A R T I C L E I N F O A B S T R A C T
Article history: Background: Effective assessment and resuscitation of trauma patients requires an organised, multi-
Received 11 September 2013 disciplinary team. Literature evaluating leadership roles of nurses in trauma resuscitation and their effect
Received in revised form 13 January 2014 on team performance is scarce.
Accepted 30 April 2014
Aim: To assess the effect of allocating the most senior nurse as team leader of trauma patient assess-
ment and resuscitation on communication, documentation and perceptions of leadership within an Aus-
Keywords:
tralian emergency department.
Trauma
Methods: The study design was a pre-post-test survey of emergency nursing staff (working at resusci-
Leadership
Resuscitation tation room level) perceptions of leadership, communication, and documentation before and after the
Nursing implementation of a nurse leader role. Patient records were audited focussing on initial resuscitation as-
Emergency sessment, treatment, and nursing clinical entry. Descriptive statistical analyses were performed.
Communication Results: Communication trended towards improvement. All (100%) respondents post-test stated they
had a good to excellent understanding of their role, compared to 93.2% pre-study. A decrease (58.1
12.5%) in intimidating personality as a negative aspect of communication. Nursing leadership had a 6.7%
increase in the proportion of those who reported nursing leadership to be good to excellent. Accuracy
of clinical documentation improved (P = 0.025).
Conclusion: Trauma nurse team leaders improve some aspects of communication and leadership. De-
velopment of trauma nurse leaders should be encouraged within trauma team training programmes.
Crown Copyright 2014 Published by Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.ienj.2014.04.004
1755-599X/Crown Copyright 2014 Published by Elsevier Ltd. All rights reserved.
4 A. Clements et al./International Emergency Nursing 23 (2015) 37
for simultaneous inputs to address the need for rapid resuscita- sensus and were based on key positive and negative leadership
tion, stabilisation and to prioritise ongoing patient care (Georgiou concepts described in the literature, such as decision making, in-
and Lockey, 2010). struction, effective communication, intimidation, knowledge, and
Leadership, documentation (Calleja et al., 2011) and communi- initiation of treatment (Cole and Crichton, 2006; Cooper and
cation are an integral part of trauma team success in major trauma Wakelam, 1999). These themes were identied from a formal lit-
resuscitation (Capella et al., 2010). As a matter of course, the erature review around nursing leadership and resuscitation
assessment and resuscitation of trauma patients at the study site (Clements and Curtis, 2012). The survey had 10 questions using a
are initially managed by emergency physicians. A senior nurse with variety of response formats: Likert scale, checklist, and open-
resuscitation and training experience is allocated to each emergen- ended questioning (Table 1). For example,
cy department (ED) resuscitation room for the shift, and others attend
When you are the resuscitation nurse in a major trauma how
and assist when required for a resuscitation, such as a major trauma.
aware are you of the injuries?
When a trauma call is activated, nurses are allocated to either the
airway, breathing and circulation or scribe roles. The resuscitation Participants were able to provide written comment after each
nurse was traditionally assigned the role of airway nurse. The airway question. The survey was piloted by ve clinicians for feedback on
nurses ability to maintain a comprehensive overview of their pa- usability and content validity. Survey results were compared pre and
tients treatment and understanding of the denitive care plan, which post implementation of the nurse team leader role.
they were expected to contribute to, as well as provide a compre- Patient medical records underwent a retrospective documenta-
hensive clinical handover to other clinicians can be dicult when tion audit using a modication of a validated tool to compare com-
focussed on particular tasks, such as airway management. Anec- pleteness and detail of nursing documentation (Calleja et al., 2011).
dotally, this lack of awareness of the patient process and plan created The audit tool enabled data extraction from three aspects of the
frustration among the nursing staff and could potentially inhibit trauma resuscitation episode of care. These were (1) initial resus-
patient care. There was also no formal nursing team leader, who citation assessment and patient demographics (such as mecha-
would delegate nursing roles and interventions in conjunction with nism of injury, vital signs, demographics and medical history), (2)
the medical team leader. resuscitation treatment (e.g. medication/intravenous uid admin-
Nurses are integral to trauma and resuscitation in the ED, and istration, investigations and interventions) and (3) the clinical nursing
their contribution through quality clinical care in addition to ef- entry (that describes a summary of the patient assessment, patient
fective communication, leadership, and team work ultimately enables progress and management plan). All these components were re-
quality patient outcomes (Clements and Curtis, 2012). However, lit- viewed as being complete or incomplete, including the nursing entry
erature evaluating the role allocation of nurses in trauma resusci- which was assessed for clarication of the patient assessment, pro-
tation and their effect on team performance is scarce. We gress and plan which are integral components of trauma patient care
hypothesised that allocating the most senior nurse as scribe and en- documentation.
hancing the role to include nursing leadership would improve
nursing documentation, awareness of the patients clinical condi- 3.2. Participants
tion, ongoing patient management plans by facilitating prioritisation
of nursing intervention and overall effective communication among Following ethics approval, all emergency nursing staff working
team members. This role would see the medical trauma team leader at resuscitation room level were invited to participate in the study
and the nurse team leader work collaboratively in major trauma (pre n = 57, post n = 52). The survey was limited to nursing staff as
resuscitations. this was a nursing role change, nurses are the consistent work-
force in the ED, and the intent of the role change was to improve
2. Aim nursing communication.
The aim of this study is to assess the effect of allocating the most 3.3. Data collection process
senior nurse as nurse team leader and scribe on effective commu-
nication, documentation, and perceptions of leadership in major A survey was placed in their staff pigeonhole/mailbox before the
trauma resuscitations. implementation of the new role. The pre-survey was available for
staff completion 2 months before the trauma nurse leader role was
3. Methods implemented. An introduction letter explained the purpose, ano-
nymity, voluntary nature and dissemination intent of the re-
A pre-post test design was used employing survey and audit search. A survey box was placed in the ED staffroom for completed
methods. The study was conducted from March 2011 (pre-test), survey forms. The surveys were collected regularly during the
implementation (AprilMay 2011) to July 2011 (post-test) at St 2 month period.
George Hospital a major trauma centre in Sydney, Australia. St George The medical records for audit were identied using the St George
Hospital is the fourth busiest in NSW and treated 66,507 patients Hospital trauma database. Trauma data are collected prospective-
in 2012. Over 1700 trauma patients presented in 2012, and of those ly on all trauma patient presentations and include demographics,
over 350 were severely injured (injury severity score >12) are ad- length of stay, injury severity score (ISS) and complications.
mitted annually. This database enabled the identication of patients that were clas-
sied as a major trauma (ISS >12) and received a trauma team
3.1. Data collection tools activation.
Two tools were developed to test the hypothesis. A staff survey 3.4. Role implementation
to determine perceptions of leadership, effective communication and
awareness of patient plan and a medical record audit form to de- A process of engagement and consultation with the ED and
termine the quality of the documentation. trauma service nursing and medical consultants resulted in the
The survey was developed using an expert group of four trauma formalisation of a nurse trauma team leader role. The senior nurse
and emergency resuscitation nurse clinicians and nurse academ- role became scribe and nurse team leader for trauma and resusci-
ics. Survey questions were developed using the expert group con- tation. The scribe component of the role ensured the nurse leader
A. Clements et al./International Emergency Nursing 23 (2015) 37 5
Table 1
Perceptions of leadership and communication in major trauma survey results*.
* Cell sizes were too small (n < 5) to perform McNemars Chi square or Wilcoxon singed-rank tests on the majority of items. No signicant relationships were seen for
those items containing larger cell sizes.
had a comprehensive, real time overview of patient care. The lead- it is likely that a proportion did. For this reason it has been assumed
ership component of the role then enabled the nurse leader to work that data samples are matched, dependent data and a pre-post anal-
in conjunction with the medical team leader, prioritise nursing in- ysis was conducted. All binary (yes/no) data were analysed using
terventions and facilitate effective team communication. While the McNemars chi square analysis. Ordinal data were analysed using
medical team leader has overarching responsibility, the medical and the Wilcoxon signed-rank test. Medical Record documentation
nurse team leaders work collaboratively. Education was provided audits used independent samples and were analysed using
to nurses working at resuscitation level over a 2 month period on Chi-square analysis.
the roles and responsibilities of being a nurse team leader. This ed-
ucation included leadership skills, clinical care, conict manage- 4. Results
ment, and graded assertiveness by formal and informal education
methods, regular in-service and mentoring during a resuscitation. 4.1. Survey
Prior to the implementation of the new role, resuscitation nursing
staff completed an in-service on the denition, purpose and re- In this study, 31 (55%) nurses completed the pre-test survey and
sponsibilities involved in the role. During the implementation, the 24 the post-test survey (48%). Communication trended towards im-
trauma and emergency nurse consultants and educators mentored provement with the nursing team leader role implementation. There
nurses in their new role by using a shadow strategy during a major were 73% (pre) compared to 80% (post) felt that overall communi-
trauma resuscitation to provide expert advice and guidance. cation was good to excellent, and the incidence of very good to ex-
cellent nursing communication increased from 58.6% (pre) to 68.2%
3.5. Data analysis (post). All respondents post-test stated they had a good to excel-
lent understanding of their role, compared to 93.2% prior. Post in-
The data were obtained in a de-identied form and only aggre- tervention there was a decrease in intimidating personality as a
gate data are reported. Data were entered into excel and imported negative aspect of communication and leadership in major trauma
into SPSS Version 20.0 (Statistical Package for the Social Sciences resuscitation, from 58.1% (n = 18) to 12.5% (n = 3) and a decrease in
(SPSS), 2010) for analysis. Analysis of the survey results was re- no team member identication (from 58% to 42%).
stricted due to the small variable cell sizes. Due to the condential Nursing leadership improved post implementation of the nurse
and non-identiable nature of data, it is not known if the same par- team leader role. There was a 6.8% decrease in respondents who
ticipants completed the pre and post questionnaires, although felt nursing leadership was poor/average and a 6.7% increase in the
6 A. Clements et al./International Emergency Nursing 23 (2015) 37
(b) MOI specics (e.g. height of fall, 37 (92.5) 37 (92.5) hesion, communication and documentation. The development of
speed of MVC) trauma nurse team leaders should be encouraged within trauma
(c) Ambulance treatment 37 (92.5) 33 (82.5)
team training programmes.
(d) Initial obs (complete) 36 (90.0) 37 (92.5) The allocation of an experienced emergency nurse to this role
(e) Initial BP manual 8 (20.0) 19 (47.5) 0.009
is supported by Cudmore (Cudmore, 1996) who reported that nurses
(f) 15 min obs per protocol for 1st hour 30 (78.9) 27 (69.2) 0.331
(g) First hourly temperature 18 (47.4) 22 (56.4) 0.427 working with trauma patients are most condent when they have
(h) Patient details name, age, DOB 40 (100.0) 38 (95.0) more than 2 years trauma experience. Experience, condence and
(i) Patient med history 36 (90.0) 33 (82.5) knowledge within the resuscitation team environment are as-
Resuscitation ow chart sisted by targeted team training and contribute to the develop-
(a) Allergies 30 (90.9) 30 (93.8)
(b) IV access identication 29 (87.9) 33 (97.1) ment of leadership skills (Mahoney, 2008). Capella (Capella et al.,
(c) Medication charted 32 (100.0) 33 (100.0) 2010) demonstrated that trauma team training signicantly im-
(d) Fluids charted 28 (96.6) 26 (92.9) proves team performance and ecacy of patient care, although the
(e) Investigations documented 19 (59.4) 18 (52.9) 0.599 contribution of the nurse was not examined independently. Team
(f) Chart singed by MO 11 (33.3) 17 (50.0) 0.167
dynamics are subject to constant change in relation to human factors
Clinical notes nursing entry
(a) MOI 36 (90.0) 37 (92.5) such as personalities, experience and communication skills which
(b) Primary survey ndings 34 (85.0) 33 (82.5) 0.762 impedes robust investigation into individual roles. Further, as is
(c) Injuries 15 (37.5) 25 (62.5) 0.025 typical in any ED, a wide variety of patient presentations and in-
(d) Investigations 34 (85.0) 31 (77.5) 0.390 juries can affect a teams performance which results in study design
(e) Interventions 33 (82.5) 36 (94.7)
experience and assertiveness of senior nurses contribute to the ef- Curtis, K., Zou, Y., Morris, R., Black, D., 2006. Trauma case management: Improving
patient outcomes. Injury. 37 (7), 626632.
fective functioning of the trauma team. The development of trauma
Curtis, K., Tzannes, A., Rudge, T., 2011. How to talk to doctors a guide for effective
nurse leaders should be encouraged within trauma team training communication. International Nursing Review. 58 (1), 1320.
programmes. Curtis, K.A., Mitchell, R.J., Chong, S.S., et al., 2012. Injury trends and mortality in adult
patients with major trauma in New South Wales. The Medical Journal of Australia.
197 (4), 233.
Dueld, C., Diers, D., OBrien-Pallas, L., et al., 2011. Nursing stang, nursing workload,
Acknowledgement the work environment and patient outcomes. Applied Nursing Research. 24 (4),
244255.
The authors acknowledge Kerri Holzhauser for her assistance with Fecura, S.E., Jr., Martin, C.M., Martin, K.D., Bolenbaucher, R.M., Cotner-Pouncy, T., 2008.
Nurses role in the joint theater trauma system. Journal of Trauma Nursing. 15
survey design and preliminary analyses and Pauline Calleja for (4), 170173.
sharing her trauma medical record audit. Georgiou, A., Lockey, D.J., 2010. The performance and assessment of hospital trauma
teams. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine.
18 (1), 66.
References Gilligan, P., Bhatarcharjee, C., Knight, G., et al., 2005. To lead or not to lead? Prospective
controlled study of emergency nurses provision of advanced life support team
leadership. Emergency Medicine Journal. 22 (9), 628632.
Australian Institute of Health and Welfare, 2010. Australias Health 2010, Hindle, D., Braithwaite, J., Iedema, R., 2005. Patient Safety: A Review of Key
Canberra. International Enquiries, Sydney.
Calleja, P., Aitken, L.M., Cooke, M.L., 2010. Barriers to information transfer for Jolley, J., Bendyk, H., Holaday, B., Lombardozzi, K.A., Harmon, C., 2007. Rapid response
multi-trauma patients upon discharge from the emergency department in a teams: Do they make a difference? Dimensions of Critical Care Nursing. 26 (6),
tertiary level hospital. Queensland State-wide Trauma Symposium 2010, Royal 253260.
Brisbane & Womens Hospital, Brisbane. Liberman, M., Mulder, D.S., Jurkovich, G.J., Sampalis, J.S., 2005. The association between
Calleja, P., Aitken, L.M., Cooke, M.L., 2011. Information transfer for multi-trauma trauma system and trauma center components and outcome in a mature
patients on discharge from the emergency department: Mixed-method narrative regionalized trauma system. Surgery. 137 (6), 647658.
review. Journal of Advanced Nursing. 67 (1), 418. Lyons, R.A., Finch, C.F., McClure, R., van Beeck, E., Macey, S., 2010. The injury list of
Cameron, P.A., Gabbe, B.J., Cooper, D.J., Walker, T., Judson, R., McNeil, J., 2008. A all decits (LOAD) framework conceptualising the full range of decits and
statewide system of trauma care in Victoria: Effect on patient survival. The adverse outcomes following injury and violence. International Journal of Injury
Medical Journal of Australia. 189 (10), 546550. Control and Safety Promotion. 17 (3), 145159.
Capella, J., Smith, S., Philp, A., et al., 2010. Teamwork training improves the clinical Mahoney, J., 2008. Leadership skills for the 21st century. Journal of Nursing
care of trauma patients. Journal of Surgical Education. 67 (6), 439443. Management. 9 (5), 269271.
Celso, B., Tepas, J., Langland-Orban, B., et al., 2006. A systematic review and meta- Peden, M., McGee, K., Krug, E., 2002. Injury: A Leading Cause of the Global Burden
analysis comparing outcome of severely injured patients treated in trauma centers of Disease, 2000, Geneva.
following the establishment of trauma systems. Journal of Trauma Injury, Statistical Package for the Social Sciences (SPSS) 2010. 19.0, [computer program]. IBM,
Infection and Critical Care. 60 (2), 371378. Chicago.
Clements, A., Curtis, K., 2012. What is the impact of nursing roles in hospital Teixeira, P.G., Inaba, K., Hadjizacharia, P., et al., 2007. Preventable or potentially
patient resuscitation? Australasian Emergency Nursing Journal. 15 (2), preventable mortality at a mature trauma center. The Journal of Trauma. 63 (6).
108115. Twijnstra, M.J., Moons, K.G.M., Simmermacher, R.K.J., Leenen, L.P.H., 2010. Regional
Cole, E., Crichton, N., 2006. The culture of a trauma team in relation to human factors. trauma system reduces mortality and changes admission rates: A before and after
Journal of Clinical Nursing. 15 (10), 12571266. study. Annals of Surgery. 251 (2), 339343.
Cooper, S., Wakelam, A., 1999. Leadership of resuscitation teams: Lighthouse Wurster, L.A., Coffey, C., Haley, K., Covert, J., 2009. The role of the trauma nurse leader
Leadership. Resuscitation. 42 (1), 2745. in a Pediatric Trauma Center. Journal of Trauma Nursing. 16 (3), 160.
Cudmore, J.E., 1996. Trauma nursing: The team approach. British Journal of Nursing. Yun, S., Faraj, S., Sims, H.P., Jr., 2005. Contingent leadership and effectiveness of trauma
5 (12), 736737. resuscitation teams. Journal of Applied Psychology. 90 (6), 12881296.