the impact of simulation on healthcare team training.

Australasian Emergency Care 22 (2019) 1–7

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Australasian Emergency Care

j o u r n a l h o m e p a g e : w w w . e l s e v i e r . c o m / l o c a t e / a u e c

esearch paper

he impact of simulated multidisciplinary Trauma Team Training on eam performance: A qualitative study

argaret Murphya,b,∗, Andrea McCloughena, Kate Curtisa,c

Sydney Nursing School, University of Sydney, Australia Emergency Department, Westmead Hospital, Australia Emergency Department, Illawarra Shoalhaven, Australia

r t i c l e i n f o

eywords: ulti-professional training

rauma care atient outcome imulation eam training eamwork skills

a b s t r a c t

Introduction: Effective teamwork is imperative in the emergency trauma setting as trauma teams work in the uncertain and complex context of resuscitating critically injured patients. Poorly performing teams have the potential to contribute to adverse events. Efforts to improve teamwork in trauma include simulation-based multidisciplinary team training with a non-technical skills (NTS) focus. However, there is a lack of evidence linking teamwork training programs with the uptake of NTS in real life trauma resus- citations. The aim of this study was to understand trauma team members’ perspectives and experiences of teamwork in real world trauma resuscitations at a Level 1 Trauma Hospital, following completion of a simulated multidisciplinary Trauma Team Training (TTT) program. Method: Semi-structured interviews were used to explore trauma team members’ experiences and per- spectives of the impact of TTT on the team’s performance. Trauma team members who had completed TTT were invited to participate in the study. Fifteen participants from various disciplines (nursing, med- ical, allied health) and specialities (emergency, intensive care, trauma, anaesthetics, allied health) were interviewed. Qualitative data were thematically analysed. Results: The overarching finding was that teamwork was the essential component to facilitate a group of skilled experts to collectively perform at an optimum level in emergency trauma care. Four main themes were developed: Leader-follower synergy promotes trauma teamwork; Instability and inconsistency threaten trauma teamwork; Clear communication enhances trauma team decision-making and Team training improves trauma team performance. Conclusion: A quickly constructed specialty team with unstable membership, will not transform nat- urally into an expert trauma team. The creation and maintenance of effective trauma teams requires training strategies such as multidisciplinary simulation that target team training and team interaction.

Specifically, training should focus on developing non-technical skills for resuscitation trauma teams that have to form quickly and function effectively, often having never met before. As participants were over- whelmingly female, the data generated by this study are not necessarily generalisable to male members of trauma teams.

Crown Copyright © 2018 Published by Elsevier Ltd on behalf of College of Emergency Nursing Australasia. All rights reserved.

. Introduction

Organising doctors, nurses, and allied health staff to provide

oordinated care for patients with complex needs requires effec- ive teamwork. This is particularly true in emergency trauma ettings where trauma teams are mobilised quickly and comprise

∗ Corresponding author at: Emergency Department, Westmead Hospital Hawkes- ury Road, Westmead, NSW 2145, Australia.

E-mail address: Margaret.Murphy@health.nsw.gov.au (M. Murphy).

ttps://doi.org/10.1016/j.auec.2018.11.003 588-994X/Crown Copyright © 2018 Published by Elsevier Ltd on behalf of College of Em

of staff from numerous specialties. This team approach allows for the simultaneous completion of time critical tasks involved in the assessment and resuscitation of critically injured patients [1]. Whilst an organised and functional team response has been shown to improve trauma care [2], dysfunctional teams contribute to adverse events and poor patient outcomes [3,4]. These failures are attributed to human factors or deficits in non-technical skills of

the teams [5].

Teamwork can be enhanced through teaching multidisciplinary team members the essential elements of non-technical teamwork skills [6]. Although standard resuscitation courses acknowledge

ergency Nursing Australasia. All rights reserved.

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review), coded data were used to form six candidate themes. All three researchers subsequently reviewed and refined the candidate themes and developed four core themes (Table 2).

Table 1 Interview Guide (questions and prompts).

1. Tell me about what you learnt in trauma team training - Prompt to encourage illustrative examples - Prompt to explore understanding

2. Explain what is has been like for you managing major trauma since trauma team training - Prompt to encourage illustrative examples from recent experience - Prompt to explore understanding from recent experience

3. Since completing the multidisciplinary trauma team training has your practice changed in any way? - Prompt to encourage illustrative examples from recent experience - Prompt to explore what hindered or helped practice

4. Tell me about any changes in trauma management that you have noticed since multidisciplinary trauma team training was introduced - Prompt to encourage illustrative examples from recent experience - Prompt to explore understanding from recent experience - Prompt to explore what hindered or helped practice

5. What factors do you think are influencing the use of teamwork skills taught in trauma team training? - Prompt to encourage illustrative examples from recent experience - Prompt to explore understanding from recent experience - Prompt to explore what hindered or helped practice

6. What are your overall impressions of your experience as a member of the

M. Murphy et al. / Australasi

on-technical skills, no structured approach or acronym exists that oncisely teaches non-technical skills [1]. The composition of the rauma team is generally directed by organisational history and ocal culture. Although trauma team training is associated with arly and effective interventions in trauma care [1,7], it is difficult to ink the influence of trauma team work to these outcomes [2,8]; in articular, the key factors that influence team performance. Under- tanding team members’ perspectives of what contributes to highly eliable, multidisciplinary trauma teams is important to ensuring hat the team progresses along the optimal course for patient safety.

Team member experiences and perspectives are fundamental o informing future multidisciplinary emergency trauma resusci- ation team training programs.

The creation and maintenance of effective trauma resuscitation eams requires the interplay of training strategies that target team raining and team interaction.

The aim of this study was to understand trauma team members’ erspectives and experiences of teamwork in real world trauma esuscitations at a Level 1 Trauma Hospital, following completion f a simulated multidisciplinary TTT program. A level 1 trauma ervice is a specialised trauma centre, which is staffed and equipped o manage severely injured patients. The research questions that uided the study were:

1) What are trauma team members’ experiences of teamwork fol- lowing a simulated multidisciplinary TTT program?

2) What are trauma team members’ perspectives on team perfor- mance following simulated multidisciplinary TTT?

. Methods

This study forms the qualitative phase of a larger embedded xperimental mixed methods study that was conducted in 2016 t a Level 1 trauma centre in Sydney, Australia. The quantitative rm of the study demonstrated that the implementation of TTT as associated with a reduction in time to critical operation for ajor trauma patients [2]. There were 2389 major trauma patients

dmitted to the hospital during the study, 1116 in the four years receding trauma team training (the PRE-group) and 1273 in the ubsequent 4 years (the POST group). There was a reduction in time o critical operation, from 2.63 h (IQR 1.23–5.12) in the PRE-group o 0.55 h (IQR 0.22–1.27) in the POST-group, p < 0.001 [2]. This qual- tative phase seeks to explore experiences and perspectives of team

ork during trauma resuscitations, by staff who had participated n the simulated multidisciplinary TTT, to inform whether team raining may contribute to team performance and hence service elivery. Semi-structured interviews were used to explore trauma eam members’ experiences and perspectives of team work, subse- uent to TTT. The interviews consisted of a blend of open-ended and ocused questions, with accompanying prompts that encouraged articipants to draw on their experience of working as a trauma eam member after their involvement in TTT. The TTT program is escribed elsewhere [2].

.1. Study participants

Members of the study site trauma team who had completed he multidisciplinary simulated TTT from 2010–2013 were invited o participate in the study. Twenty-eight staff members indicated heir willingness to participate in a follow up interview when com- leting a questionnaire during the quantitative phase of the larger

tudy.

Approval to conduct the study was granted from the local uman Research Ethics Committee; Reference No. 4199. All par-

icipants gave written and verbal consent. Selection of participants

ergency Care 22 (2019) 1–7

took into account their discipline (nursing, medical, allied health) and speciality (emergency, intensive care, trauma, anaesthetics, allied health) with the aim of fair representation of the trauma team. To ensure that enough information was gained to allow rep- resentative conclusions to be drawn, recruitment of participants to interview continued until data saturation was reached, that is until no further information significantly contributed to the data already collected [9,10]. Fifteen participants were interviewed.

2.2. Data collection

Face-to-face interviews in a meeting room at the study site occurred at times suited to participants and took on average 42 min to complete. The interviews focused on participants’ perspectives of the current performance of the trauma team and encouraged them to discuss experiences that were salient to them. Open-ended questions allowed participants to share their perspectives on cur- rent team performance and prompts helped them to reflect on their practice as a trauma team member since completing the training (Table 1). The interviews were audio recorded and later transcribed verbatim. Pseudonyms were used for all participants.

2.3. Data analysis

Thematic analysis was guided by Braun and Clark’s (2006) six- step thematic analytical approach to coding [11]. A theoretical approach was used to guide a detailed analysis of key aspects of the data and included coding for specific research questions related to teamwork and team performance. Two pilot interviews were used to formulate a coding strategy. During coding, transcripts were re-read several times and recordings replayed by two researchers. Initially, descriptive codes were examined for patterns, collated and summarised. Thirty-four initial codes were developed. Coded data were then interrogated more deeply for meanings and relation- ships to develop interpretive themes. Using consensus discussion between two researchers (MM and AM) – anonymised for peer

trauma team? - Prompt to encourage illustrative examples from recent experience - Prompt to explore understanding from recent experience - Prompt to explore what hindered or helped practice

M. Murphy et al. / Australasian Emergency Care 22 (2019) 1–7 3

Table 2 Thematic coding framework of interview data from trauma team members.

Exemplar data extracts Exemplar initial codes Secondary codes Candidate themes Core themes

‘Leadership is varied, some do it well, some think they do it well but don’t’

Leadership in trauma Skills used in practice Being an effective team leader 1. Leader-follower synergy promotes trauma team work

‘I felt I was more competent at expressing concerns after practicing it’

Working as a team Smoother slicker team Conflict between team members

2. Instability and inconsistency threaten trauma team work

‘I used to be an observer; I have learnt how to be an active team member’

Conflict Interpersonal communication Interpersonal communication is important

3. Clear communication enhances trauma team decision-making

‘I remember it was run well, very little noise, everyone working together’

Smoother slicker team Multidisciplinary interaction Consistent teamwork 4. Team training improves team performance

‘The intervention was avoided because of the earlier conflict’

Team communication Patient improvements Effective multidisciplinary team interaction

‘We knew the patient was going to deteriorate but we were not communicating the same message and were not working as a team’

When things are different Trauma team training Trauma team training

‘If I question a decision from a colleague I won’t be reprimanded as I can have a say’

Skills in trauma management Consistent teamwork

‘Someone talked over her all the time’ Changing team membership Decision making ‘Comparably transfer to Operating

Theatre is smoother and quicker’ Nurses input Core team membership

‘I think we have a power gradient that stops the team functioning well’

Consistent practice Graded assertiveness

‘The biggest learning was to communicate my thoughts not keep them to myself’

Trauma team training Organisation of the team

‘It didn’t function smoothly like it usually does because team members did not know the management plan’

Patient improvements Ineffective teamwork

“You always have a different team’ Situational awareness Leadership ‘The nurse, who was raising a concern,

was told to be quiet and stand aside’ Shared language and goal Empowered communication

‘I think preparation is really important as it allows you to follow what is going on’

Preparation is important Conflict

‘I use the learnings from TTT for all patients not just trauma’

NTS useful in other areas Skill set required by team

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Decision making Impa Graded assertiveness

. Results

Fifteen members of the trauma team, primarily females (n = 12) ho had completed TTT, participated in the study. Participants ad completed the TTT two to six years prior to the interviews. ll professional groups were represented. The participants were ither nurses (40.0%, n = 6), doctors (40.0%, n = 6) or allied health taff (20.0%, n = 3). Most participants were from the ED (46.6%,

= 7), followed by Trauma Service (20.0%, n = 3), Anaesthetic Service 13.3%, n = 2), Radiology (13.3%, n = 2), and Social Work (6.6.3%,

= 1). Most participants had between one- and five-years’ trauma eam experience (60.0%, n = 9); 40.0% (n = 6) had more than six ears’ experience. Frequency of involvement in trauma manage- ent ranged from once a week to daily. Four themes were developed: Leader-follower synergy pro-

otes trauma teamwork; Instability and inconsistency threaten rauma teamwork; Clear communication enhances trauma team ecision-making; and team training improves trauma team per- ormance.

.1. Leader-follower synergy promotes trauma team work

The importance of a synergistic relationship between team embers and team leaders in the context of the trauma team was

ery apparent. In particular, optimal teamwork was perceived by

eniority

participants to be dependent on an interrelationship between lead- ership and followership. Teamwork was experienced when team members responded to the leadership of the team and the leader facilitated team member interaction.

Participants believed that proficient leadership was a catalyst for teamwork, as there was an understanding that the leader had responsibility for individual team member performance as well as the overall direction of team activities. A competent trauma team leader established the behavioural and performance expectations of the team. On those occasions when trauma emergencies were managed without an obvious leader, the team was described as ‘disorganised’ and ‘chaotic’. Participants defined an effective team leader as someone who was able to direct the team while also responding to input from team members.

“You need to be together as a team, listening to each other and have confidence in the leader, otherwise everything becomes manic.” (P1, Nurse)

Participants described a range of leadership techniques needed to direct a trauma resuscitation, including structured planning and preparation to receive a trauma, establishing patient management

plans, prioritising tasks and delegating actions to team mem- bers. Participants identified leadership behaviours that enabled teamwork included actively involving the team in decision- making.

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“It’s a very challenging job that is very rewarding, but if you don’t have the rest of the team with you it can be very difficult to work to the optimal level.” (P12, Doctor)

Good followership was perceived to be as important to team unctioning as good leadership. Team members wanted to know heir individual role within the team and to contribute to the overall erformance of the team. Rather than assuming the leader’s under- tanding of the situation, effective team members verbalised their bservations about changes in the patient’s condition, expressed deas about diagnosis and shared information that might impact atient outcome.

“You need to include all parties, as the team leader by them- selves means nothing.” (P3, Doctor)

Decisions about who leads the trauma team can impact on he collaboration between team leader and team members. Par- icipants recognised that when junior doctors were given the pportunity to lead the team, they were often reassured by the resence of senior clinicians in the team and were supported to

ead effectively. However, some junior doctors were not readily ccepted as the team leader when there was a consultant doctor n the team. Their ability to lead the team was negatively impacted ecause they were uncomfortable giving directions to a senior col-

eague.

“When you are junior, and consultants are involved in the trauma, it is very difficult to manage them as well as the patient.” (P7, Registrar)

.2. Instability and inconsistency threaten trauma team work

Participants were frequently unsure of who members of their eam were due to the changing composition of the trauma team rom shift to shift and sometimes from patient to patient. The rauma team was often being formed as the clinical situation devel- ped and team members may not have met each other or worked ogether previously. This team typology is hereafter referred to as

“flash team”.

“They suddenly become part of the team so we have to adjust to each other.” (P2, Doctor)

Participants struggled with the dynamic nature of spon- aneously created trauma teams with constantly changing

embership. Instability complicated team processes and threat- ned teamwork because it was difficult for members to anticipate ach other’s expertise and experience when they did not know each ther. They perceived this lack of familiarity between team mem- ers as a catalyst for chaotic trauma management which at times

ncluded feelings of panic, exposure to excessive noise and chatter nd overcrowding of staff in the resuscitation bay.

“I have seen the opposite to good teamwork; a frantic environ- ment with people running everywhere and talking over each other, and I can’t tell if the patient is sick or not.” (P8, Allied Health)

Participants identified that team performance improved when tandardisation was introduced into trauma operating procedures, eam size and composition and role identification. Consistency n systems and processes were considered paramount for ‘flash’ eams.

“It (standardisation) gives an amazing structure when dealing with a very unwell patient.” (P6, Nurse)

When the trauma team was activated, a group of specialised linicians responded to the trauma call. Some participants

ergency Care 22 (2019) 1–7

identified this leverage of specialised expertise as beneficial for trauma management. Others believed it contributed to fragmented care as it spontaneously brought together individuals with com- peting priorities and timelines, and different personalities and skill sets.

“They don’t quite know their place in the team and they try and do their own thing which destroys teamwork and even the standard small things such as x-rays and blood ordering were not done.” (P4, Nurse)

It was challenging for some experts to respond to the differ- ent expectations of them outside of their specialty environment. Functioning as a member of a larger trauma team, comprising of various disciplines and specialties, was quite different to operat- ing as a sole expert with autonomous decision-making power. In particular, specialist registrars were frustrated that they ostensibly had to put teamwork ahead of their expertise.

“It’s frustrating when they completely ignore you as the spe- ciality registrar and the expertise that you bring to the trauma team.” (P7, Doctor)

3.3. Clear communication enhances trauma team decision-making

Participants identified collaborative communication as the cor- nerstone of safe decision making in time-critical situations. They agreed that clinical decisions needed to be based on reliable con- temporaneous information. It was vital for each team member to obtain and share information gathered during the resuscitation and then to collectively interpret that information. Given that a resuscitation is constrained by time, participants viewed clear com- munication and identification of treatment goals as imperative to safe trauma care.

“When the team members communicate with each other, the resus is co-ordinated and the team is faster to assess and treat.” (P6, Nurse).

Effective communication strategies acknowledged by partic- ipants included actively listening, asking questions and sharing opinions and updates with team members across all disciplines and specialities. These approaches enabled all team members to have a clear understanding of the nature of the emergency, the manage- ment plan and treatment required. Shared communication allowed the team to work cohesively together under pressure without creat- ing chaos. This co-ordination of activities contributed to the team’s efficiency.

“You feel a level of calm in the room balanced by the required level of urgency because you know what is happening and what you need to do.” (P5, Doctor)

Communication within the trauma team was challenging at times, impaired by a lack of openness and solo decision-making. Participants perceived that differences among professional hierar- chies, particularly physicians and non-physicians, was a powerful barrier to some team members being actively involved in decision making. Limited communication resulted in a poor shared under- standing of the patient’s treatment and led to conflict between team members.

Participants identified that high levels of stress, frequent interruptions, severity of injury and the need to multitask threat- ened communication. They believed that the key to successful

communication was to ensure that team members possessed communication techniques that were effective in an emergency context. These included closed loop and assertive communication. Closed loop communication is a communication technique that

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erifies information has been received and interpreted correctly i.e. the loop is closed) by team members [12]. However, these ritical communication skills did not come naturally to all team embers. Some members found speaking up in critical situations

hallenging. Participants identified that training in critical com- unication skills was necessary to promote positive exchanges

etween multidisciplinary team members to enhance teamwork.

“You have got to empower the whole team to speak up if they are concerned, but this is difficult.” (P12, Doctor)

.4. Team training improves trauma team performance

Despite being part of the same broader group (the trauma team), ndividual team members often did not know each other and fre- uently worked in different combinations of colleagues leading to ariation in team composition. Participants acknowledged that tra- itional healthcare education does not effectively prepare them for eam work and there is a misconception that team skills are ‘learnt n the job’. Other participants identified that limited uptake of eamwork skills in clinical practice is also influenced by ‘workplace ulture’ and a perceived lack of psychological safety. Even though ome participants felt ill-equipped to function in a team because hey had trained as individuals during their professional education, hey also believed if you work clinically in a multidisciplinary team ou should train as a team.

“There is no point in doctors and nurses training separately as we are treating together.” (P2, Doctor)

TTT was acknowledged by participants as contributing to their nderstanding of team phenomena such as teamwork behaviours, eam processes and working in a multi-team system because the imulation training offered them a unique opportunity to inter- ct and collaboratively learn within a multidisciplinary setting. TT helped participants to gain a better understanding of the links etween team training, team effectiveness and patient care. Partic-

pants associated TTT with improvements in trauma care as they ere better able to recognise organisational risks, expose hidden

rrors and find ergonomic problems during trauma resuscitation.

“I think TTT is very important as it teaches non-technical skills such as team structure and the recognition of the dangers of overcrowding in resus and its impact on patient care.” (F5, Nurse)

Participants valued the simulation aspects of the training. Devel- ping communication, leadership and teamwork skills within imulated trauma emergencies, enabled participants learning in oth affective and cognitive domains. Team members were able o link across disciplines and specialities, and practice team man- gement of real-life scenarios in a safe environment.

“You get to meet the other members of the team which is helpful as previously they just appeared during the actual trauma.” (P1, Nurse)

Participants believed that TTT should be repeated on a regular asis for the effects to be sustained.

. Discussion

Our study explored the experience of trauma team members ho had previously participated in a contextualised simulated ultidisciplinary TTT program, to elicit their perspectives on

eam performance and whether teamwork was practiced in real ife trauma emergencies. This study builds on quantitative work hat demonstrated the introduction of TTT is associated with a eduction in time to critical operation for major trauma patients

ergency Care 22 (2019) 1–7 5

[2]. Participants acknowledged that bringing together a group of highly skilled individual experts was not sufficient on its own for the group to work effectively during trauma resuscitations. They identified teamwork as the essential component to facilitate this group of individuals to collectively perform at an optimum level in emergency trauma care. They highlighted that the group will not necessarily transform naturally into an effective team.

While teamwork practices are commonly addressed in the lit- erature, factors that influence teamwork during real life trauma resuscitations are not clearly defined [1,13]. One of the major team- work challenges was the changing team dynamics resulting from new members constantly joining the trauma team. This ‘flash’ team composition made teamwork especially challenging for the par- ticipants in an emergency. Our findings suggest that creation and maintenance of effective trauma teams involves an interplay of strategies that target team training and team interaction. As flash teams are a reality in our current health care system, we suggest a new approach to training whereby the multidisciplinary team trains together using simulation, rather than the disciplines and groups of specialists that make up the team being trained sepa- rately.

Trauma resuscitation requires designated leadership over a multidisciplinary group of highly differentiated personnel, to function effectively. Participants viewed effective leadership as facilitating the integration of expertise from across the varied spe- cialists that make up the team. The resuscitation leader was seen to be the catalyst for teamwork and leadership was identified as having significant impact on trauma care [14–17]. But trauma resuscitation can pose a challenge for some leaders as it involves the interplay of team interaction in unpredictable time criti- cal situations. The trauma management context requires urgent coordination of cognitive, task and systems-based resources, but participants identified that leaders need to focus on more than task performance and encourage contributions from each team mem- ber’s unique discipline or specialty. While research on leadership in trauma has focused on who should lead and the leader’s position in the team [6,18], participants in our study highlighted that the trauma leader must play a role in merging multidisciplinary silos to achieve teamwork. Therefore, we suggest an empowering lead- ership style to effectively lead a trauma team [17–19]. This pivotal role of the trauma team leader in creating and maintaining effec- tive teams is also reported in other studies [19,20]. The existence of a professional hierarchy within the team and the different status accorded to those in different disciplines impacted on the psycho- logical safety of some team members, as they were less confident to lead the team or speak up when there was a problem. Even though proficient leadership is vital to team functioning the influence of team members is also important.

The use of standardised practices to optimise teamwork by a newly formed team, when navigating a dynamically changing environment, was viewed as necessary by the study participants. When team members were unknown to one another, standardisa- tion of team structure, communication and equipment contributed to team efficiency and performance. There is evidence to sug- gest that standardised care minimises variation and improves trauma outcomes [23,24]. Participants in our study found that the resuscitation environment influenced team performance. They perceived that when the clinical environment was designed to align with team priorities, the team performed more efficiently. They highlighted that trauma resuscitation bays were busy clin- ical areas where there were competing pressures and priorities. They were unable to invest time during an emergency resuscitation

to organise their environment and optimise logistics. This finding confirms current literature which supports a consistent systematic approach to trauma care [21,25,26]. The performance of the trauma team could be further enhanced by reducing variation in trauma

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anagement by adopting standardised procedures and processes. owever, trauma teams also need to have the flexibility to respond

o dynamically changing scenarios. So, in summary they need a mix f planned and spontaneous coordination.

Open communication is needed to develop a common under- tanding of the trauma situation. This is called a shared mental odel and it involves the team leader periodically verbalising an

pdate on the patient’s status (mental model) and team goals priorities) to the team during the resuscitation [12,27]. Flexi- le communication is also required, in particular the ability for he mental model to evolve as clinical circumstances change. owever, participants reported that developing accurate shared ental models is challenging for the ‘flash’ trauma team, as mem-

ers are unfamiliar with each other’s abilities and expertise. The xperiences of participants in our study suggest that using com- unication techniques that establish a common language across

he team are needed. Concise and direct language, standard- sed handover procedures, closed loop communication and graded ssertiveness [12,14], a structured way to speak out about concerns ith escalating levels of urgency, were proposed as improving the

uality of communication between team members. We suggest hat techniques such as openly sharing information, summarising ituations and voicing urgent clinical findings are important to facil- tate team input into decision-making. Poor communication and ack of shared mental models have been identified as detrimental o effective decision making in the trauma literature and poses sig- ificant risk to patient safety [4]. Our study adds context to this vidence.

Participants in our study recognised that a long-term com- itment to a teamwork training program using simulation,

ntegrated throughout the professional development of all dis- iplines involved in trauma care, was necessary to foster ultidisciplinary teamwork. A wide range of studies have shown

ositive effects of simulation on teamwork [1]. However, most ave been conducted in the simulation setting. Our study exa- ines multidisciplinary team performance in the applied clinical

etting of real-life trauma resuscitations. Based on our findings we dvocate for multidisciplinary teamwork skills to be incorporated nto simulated trauma training programs alongside technical skills. owever, it is not clear if improvements in teamwork occur imme- iately after simulated training or if improvements develop over ime as non-technical skills are practised in the clinical setting nd progressively built on. Participants in our study shared per- pectives about the current performance of the trauma team that ndicated sustained improvements in teamwork and team perfor-

ance beyond their initial trauma team training. Findings from this tudy highlight that a translational research approach is needed o evaluate simulation-based training and to elucidate the rela- ionship between training, patient and system level outcomes. The eam typology of the ‘flash’ trauma team is important to consider hen designing such training programs. Training should focus on eveloping skills for spontaneously constructed teams with poorly cquainted members, as well as intact stable teams. In addition, he design and delivery of trauma team training must be optimised y using proven educational methods, knowledge translation and

mplementation science, in addition to simulation, to ensure that rauma teams provide excellent trauma care.

. Limitations

This study focused on a relatively small number of clinicians

nd the sample was overwhelmingly female. Although represen- ative of the workforce demographics at the study site, the results hould be interpreted with this consideration due to the potential ifferences in communication and leadership styles between men

ergency Care 22 (2019) 1–7

and women. However, the sample range was appropriate, cover- ing the disciplines involved in emergency trauma care. Given the purpose of this study, interviews were the appropriate method of data collection. The participants had completed the TTT two to six years prior to the interviews and thus participants’ recall of the training, and subsequent events, may have been limited by the passage of time. But as participants were current members of the trauma team, and the interview questions were closely aligned with current team practices and processes, their recall of the training was a valid way to evaluate the impact of training on team- work. Future work should focus on observed behaviour of trauma team members alongside individuals’ reflections on teamwork. The inclusion of a single site means that local contextual issues may have influenced results, and care needs to be taken with assum- ing transferability of findings to other trauma sites and emergency teams.

6. Conclusion

This study highlighted that a quickly constructed specialty team with unstable membership, will not transform naturally into an expert trauma team. Our findings suggest that the creation and maintenance of effective trauma teams requires the interplay of training strategies that target team training and team interaction. Specifically, training should focus on developing non-technical skills for resuscitation trauma teams that have to form quickly and function effectively, often having never met before. As the partic- ipants were overwhelmingly female, the data generated by this study are not necessarily generalisable to male members of trauma teams.

What this paper adds

Whilst team training has been reported to be effective in improving teamwork in the simulation setting, evaluating the translation of the training into the clinical practice of emergency trauma resuscitation is important.

This evaluation should include team members’ views on and experiences of teamwork following multidisciplinary trauma team training as this identifies factors, in addition to education, that make a team work well (or not) in the clinical setting of an emergency trauma resuscitation.

Author contribution

MM, KC, and AM conceived and designed the study. KC and AM oversaw all aspects of the study. MM conducted the interviews and data collection, AM, MM and KC conducted the data analysis. All authors have been actively involved in the drafting and critical revision of the manuscript.

Sources of funding

Margaret Murphy is currently receiving a grant from the West- ern Sydney Local Health District Research Network Grant Scheme, NSW ($31,361) to support this project.

Provenance and conflict of interest

Margaret Murphy, Andrea McCloughen and Kate Curtis declare that they have no conflict of interest in either the development or

conduct of this study.

References

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