Negotiated knowledge positions : communication in trauma teams

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