatic injury accounts for 11% of global mortality and is a leading cause of
61
disability1. Trauma affects society on a physical, psychological and economical level2,
62
and in Australia injuries are one of the most costly disease groups3.
63 64
Quality trauma care required an integrated and resourced trauma system. The aim of a
65
trauma system is to facilitate the timely treatment of severely injured patients where
66
resources are available for their optimal management and rehabilitation. Trauma
67
systems have significantly reduced trauma patient mortality in Australia4,5 and
68
internationally6,7.
69
Once the trauma patient has arrived at the trauma centre, in-hospital trauma systems,
70
such as trauma teams, are activated and facilitate systematic clinical assessment and
71
ongoing patient care8,9. Quality and effective initial assessment and resuscitation of
72
trauma patients [requires a multidisciplinary trauma team led by medical and nursing
73
staff10,11. Adopting a structured team-based approach to trauma care in resuscitation
74
allows for simultaneous inputs to address the need for rapid resuscitation, stabilisation
75
and to prioritise ongoing patient care11.
76
Leadership, documentation12 and communication are an integral part of trauma team
77
success in major trauma resuscitation13. As a matter of course, the assessment and
78
resuscitation of trauma patients at the study site is initially managed by emergency
79
physicians. A senior nurse with resuscitation and training experience is allocated to
80
each emergency department (ED) resuscitation room for the shift, and others attend
81
and assist when required for a resuscitation, such as a major trauma. When a trauma
82
call is activated, nurses are allocated to either the airway, breathing and circulation or
5 Page 4 of 18
83
scribe roles. The resuscitation nurse was traditionally assigned the role of airway
84
nurse. The airway nurse’s ability to maintain a comprehensive overview of their
85
patients’ treatment and understanding of the definitive care plan, which they were
86
expected to contribute to, as well as provide a comprehensive clinical handover to
87
other clinicians can be difficult when focussed on particular tasks, such as airway
88
management. Anecdotally, this lack of awareness of the patient process and plan
89
created frustration among the nursing staff and could potentially inhibit patient care.
90
There was also no formal nursing team leader, which would delegate nursing roles
91
and interventions in conjunction with the medical team leader.
92 93
Nurses are integral to trauma and resuscitation in the ED, and their contribution
94
through quality clinical care in addition to effective communication, leadership, and
95
team work ultimately enables quality patient outcomes14. However, literature
96
evaluating the role allocation of nurses in trauma resuscitation and their effect on
97
team performance is scarce. We hypothesised that allocating the most senior nurse as
98
scribe and enhancing the role to include nursing leadership would improve nursing
99
documentation, awareness of the patient’s clinical condition, ongoing patient
100
management plans by facilitating prioritisation of nursing intervention and overall
101
effective communication among team members. This role would see the medical
102
trauma team leader and the nurse team leader work collaboratively in major trauma
103
resuscitations.
104 105
AIM
6 Page 5 of 18
106
To assess the effect of allocating the most senior nurse as nurse team leader and scribe
107
on effective communication, documentation, and perceptions of leadership in major
108
trauma resuscitations.
109 110
METHODS
111
A pre—post test design was used employing survey and audit methods. The study
112
was conducted from March 2011 (pre-test), implementation (April – May 2011) to
113
July 2011(post-test) at [Anonymised] a major trauma centre in [Anonymised],
114
Australia. The [Anonymised] is the fourth busiest in the [Anonymised] and treated
115
66507 patients in 2012. Over 1700 trauma patients presented in 2012, and of those
116
over 350 were severely injured (injury severity score > 12) are admitted annually.
117 118
Data Collection Tools
119
Two tools were developed to test the hypothesis. A staff survey to determine
120
perceptions of leadership, effective communication and awareness of patient plan and
121
a medical record audit form to determine the quality of the documentation.
122 123
The survey was developed using an expert group of four trauma and emergency
124
resuscitation nurse clinicians and nurse academics. Survey questions were developed
125
using the expert group consensus and were based on key positive and negative
126
leadership concepts described in the literature, such as decision making, instruction,
127
effective communication, intimidation, knowledge, and initiation of treatment10,15.
128
These themes were identified from a formal literature review around nursing
129
leadership and resuscitation14. The survey had ten questions using a variety of
7 Page 6 of 18
130
response formats: likert scale, checklist, and open-ended questioning (Table 1). For
131
example;
132 133
“When you are the resuscitation nurse in a major trauma how aware are you of the
134
injuries?”
135 136
Participants were able to provide written comment after each question. The survey
137
was piloted by five clinicians for feedback on usability and content validity. Survey
138
results were compared pre and post implementation of the nurse team leader role.
139 140
Patient medical records underwent a retrospective documentation audit using a
141
modification of a validated tool to compare completeness and detail of nursing
142
documentation12. The audit tool enabled data extraction from three aspects of the
143
trauma resuscitation episode of care. These were; 1) initial resuscitation assessment
144
and patient demographics (such as mechanism of injury, vital signs, demographics
145
and medical history), 2) resuscitation treatment (e.g. medication/intravenous fluid
146
administration, investigations and interventions) and 3) the clinical nursing entry (that
147
describes a summary of the patient assessment, patient progress and management
148
plan). All these components were reviewed as being complete or incomplete,
149
including the nursing entry which was assessed for clarification of the patient
150
assessment, progress and plan which are integral components of trauma patient care
151
documentation.
152 153
Participants
8 Page 7 of 18
154
Following ethics approval, all emergency nursing staff working at resuscitation room
155
level were invited to participate in the study (pre n=57, post n=52). The survey was
156
limited to nursing staff as this was a nursing role change, nurses are the consistent
157
workforce in the ED, and the intent of the role change was to improve nursing
158
communication.
159 160
Data Collection Process
161
A survey was placed in their staff pigeonhole/mailbox before the implementation of
162
the new role. The pre-survey was available for staff completion two months before the
163
trauma nurse leader role was implemented. An introduction letter explained the
164
purpose, anonymity, voluntary nature and dissemination intent of the research. A
165
survey box was placed in the ED staffroom for completed survey forms. The surveys
166
were collected regularly during the two month period.
167 168
The medical records for audit were identified using the [Anonymised] trauma
169
database. Trauma data is collected prospectively on all trauma patient presentations
170
and includes demographics, length of stay, injury severity score (ISS) and
171
complications. This database enabled the identification of patients that were classified
172
as a major trauma (ISS >12) and received a trauma team activation.
173 174
Role implementation
175
A process of engagement and consultation with the ED and trauma service nursing
176
and medical consultants resulted in the formalisation of a nurse trauma team leader
177
role. The senior nurse role became scribe and nurse team leader for trauma and
178
resuscitation. The scribe component of the role ensured the nurse leader had a
9 Page 8 of 18
179
comprehensive, real time overview of patient care. The leadership component of the
180
role then enabled the nurse leader to work in conjunction with the medical team
181
leader, prioritise nursing interventions and facilitate effective team communication.
182
While the medical team leader has overarching responsibility, the medical and nurse
183
team leaders work collaboratively. Education was provided to nurses working at
184
resuscitation level over a two month period on the roles and responsibilities of being a
185
nurse team leader. This education included leadership skills, clinical care, conflict
186
management, and graded assertiveness by formal and informal education methods,
187
regular in-service and mentoring during a resuscitation. Prior to the implementation of
188
the new role, resuscitation nursing staff completed an in-service on the definition,
189
purpose and responsibilities involved in the role. During the implementation, the
190
trauma and emergency nurse consultants and educators mentored nurses in their new
191
role by using a shadow strategy during a major trauma resuscitation to provide expert
192
advice and guidance.
193 194
Data Analysis
195
The data were obtained in a de-identified form and only aggregate data is reported.
196
Data were entered into excel and imported into SPSS Version 20.016for analysis.
197
Analysis of the survey results was restricted due to the small variable cell sizes. Due
198
to the confidential and non-identifiable nature of data, it is not known if the same
199
participants completed the pre and post questionnaires, although it is likely that a
200
proportion did. For this reason it has been assumed that data samples are matched,
201
dependent data and a pre-post analysis was conducted. All binary (yes/no) data were
202
analysed using McNemar’s chi square analysis. Ordinal data were analysed using the
203
Wilcoxon signed-rank test. Medical Record documentation audits used independent
10 Page 9 of 18
204
samples and were analysed using Chi-square analysis.
205 206 207
RESULTS
208 209
Survey
210
In this study, 31 (55%) nurses completed the pre-test survey and 24 the post-test
211
survey (48%). Communication trended towards improvement with the nursing team
212
leader role implementation. There were 73% (pre) compared to 80% (post) felt that
213
overall communication was good to excellent, and the incidence of very good to
214
excellent nursing communication increased from 58.6% (pre) to 68.2% (post). All
215
respondents post-test stated they had a good to excellent understanding of their role,
216
compared to 93.2% prior. Post intervention there was a decrease in ‘intimidating
217
personality’ as a negative aspect of communication and leadership in major trauma
218
resuscitation, from 58.1% (n = 18) to 12.5% (n = 3) and a decrease in ’no team
219
member identification’ (from 58% to 42%).
220 221
Nursing leadership improved post implementation of the nurse team leader role. There
222
was a 6.8% decrease in respondents who felt nursing leadership was poor/average and
223
a 6.7% increase in the proportion of those who felt nursing leadership was good to
224
excellent. One participant recorded on their survey responses when asked how aware
225
they were of the patients’ injuries and plan: “In the leadership and/or scribe role I am
226
very aware. As the airway nurse - variably - as you can get tunnel vision in the role
227
or[only] just hear due to softly spoken voices or just general noise”. Another nurse
228
commented that knowledge of the patient’s injury and condition improved with a
11 Page 10 of 18
229
nurse leader in charge of the trauma and resuscitation:“The primary nurse knows
230
about the patient’s injuries and treatment plan properly”
231 232
Prior to the nurse team leader role, respondents noted that communication was poor
233
and problematic. As one respondent noted:“Often there is simply too much noise and
234
therefore poor communication and interaction. We all need clear direction on any
235
given resus[citation] and effective communication” Participant A
236 237
Medical Records Audit
238
There was an improvement in the recording of the first blood pressure being
239
performed manually rather than with an automated device (χ²(1) = 6.765, p = 0.009).
240
The clinical nursing entry that describes a summary of the patient assessment, patient
241
progress and plan was improved in terms of the accuracy of injuries (χ²(1) = 5.00, p =
242
0.025). No other significant changes were seen (Table 2).
243 244
Discussion
245
The results of this study reinforce the evidence that nurses contribute to the effective
246
communication and functioning of the trauma team. The introduction of a nurse team
247
leader improved perceptions of nursing leadership in our ED. The leadership role
248
required the nurse to oversee the trauma resuscitation in conjunction with the medical
249
team leader. The “overseeing” concept enables the leader to compile a structured team
250
which is known to work more harmoniously and perform the tasks of resuscitation
251
more effectively.15 Leadership along with competence, communication and the status
252
of the patient influence the culture of the trauma team10. Wurster et al17 suggests that
253
advanced autonomous trauma nurses who are able to identify and resolve issues in the 12 Page 11 of 18
254
trauma room improve team performance for trauma patients, enhance group cohesion,
255
communication and documentation. The development of trauma nurse team leaders
256
should be encouraged within trauma team training programs.
257
The allocation of an experienced emergency nurse to this role is supported by
258
Cudmore18 who reports that nurses working with trauma patients are most confident
259
when they have more than two years trauma experience. Experience, confidence and
260
knowledge within the resuscitation team environment are assisted by targeted team
261
training and contribute to the development of leadership skills19. Capella13
262
demonstrated that trauma team training significantly improves team performance and
263
efficacy of patient care, although the contribution of the nurse was not examined
264
independently. Team dynamics are subject to constant change in relation to human
265
factors such as personalities, experience and communication skills which impedes
266
robust investigation into individual roles. Further, as is typical in any ED, a wide
267
variety of patient presentations and injuries can affect a team’s performance which
268
results in study design complexities20
269
Verbal and written communication directly relate to patient outcomes21. The main
270
issues around trauma care communication processes include a lack of clarity during
271
clinical handovers including missing or inaccurate information given and poorly
272
documented care12. The implementation of a nurse team leader improved verbal
273
communication in major trauma resuscitations in our ED and to a lesser degree
274
written communication. This study could be explained by the small sample size, the
275
pre-existing high quality of documentation, patient stability or a lack of resources
276
equating to time constraints and the nurse prioritising verbal communication and
277
patient care above written documentation, all of which are known barriers22. An
13 Page 12 of 18
278
increase in nurse patient ratios may go some way to address this23, although the onus
279
remains on nurses to be proactive in ascertaining and communicating information
280
regarding patient care24. For example, these findings are applicable to other
281
resuscitation contexts, for example a rapid response nurse. A rapid response nurse is a
282
member of a team who responds to deteriorating patients outside of the ED or ICU
283
environment has been shown to be effective in leadership, improving team dynamics, the
284
identification of patient deterioration, improving patient outcomes and communication25,26.
285
The trauma leadership role could be further enhanced by extending the leadership role
286
past the ED to the inpatient setting. Fecura27 demonstrated that trauma nurse
287
coordinators in the military setting showed improved performance in trauma care by
288
improving patient care processes, policy refinements, and clinical practice guidelines
289
implementation. The military setting and trauma case management model is known to
290
reduce inpatient complication rates while improving communication28.
291
This study was limited by the small sample size necessitated by a single site and
292
specific population. Further research is required to evaluate this role with the medical
293
team members and its effect on patient outcomes.
294 295
Conclusion
296
Trauma nurse team leaders improve leadership and communication in trauma
297
resuscitations. The knowledge, trauma experience and assertiveness of senior nurses
298
contribute to the effective functioning of the trauma team. The development of trauma
299
nurse leaders should be encouraged within trauma team training programs.
14 Page 13 of 18
300 301 302 303 304 305 306 307 308 309 310 311 312 313 314 315 316 317 318 319 320 321 322 323 324 325 326 327 328 329 330 331 332 333 334 335 336 337 338 339 340 341 342 343 344 345 346 347 348 349
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Mahoney J. Leadership skills for the 21st century. Journal of Nursing Management. 2008;9(5):269-271. Yun S, Faraj S, Sims Jr HP. Contingent Leadership and Effectiveness of Trauma Resuscitation Teams. Journal of Applied Psychology; Journal of Applied Psychology. 2005;90(6):1288. Hindle D, Braithwaite, J., Iedema, R. Patient safety: a review of key international enquiries. Sydney2005 Calleja P, Aitken LM, Cooke ML. Barriers to information transfer for multitrauma patients upon discharge from the Emergency Department in a tertiary level hospital. Queensland State-wide Trauma Symposium 2010 Royal Brisbane & Women’s Hospital, Brisbane, Queensland. 2010. Duffield C, Diers D, O'Brien-Pallas L, et al. Nursing staffing, nursing workload, the work environment and patient outcomes. Applied Nursing Research. 2011;24(4):244-255. Curtis K, Tzannes A, Rudge T. How to talk to Doctors - A guide for effective communication. International Nursing Review. 2011;58(1):13-20. Gilligan P, Bhatarcharjee C, Knight G, et al. To lead or not to lead? Prospective controlled study of emergency nurses' provision of advanced life support team leadership. Emergency Medicine Journal. 2005;22(9):628-632. Jolley J, Bendyk H, Holaday B, Lombardozzi KA, Harmon C. Rapid response teams: do they make a difference? Dimensions of Critical Care Nursing. 2007;26(6):253-260. Fecura Jr SE, Martin CM, Martin KD, Bolenbaucher RM, Cotner-Pouncy T. Nurses' Role in the Joint Theater Trauma System. Journal of trauma nursing. 2008;15(4):170-173. Curtis K, Zou Y, Morris R, Black D. Trauma case management: Improving patient outcomes. Injury. 2006;37(7):626-632.
Table 1: Perceptions of leadership and communication in major trauma survey results¹
Question
Pre (n = 31)
Post (n = 24)
n (%)
n (%)
(n = 31)
(n = 24)
2 (6.5)
0 (0)
29 (93.5)
24 (100.0)
(n = 29)
(n = 21)
Poor/average
13 (44.8)
8 (38.1)
Good/very good/excellent
16 (55.2)
13 (61.9)
I understand what my role is during a major trauma resuscitation? Poor/average Good/very good/excellent
How well do you think nurses lead an after hours major trauma resuscitation in the traumas you have been involved in?
16 Page 15 of 18
(n = 31)
(n = 23)
Never/rarely/sometimes
2 (6.5)
0 (0.0)
Most of the time/Always
29 (93.5)
23 (100.0)
(n = 30)
(n = 20)
Poor/average
8 (26.7)
4 (20.0)
Good/very good/excellent
22 (73.3)
16 (80.0)
Intimidating personality
18 (58.1)
3 (12.5)
No identification team member
18 (58.1)
10 (41.7)
Unclear instructions
16 (51.6)
19 (79.2)
No documentation
11 (35.5)
10 (41.7)
Language barrier
3 (9.7)
3 (12.5)
Workload
10 (32.3)
11 (45.8)
Absent verbal patient plan
19 (61.3)
17 (70.8)
Approachable personality
20 (64.5)
18 (75.0)
Clear instructions
23 (74.2)
18 (75.0)
Verbal patient plan
19 (61.3)
14 (58.3)
Audible instruction
20 (64.5)
17 (70.8)
Defined team leader
20 (64.5)
18 (75.0)
Identification of team members
16 (51.6)
10 (41.7)
Clear documentation
22 (71.0)
13 (54.2)
When you are the resuscitation nurse in a major trauma how aware are you of the injuries?
How do you rate the overall level of verbal communication regarding the patient management plan and progress between all members of the trauma team in a major trauma resuscitation?
Of the choices below what do you feel are negative aspects of communication that occur in a major trauma resuscitations you have been involved in?
Of the choices below what do you feel are positive aspects of communication in a major trauma resuscitation?
17 Page 16 of 18
(n = 29)
(n = 22)
0 (0)
0 (0)
1 (3.5)
2 (9.1)
Good
11 (37.9)
5 (22.7)
Very good
11 (37.9)
11 (50.0)
Excellent
6 (20.7)
4 (18.2)
How do you rate the overall level of communication between nursing staff in a after hours major trauma resuscitations you have been involved in? Poor Average
382 383 384 385
¹ Cell sizes were too small (n < 5) to perform McNemar’s Chi square or Wilcoxin singed-rank tests on the majority of items. No significant relationships were seen for those items containing larger cell sizes.
18 Page 17 of 18
386 387
Table 2: Documentation quality pre and post nurse leader role implementation Trauma Admission Sheet (answer of yes to the following:)
Pre n (%)¹ (n = 40)
Post n (%)¹ (n = 40)
Sig (p)
a) MOI
40 (100.0)
39 (97.5)
*
b) MOI specifics (eg height of fall, speed of MVC)
37 (92.5)
37 (92.5)
*
c) Ambulance treatment
37 (92.5)
33 (82.5)
*
d) Initial obs (complete)
36 (90.0)
37 (92.5)
*
e) Initial BP manual
8 (20.0)
19 (47.5)
.009
f) 15 minute obs per protocol for 1st hour
30 (78.9)
27 (69.2)
.331
g) 1st hourly temperature
18 (47.4)
22 (56.4)
.427
h) Patient details – name, age, DOB
40 (100.0)
38 (95.0)
*
i) Patient med history
36 (90.0)
33 (82.5)
*
a) Allergies
30 (90.9)
30 (93.8)
*
b) IV access identification
29 (87.9)
33 (97.1)
*
c) Medication charted
32 (100.0)
33 (100.0)
*
d) Fluids charted
28 (96.6)
26 (92.9)
*
e) Investigations documented
19 (59.4)
18 (52.9)
.599
f) Chart singed by MO
11 (33.3)
17 (50.0)
.167
a) MOI
36 (90.0)
37 (92.5)
*
b) Primary survey findings
34 (85.0)
33 (82.5)
.762
c) Injuries
15 (37.5)
25 (62.5)
.025
d) Investigations
34 (85.0)
31 (77.5)
.390
e) Interventions
33 (82.5)
36 (94.7)
*
f) Patient plan
34 (85.0)
30 (75.0)
.264
Resuscitation Flow Chart
Clinical Notes – Nursing Entry
388 389 390 391
¹ Percentages are based on numbers of responders * Cell sizes were too small (n < 5) to perform analyses on these items.
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