Leadership structures in emergency care settings: A study of two trauma centers

Abstract

Background

Trauma resuscitation involves multidisciplinary teams under surgical leadership in most US trauma centers. Because many trauma centers have also incorporated emergency department (ED) physicians, shared and cross-disciplinary leadership structures often occur. Our study identifies leadership structures and examines the effects of cross-disciplinary leadership on trauma teamwork.

Methods

We conducted an ethnographic study at two US Level-1 trauma centers, one of which is a dedicated pediatric trauma center. We used observation, videotaping and interviews to contextualize and classify leadership structures in trauma resuscitation. Leadership structures were evaluated based on three dimensions of team performance: defined leadership, likelihood of conflict in decision making, and appropriate care.

Findings

We identified five common leadership structures, grouped under two broad leadership categories: solo decision-making and intervening models within intra-disciplinary leadership; intervening, parallel, and collaborative models within cross-disciplinary leadership.

Conclusion

Most important weaknesses of different leadership structures are manifested in inefficient teamwork or inappropriate patient care. These inefficiencies are particularly problematic when leadership is shared between physicians from different disciplines with different levels of experience, which often leads to conflict, reduces teamwork efficiency and lowers the quality of care. We discuss practical implications for technology design.

Introduction

Trauma teams are faced with complex problems under time pressure. Teams performing trauma resuscitation form rapidly upon patient arrival and carry out urgent and highly consequential tasks while coping with frequent changes in team composition and dynamics of the environment. Despite the introduction of standard protocols, the diversity of injuries that occur requires a coordinated approach to the evaluation and treatment of each patient. Effective leadership is essential for successful and error-free team performance during trauma resuscitation.

Although there is a large body of research on leadership and team effectiveness, much of it has focused on functions and behaviors of leaders of stable teams, such as those found in production and development teams (e.g., Refs. [1], [2], [3]). Leaders of stable teams mostly monitor team performance, delegate tasks, and provide guidance, assistance and encouragement. In contrast to stable teams, action teams are highly skilled specialist teams working in a fast-paced context, such as firefighter teams, cockpit crews and military teams. Studies of leadership in action teams have revealed the importance of an effective leader in coordinating task performance in response to unpredictable situations [4], [5], [6]. Because action teams often include members with different expertise and levels of experience, leadership may be distributed across several members [7], [8], [9], [10], [11]. These studies have offered important insights and provided a foundation for our study on leadership structures in an emergency care setting.

The lack of leadership, ineffective communication, and poor team performance can negatively affect clinical outcomes in several settings, including trauma resuscitation [12], [13], [14], [15]. Trauma teams are an example of action teams because their work is highly complex, although structured, and team composition changes frequently to adjust to the rapidly evolving needs of the patient. The presence of an identified and experienced command-physician, such as an attending surgeon or a trauma fellow, enhances team performance and ensures completion of needed resuscitation tasks [15].

Studies of leadership in trauma resuscitation have focused on the adaptation of leaders to changing task demands (e.g., Refs. [16], [17]), the impact of leader's location (collocated vs. remote) on team performance (e.g., Ref. [18]), and leadership adaptation to team structure (e.g., Ref. [19]). These studies suggest that different team structures emerge during trauma resuscitation, each in response to the needs of the patient and the team composition. Key gaps in knowledge remain about the nature of leadership structures during trauma resuscitation and their effects on team performance.

Trauma has been referred to as a disease that requires the involvement and leadership of surgeons [20]. Although surgical leadership is common in most US trauma centers, many centers have strong emergency medicine programs, with emergency department (ED) physicians and fellows regularly assuming leadership roles. Our study examines the effects of cross-disciplinary leadership on trauma teamwork.

We conducted an ethnographic study to observe, contextualize and classify leadership structures in trauma resuscitation. The goal of this research was twofold. First, we were interested in the types of leadership structures that occur when leadership roles come from either one (intra-disciplinary leadership) or more disciplines (cross-disciplinary leadership). Because trauma resuscitation involves rapidly changing and multi-disciplinary teams, shared and cross-disciplinary leadership structures are likely to occur. Second, we studied the effects of leadership structure on team performance. We focused on three dimensions of performance: recognition of the designated leader, level of agreement in decision making, and appropriate care delivery. In particular, we examined whether teams recognize their leader when more than one discipline is involved, whether conflict appears because of differing opinions among those sharing the leadership role, and whether leadership structure affects the patient care. Although other dimensions of performance may be affected by leadership (e.g., delay in care delivery), we chose to focus on these three because each is observable and less likely to be confounded by other factors. For example, while prolonged discussion by two leaders could delay care delivery, delays can also be due to missing patient information or an absent specialist. By studying team leadership in the fast-paced, emergency care setting of the trauma bay, we hoped to develop hypotheses about leadership structures and derive implications for technology design to support efficient teamwork and optimal patient care.