BMJ OpenMaria Härgestam1,4, Marie Lindkvist2, Christine Brulin1, Maritha Jacobsson3 & Magnus Hultin4 1Department of Nursing, Umeå University, Umeå, Sweden 2Department of Statistics,

For peer review only

Communication in interdisciplinary teams:

Exploring closed-loop communication during emergency

situations

Journal: BMJ Open

Manuscript ID: bmjopen-2013-003525

Article Type: Research

Date Submitted by the Author: 10-Jul-2013

Complete List of Authors: Härgestam, Maria; Umeå university, Nursing; University, Umeå, Department of Surgical and Perioperative Sciences, Anaesthesiology and Intensive Care Lindkvist, Marie; Umeå University, Department of Statistics, Umeå School of Business and Economics Brulin, Christine; Umeå University, Nursing Jacobsson, Maritha; Umeå University, Department of Social Work Hultin, Magnus; University, Umeå, Department of Surgical and Perioperative Sciences, Anaesthesiology and Intensive Care

<b>Primary Subject Heading</b>:

Emergency medicine

Secondary Subject Heading: Communication, Anaesthesia, Medical education and training

Keywords: ACCIDENT & EMERGENCY MEDICINE, ANAESTHETICS, MEDICAL EDUCATION & TRAINING

For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml

BMJ Open on A

ugust 2, 2021 by guest. Protected by copyright.

http://bmjopen.bm

j.com/

BM

J Open: first published as 10.1136/bm

jopen-2013-003525 on 21 October 2013. D

ownloaded from

http://bmjopen.bmj.com/


Figure

CO (1)

(2)

CLC (3)

Figure1. The sender (S) transmits a message and the receiver (R) acknowledges the message. The sender verifies

the message.

Page 1 of 25


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960

on August 2, 2021 by guest. P

rotected by copyright.http://bm

jopen.bmj.com

/B

MJ O

pen: first published as 10.1136/bmjopen-2013-003525 on 21 O

ctober 2013. Dow

nloaded from



1

Communication in interdisciplinary teams: Exploring closed-loop communication during emergency situations

Maria Härgestam1,4

, Marie Lindkvist2, Christine Brulin

1, Maritha Jacobsson

3 & Magnus Hultin

4

1Department of Nursing, Umeå University, Umeå, Sweden

2Department of Statistics, Umeå School of Business and Economics, Umeå International School of

Public Health, Epidemiology and Global Health, Department of Public Health and Clinical Medicine,

Umeå University, Umeå, Sweden

3Department of Social Work, Umeå University, Umeå, Sweden

4Department of Surgical and Perioperative Sciences, Anaesthesiology and Intensive Care, Umeå

University, Umeå, Sweden

Corresponding author

RNA, MSc, PhD student, Maria Härgestam, Department of Nursing, Umeå University, S-90187 Umeå,

Sweden. [email protected],

phone number +46-907869068, fax number +46 90786 91 69

Key words: Communication, team, leadership, simulation, team training.

Word count: 3422

Page 2 of 25


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from



2

ARTICLE SUMMARY

Article focus:

• Call-out (CO) and closed-loop communication (CLC) have been assumed to be

necessary elements to ensure safe team communication in the health care context.

• Structured team training focused on CRM-principles including CO and CLC are

assumed to facilitate and increase safer communication in trauma team during

emergency situation.

• Profession, age, gender, ethnicity, years in profession, educational experience, work

experience and leadership style may affect the team members use of CLC.

Key message:

• Previous participation in trauma team training with learning goals including the use of

CO and CLC did not increase the frequency of use of CLC.

• Having participated in two or more structured trauma courses (e.g. ATLS, TNCC and

PTHLS) correlated with increased use of CLC.

• The observed gap between having been taught and application of the communication

model emphasizes the need for validated training models combined with

implementation studies.

Strengths and limitations:

• The team members participated in their own roles in their standard working at the

emergency department. Efforts were made to ensure the simulation training was as

authentic as possible.

• Studying trauma care of an advanced mannequin instead of a real patient imposes

limitations that could affect the authenticity of the situation

Page 3 of 25


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from



3

The limited use of CO and CLC in the teams makes it difficult to draw general conclusions,

but indicate important issues for further studies, especially the difficulties in establishing safe

forms of verbal communication and the practical implementation of learning objectives for

non-technical skills in clinical practice.

Page 4 of 25


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from



4

ABSTRACT

Objectives: Investigate the use of Call-Out (CO) and Closed-Loop Communication (CLC)

during a simulated emergency situation, and its relation to profession, age, gender, ethnicity,

years in profession, educational experience, work experience and leadership style.

Design: Exploratory study

Setting: Trauma team training sessions during in-situ simulator-based interdisciplinary team

training.

Participants: The reported result was based on 16 trauma teams with totally 96 participants.

Each team consisted of two physicians, two registered nurses and two enrolled nurses.

Results: The use of CO and CLC in trauma teams was limited, with an average of 20 CO and

2.8 CLC per team. Previous participation in trauma team training did not increase the

frequency of use of CLC while ≥2 structured trauma courses correlated with increased use of

CLC (RR 3.17, CI 1.22 to 8.24). All professions in the trauma team were observed to initiate

and terminate CLC (except for the enrolled nurse from the OT). The frequency of team

members’ use of CLC significantly increased with egalitarian leadership style (RR 1.14, CI

1.04 to 1.26).

Conclusion: This study investigates the use of CO and CLC in trauma teams and factors that

may increase the use among team members. The observed gap between what has been taught

and the practical use of the communication model emphasizes the need for validated training

models combined with implementation studies.

Extra data is available by emailing the first author (MHa)

Page 5 of 25


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from



5


Exploring closed-loop communication during emergency situations

INTRODUCTION

Failure in communication as a basis for errors and patient injuries in health care was brought

into focus by the Institute of Medicine at the end of 1990s (1). When things go wrong it is

often a potentially preventable incident, caused by the interaction of several human factors

rather than the result of a single mistake by an individual (2-5). The change from reliance on

vigilant health care providers to the systematic prevention of errors has just started.

Deficiencies in verbal communication appear at all levels in organizations. One key element

is the hand-over between and/or within departments (4, 6-8). Shortcomings also occur within

the interdisciplinary team where misunderstandings, language difficulties, interruptions and

hesitation to speak up (against authority) have been reported (3, 6, 9-11). Communication has

been shown to be an important prerequisite for the team’s structure, collaboration and task

performance (9, 12, 13).

Standardized schemes of communication have been developed to achieve safe communication

and reduce the risk of miscommunication resulting in team breakdowns (14-17). Experience

from the field of aviation has led to major changes with the development of team training

concepts to increase safety, e.g. Crew Resource Management (18-20). Closed-loop

communication (CLC), including call-out (CO), is an important part of the concept based on

the assumption that safe communication in an emergency situation is achieved by

standardized terminology and procedures (14, 15). CO is the first verbalisation of an

Page 6 of 25


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from



6

observation and makes the team aware of important changes, when something appears to be

wrong. CLC can be described as a transmission model where verbal feedback is of great

importance to ensure that the team members correctly understand the message. The

communication strategy involves three steps; (1) the sender transmits a message: the call-out

(CO), (2) the receiver accepts the message and acknowledges its receipt; the check-back, and

(3) the sender verifies that the message has been received and interpreted correctly (i.e. the

loop is closed) (Figure 1) (14, 21).

Insert Figure 1 about here please.

When Bowers, Jentsch, Salas and Braun compared communication patterns among aircraft

crews during simulation training they found that high-performing teams used feedback (CLC)

more frequently and repeated commands more often than did low-performing teams (22).

Similar results were found when studying teams during simulation training in cases of

emergency obstetric care. Teams that described in clear terms the emergency (CO) and used

feedback (CLC) were more efficient in completing critical tasks (administering Mg infusion

during an eclamptic event) than were teams that were ambiguous in their communication (23).

However, there might be a problem with transferring CLC skills from the training

environment to clinical praxis (24).

The leaders’ communication styles influence the team’s task execution. In a previous study

we showed that trauma team leaders used a mix of authoritarian and egalitarian leadership

styles in order to achieve common goals (20). Leadership style is important as it determines

the culture within the team and can in turn influence how often team members speak up when

unexpected and urgent changes in a patient’s condition occur (11).

Page 7 of 25


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from



7

Errors occur frequently in health care and root cause analysis have pointed to failures in team

communication as being one of the major contributors to these (1). Team training with patient

simulators and facilitated debriefing with a focus on CRM have been suggested as one

remedy (25, 26). CLC has been assumed to be a necessary element to ensure safe team

communication (25, 27).

The purpose of this exploratory study was to investigate (1) the use of CO and CLC during a

simulated emergency scenario, and (2) its relation to profession, age, gender, ethnicity, years

in profession, educational experience, work experience, and leadership style.

METHODS

Participants

The participants consisted of personnel from nineteen trauma teams involved in regular team

training. Two of the teams were excluded from this analysis due to technical problems and

one team was incomplete. Thus, the reported results are based on 16 teams with 96

participants in total (S n=16, AN n=16, RN n=16, RNA n=16, ENED n=16 and ENOT n=16).

Before the training session, the participants were informed that the recorded material would

be treated in confidence and that they could leave the session whenever they wished to.

Individual informed consent was obtained before the start of each training session.

Page 8 of 25


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from



8

Research setting

Trauma team training sessions were audio and video recorded during in situ simulator-based

training in an emergency department (ED) in Northern Sweden. Efforts were made to make

the simulated environment as authentic as possible; therefore the training was executed in the

regular emergency room (ER) in the ED. An advanced patient simulator (PS) was pre-

programmed to represent a severely injured patient (ISS-Injury Severity Score 25) suffering

from hypovolemia due to external trauma (SimMan 3G, Laerdal, Stavanger, Norway). Before

the training, the participants were asked to view an introductory video about teamwork in

emergency settings, with the focus on collaboration and communication. In this introductory

video the importance of using CLC by giving feed back to the sender was highlighted.

The members of the trauma team gathered in the ER when the ED alerted them of the call.

The team members started to prepare the ER with equipment and materials according to the

hospital’s standard operating procedures for trauma care. A surgeon (S) or an emergency

physician was the designated leader of the team and was responsible in the ER for the team’s

performance. An anaesthesiologist (AN) was in charge of assessing and maintaining the

airways and breathing. A registered nurse (RN) from the ED was responsible for inserting an

intravenous line and fluids. The registered nurse anaesthetist (RNA) assisted the

anaesthesiologist with the airways and initiated monitoring of vital parameters (ECG, blood

pressure and saturation). If there was need for another intravenous line and more fluids, the

RNA inserted a second intravenous line. The enrolled nurse (EN) from the ED (ENED)

removed clothing and assisted the team members with various tasks. The EN from the

operating theatre (ENOT) had no written directions but assisted the AN with the airways and

the S with the documentation.

Page 9 of 25


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from



9

The ambulance personnel transported the PS from the scene of accident to the ED, and after a

verbal hand-over from the ambulance personnel the trauma team started with the initial

assessment and resuscitation. The initial assessments of the PS were based on current

guidelines to identify early on life-threatening injuries according to the Advanced Trauma

Life Support programme (ATLS) (28) and the equivalent courses for nurses: the Trauma

Nursing Core Course (TNCC) (29) and Pre-Hospital Trauma Life Support (PHTLS) (30). To

increase the task load, systolic blood pressure was decreased to 48 mmHg when the PS was

transferred to the stretcher. The length of the simulation scenario was designed to last for 15

minutes before the instructor interrupted the session.

Data collection

Data was collected during a period of six months in 2009/ 2010 in a hospital in Northern

Sweden. Three video surveillance cameras were placed in the emergency room. Wireless

microphones attached to each team member registered the communication between the team

members. Background information about the participants was taken from questionnaires the

team members filled in before the start of the training session.

Closed-loop communication was quantified as CO (step one) and CLC (all three steps

included) (Figure 1), according to definitions set out in advance (14, 21). Preliminary

quantifications were made by two of the authors (MHa and MHu) and then discussed in the

research group. The number of CO and CLC initiated by the different individual team

members in each team was analyzed in relation to the independent variables.

Years in profession was categorized as; 0-10 years, and ≥11 years in profession. Profession

was categorized as; S (including emergency physicians), AN, RN, RNA and EN (ENED and

ENOT grouped together). Ethnicity was divided into two groups: Scandinavian and Non-

Page 10 of 25


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from



10

Scandinavian. Previous educational experience measured previous participation in (1) a

structured trauma course; ATLS, TNCC and/or PHTLS, and (2) a simulation training with

PS. The latter variables were categorized as none, 1 course and ≥2 courses/training. Previous

work experience described the participant’s most recent experience of trauma and the variable

was categorized as; no experience of trauma, most recent experience of trauma <1 year ago

and most recent experience of trauma ≥1 year ago. In order to gain an overview of leadership

styles, the number of turn-constructional units of the different communication strategies used

by the leader (coercive, discussing, educating and negotiating) in each training session was

counted (cf.(20)). The variable Authoritarian leadership style is the sum of coercive (orders,

commands) and educating (transferring knowledge) turn-constructional units (20). Since the

variable is the sum of turn-constructional units it is a continuous variable and can vary

between 0 - ∞. In this study the variable Authoritarian leadership style varied between 0-20.

The variable Egalitarian leadership style is the sum of discussing (involved team members

agree in the decision-making process) and negotiating (disagreements between team members

in the decision-making process) turn-constructional units (20). The variable is a continuous

variable, the sum of turn-constructional units, and can vary between 0 - ∞. In this study the

variable Egalitarian leadership style varied between 2-16.

Statistical analysis

Descriptive statistics are presented as median (md) and quartiles (Q1, Q3) for age and years in

profession. Numbers of CO and CLC initiated by the individual team members in each team

for each profession are presented as number (n) and percentage (%).

Poisson regression analyses were performed to assess the impact of independent explanatory

variables on the outcome variables; i.e., the number of CLC and number of CO during each

Page 11 of 25


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from



11

session. Poisson distribution was assumed, as the number of discrete events was rare. The fact

that participants were correlated in each team presupposed an exchangeable correlation

structure and the parameters were estimated by Generalized Estimating Equations (GEE). A

backward elimination procedure was undertaken starting with all six independent variables

and the deleting of non-significant variables one at a time, and the final model consisted of the

remaining significant variables. The results were presented by risk ratio (RR) with 95%

confidence intervals (CI) and p-values, and p < 0.05 was considered statistically significant.

IBM SPSS (IBM Corp. Released 2011. IBM SPSS Statistics for Windows, Version 20.0.

Armonk, NY: IBM Corp.) was used for statistical analysis.

RESULTS

Demographic characteristics

Table 1 shows gender, age and years in profession. Seven of the participants were of non-

Scandinavian origin. Eight of the surgeons and eleven of the anaesthesiologists were

residents. All RNAs had postgraduate diploma in Specialist Nursing in Anesthesia Care,

while only three of the RNs had a postgraduate diploma (in Pre-hospital Emergency Care).

The participants’ previous education and work experience are shown in Table 2.

Table 1. Descriptives of the profession, gender, age and years in profession.

Profession

Gender

male/female, n/n

Age

median (Q1, Q3)

Years in profession

median (Q1, Q3)

S 11/5 40 (30, 55) 4 (2, 23)

AN 10/6 40 (35, 45) 11 (4, 16)

RN 8/8 31 (30, 34) 5 (1, 6)

RNA 7/9 39 (34, 45) 10 (5, 16) ENED 2/14 45 (37, 51) 17 (10, 30)

ENOT 2/14 50 (32, 55) 24 (6, 30)

Total 40/56 39 (32, 48) 9 (3, 18)

Page 12 of 25


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from



12

Table 2. Descriptives of the professions previous educational experience and work experience.

Educational experience

Work experience

Previous participation in

trauma team training with

patient simulator, n (%)


structured trauma courses,

n (%)

Most recent participation in

real trauma situation, n (%)

None 1 ≥2

None 1 ≥2 None < 1 year ≥1 year

S 6(37) 6(37) 4(25) 1(6) 11(69) 4 (25) 6(37) 6(37) 4(25)

AN 1(6) 6(37) 9(56) 3(19) 10(62) 3(19) 1(6) 9(56) 6(37)

RN 7(44) 5(31) 4(25) 8(50) 6(38) 2(12) 2(12) 9(56) 5(31)

RNA 2(12) 9856) 5(31) 4(25) 9(56) 3(19) 2(12) 9(56) 5(31)

ENED* 2(12) 4(25) 8(50) 9(56) 5(31) - 3(19) 9(56) 2(12)

ENOT 2(12) 10(62) 4(25) 7(44) 9(56) - 5(31) 6(37) 5(31)

Total* 20(21) 40(42) 34(35) 32(33) 50(52) 12(12) 19(20) 48(50) 27(28)

*2 missing

Description of CLC and CO

In this study, 319 CO were observed in a total of 16 trauma team training sessions resulting in

45 CLC (14% of the total CO). This translates into an average of 20 CO and 2.8 CLC per

team (Table 3). All professions initiated CO and all professions except for the ENOT initiated

CLC (Table 3). The frequency of initiation of CO and CLC varied between the professions,

with the leader initiating the most and the ENOT the fewest.

Table 3. The number of closed-loop communication (CLC) and call-out (CO) initiated by each profession.

Profession

CLC

n (%)

CO

n (%)

CLC/CO

%

S 21 (47) 151 (47) 14

AN 12 (27) 93 (29) 13

RN 1 (2) 22 (7) 4

RNA 10 (22) 43 (14) 23

ENED 1 (2) 6 (2) 17

ENOT - 4 (1) -

Total 45 (100) 319 (100)

Page 13 of 25


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from



13

CO in relation to explanatory factors

The final Poisson regression model with the number of CO defined as the dependent variable

showed that the frequency of use of CO (RR=1.51) among team members with ≥ 11 years in

the profession had undergone a significant increase compared to those with ≤10 years in the

profession (Table 4). Furthermore, team members with the most recent experience of trauma

(< 1 year ago) significantly increased the frequency of use of CO (RR= 1.43) compared to

team members with no experience. Compared to the EN, significantly more CO was used by

S (RR=32.63), AN (RR=17.47), RNA (RR=8.17) and RN (RR=5.36).

Page 14 of 25


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from



14

Table 4. Poisson regression with CO, as dependent variable, full and final model.

CO Full model

CO Final model

Variable

Profession

S

AN

RN

RNA

EN

Gender

Male

Female

Ethnicity

Scandinavian

Non-

scandinavian

Leadership style

Authoritarian

Egalitarian

Age

Years in profession ≥11 years

≤10 years

Trauma course

≥ 2

1

None

Simulation training

≥2

1

None

Most recent experience of

trauma

≥1year

<1 year

None

RR

95 % CI p RR 95 % CI p

40.48 (26.28, 62.36) .000 32.63 (18.04, 59.00) .000

21.76 (11.80, 40.11) .000 17.47 (8.99, 33.94) .000

5.88 (3.08, 11.22) .000 5.36 (2.84, 10.14) .000

9.04 (4.49, 18.21) .000 8.17 (4.08, 16,34) .000

1 1

.82 (0.56, 1.21) .310

1

1.44 (0.82, 2.54) .203

1

.99 (0.96, 1.04) .856

1.01 (0.97, 1.05) .613

1.01 (0.97, 1.04) .678

1.28 (0.72, 2.29) .394 1.51 (1.10, 2.06) .011

1 1

.98 (0.65, 1.47) .925

.77 (0.53. 1.13) .184

1

1.17

(0.85, 1.61)

.348

1.10 (0.63, 1.92) .742

1

.86 (0.47, 1.58) .656 .93 (.60, 1.45) .761

1.33 (0.83, 2.14) .298 1.43 (1.03, 1.99) .034

1 1

Page 15 of 25


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from



15

CLC in relation to explanatory factors

The final Poisson regression model with the number of CLC as dependent variable (Table 5)

showed that having a Scandinavian background meant a significant increase in frequency of

the team members’ use of closed-loop communication (RR=4.46) compared to having a non-

Scandinavian background. Compared to EN, significantly more CLC were used by S

(RR=34.87), AN (RR=17.92) and RNA (RR=13.39). The Poisson regression further showed

that having a leader with an egalitarian leadership style meant a significant increase in the

frequency of the team members’ use of CLC (RR=1.14) whereas having a leader with an

authoritarian leadership style meant a significant decrease in the frequency of the team

members’ use of CLC (RR=0.85). Further, team members with previous experience of

participating in trauma team training with PS did not use CLC more frequently than did team

members with no such experience. Previous experience of participating in ≥ 2 structured

trauma courses significantly increased the use of CLC (RR=3.17) compared to no experience

of previous trauma courses.

Page 16 of 25


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from



16

Table 5. Poisson regression with CLC as dependent variable, full and final model.

CLC Full model

CLC Final model

Variable

Profession

S

AN

RN

RNA

EN

Gender

Male

Female

Ethnicity

Scandinavian

Non-

scandinavian

Leadership style

Authoritarian

Egalitarian

Age

Years in profession

≥11 years

≤10 years

Trauma course

≥2

1

None

Simulation training

≥2

1

None

Most recent experience of

trauma ≥1 year

<1 year

None

RR 95 % CI

p RR 95 % CI

p

36.59 (4.21, 318.32) .001 34.87 (4.24, 286.94) .001

19.36 (2.17, 172.99) .008 17.92 (2.36, 136.22) .005

1.87 (0.13, 27.75) .649 1.42 (0.09, 23.36) .805

17.29 (1.89,158.07) .012 13.39 (1.62,110.54) .016

1 1

1.26 (0.66, 2.38) .481

1

5.33 (1.49, 19.01) .010 4.46 (1.87, 10.65) .001

1 1

.84 (0.76, 0.94) .002 .85 (0.77, 0.93) .000

1.61 (1.04, 1.31) .012 1.14 (1.04, 1.26) .007

1.02 (0.95, 1.10) .53

.97 (0.28, 3.32) .96

1

2.31 (0.70, 7.68) .171 3.17 (1.22, 8.24) .018

1.01 (0.28, 3.60) .991 1.67 (0.38, 3.60) .789

1 1

.97 (0.41, 2.30) .951

.84 (0.36, 1.98) .686

1

.58 (0.12, 2.79) .494

1.18 (0.41, 3.44) .760

1

Page 17 of 25


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from



17

DISCUSSION

The main results in this study show that the use of CLC in the trauma teams was limited. Only

one of seven CO led to a completed CLC and less than three CLC were completed per team

training session.

It is interesting to note that in this study, the team members’ previous experience of

simulation training with PS did not serve to increase the frequency of their use of CO and

CLC. Seventy-four percent of the participants in the study had participated in previous trauma

team training. Additionally, the participants had watched a video introduction to the trauma

team training, where the importance of using CO and CLC in emergency situations had been

emphasized. Apparently there seems to be a gap between theoretical knowledge and the

practical implementation of the communication model in team training. Similar results were

found in resuscitation teams that successfully used CLC in order to give verbal feedback in

training situations, but the participants did not apply these skills in cardiac arrest situations

(24). The content, didactics and learning objectives of the training in communication are

important to consider when trying to remedy this. The present study found that despite the

explicit focus on the importance of communication in terms of CO and CLC, the difficulty in

establishing a safe and reliable form of verbal communication within the interdisciplinary

team remained. The participants’ main focus was on completing their assigned tasks, and

communication appeared to be of minor importance. Studying leadership behaviors in the

operating theatre, Parker, Yule, Flin and McKinley found that collaboration and

communication were focused at optimizing technical skill performance rather than on

intentional teambuilding (31). Perhaps this reflects a common perception that communication

is something that can be taken for granted and therefore not necessary to practice.

Page 18 of 25


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from



18

In this study, having attended ≥ 2 structured trauma courses were associated with more

initiation of more CLC. Even though it is the ABCDE principle that are trained during

structured life support courses this repeated training may provide a solid foundation for

trauma care. Better performance in emergency situations are thus in line with other studies

showing that deliberate practice is key to excellence (32, 33).

Members of all the professions represented by the trauma teams initiated CO and the

frequency of use of CO increased significantly with professional experience. Use of CO

meant that team members were encouraged to speak up in order to make the other members

aware of completed tasks or important changes (34). When there are too many call-outs being

sent out to no one in particular, there is a risk that the commands given will not make

themselves heard in the noise, and the task will not lead to action. Directed commands were

found by Siassakos, Draycott, Montague and Harris to be more likely to be executed,

compared to commands called out "in the air” that were less likely to lead to action (35).

Multiple orders called out "in the air” were also found to lead to task overload for the

members of resuscitations teams, thus having a negative influence on team performance (24).

All professions were observed to initiate and end a CLC (except for the ENOT). As expected,

the surgeon, as the designated trauma team leader, used CLC to a greater extent than did the

other members in the team. A trauma team where all members were active and used CLC

could indicate their leader having a more egalitarian leadership style, thus encouraging team

members to speak up (cf (11, 36)). An authoritarian leadership style meant a less common use

of CLC in the trauma teams. Speaking up is an important issue in interdisciplinary teams

where power conflicts between professionals (nurses and doctors) and within professions

(junior and senior doctors) can obstruct the delivery of crucial information about the patient to

the team.

Page 19 of 25


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from



19

The RNAs were using CLC to a greater extent than the RNs during the simulation training.

This might be explained by a combination of a higher level of education and experience

among the RNAs in this study. Qualifying as RNA involves an additional year of study at

university after becoming a RN. The RNAs had participated in more trauma team training

with PS before this session and had also participated in more structured trauma courses. As

has already been mentioned, the nurses’ vital role in a resuscitation team depends on (37, 38);

good communication skills, the ability to work independently and to prioritize tasks. These

skills, which develop with experience, improve the team's performance.

Asymmetrical power relations in interdisciplinary teams may influence the interaction and

inhibit safety (3). In order to further investigate those factors already described as being

important for team communication, the effects of gender, ethnicity, and years in profession

were studied. In this study, it was having a Scandinavian background, not one’s gender or

years in the profession that determined a significant increase in the team members’ use of

CLC. In this study, all leaders in the trauma teams spoke Swedish fluently, some leaders with

an accent, which otherwise would have caused difficulties for the team members. In general,

language is an important factor for gaining and keeping power in conversation (39), and a

focus of research in the contexts of doctor-patient communication (40). Communication is

complex and simple models might not solve the multi-faceted problems interdisciplinary

teams. Empirical studies of interdisciplinary teams are needed in order to further study the

factors influencing communication.

Page 20 of 25


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from



20

Limitations

Communication between trauma team members was investigated during interdisciplinary in-

situ team training. Efforts were made to ensure the simulation training was as authentic as

possible. The team members were acting in their own roles in their regular environment at the

emergency department. In this study, the patient was a PS, which imposed limitations that

could affect the authenticity of the situation. The study points to factors seen as important for

the use of CO and CLC within trauma teams. However, the use of CO and CLC was

inconsistent. The limited use of CLC makes it difficult to discuss the result in general, but

indicate important issues for further studies; the difficulties in establishing a safe form of

verbal communication and the implementation of objectives of non-technical skills as

communication in clinical practice.

CONCLUSIONS

This study investigates the use of CO and CLC in trauma teams and factors that may help

increase the use of CLC among the team members. The use of CLC was surprisingly limited,

and in this study, members with previous experience of participating in trauma training did

not use CLC to a greater extent than did members with no previous experience. Despite

efforts to emphasize the importance of communication in trauma team training, the difficulty

in establishing a safe and reliable form of verbal communication in the interdisciplinary team

remained. The gap observed between theoretical knowledge and practical use of the

communication model emphasizes the need for validated training models combined with

implementation studies in trauma team training.

Page 21 of 25


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from



21

Acknowledgements

This study was a part of Nordic Safety and Security (NSS), a collaboration between Umeå

University, the Västerbotten County Council (VLL), Luleå University of Technology (LTU)

and the Swedish Defence Research Agency (FOI).

Funding

The NSS project was sponsored by EU regional funds (ref no. 41952) and this study was also

supported in part by the Laerdal Foundation.

Contributors

MHa, CB and MHu planned the initial study. All authors were involved in data analysis and

in both the initial drafting and finalizing the manuscript. The regression analyses were done

by MHa and ML.

Competing interests

The authors have no competing interests to declare.

Ethics approval

The study was approved by the Ethical Review Board in Northern Sweden, June 9, 2009

(Reg. no 09-106M).

Page 22 of 25


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from



22

REFERENCES

1. Kohn LT, Corrigan J, Donaldson MS. To err is human : building a safer health system.

Washington, D.C.: National Academy Press; 2000.

2. Lingard L, Espin S, Whyte S, Regehr G, Baker GR, Reznick R, et al. Communication

failures in the operating room: an observational classification of recurrent types and

effects. Qual Saf Health Care 2004;13:330-4.

3. Sutcliffe KM, Lewton E, Rosenthal MM. Communication failures: an insidious

contributor to medical mishaps. Acad Med 2004;79:186-94. 4. Arora V, Johnson J, Lovinger D, Humphrey HJ, Meltzer DO. Communication failures

in patient sign-out and suggestions for improvement: a critical incident analysis. Qual

Saf Health Care 2005;14:401-7.

5. Reason J. Human error: models and management. BMJ 2000;18: 768-70.

6. Gawande AA, Zinner MJ, Studdert DM, Brennan TA. Analysis of errors reported by

surgeons at three teaching hospitals. Surgery 2003;133:614-21.

7. Rabol LI, Andersen ML, Ostergaard D, Bjorn B, Lilja B, Mogensen T. Descriptions of

verbal communication errors between staff. An analysis of 84 root cause analysis-

reports from Danish hospitals. BMJ Qual Saf 2011;20:268-74.

8. Nagpal K, Arora S, Vats A, Wong HW, Sevdalis N, Vincent C, et al. Failures in

communication and information transfer across the surgical care pathway: interview

study. BMJ Qual Saf 2012;21:843-9.

9. Lingard L, Whyte S, Espin S, Baker GR, Orser B, Doran D. Towards safer

interprofessional communication: constructing a model of "utility" from preoperative

team briefings. J Interprof Care 2006;20:471-83.

10. Bergs EAG, Rutten FLPA, Tadros T, Krijnen P, Schipper IB. Communication during

trauma resuscitation: do we know what is happening? Injury 2005;36:905-11.

11. Edmondson AC. Speaking up in the operating room: How team leaders promote

learning in interdisciplinary action teams. Journal of Management Studies

2003;40:1419-52.

12. Cooper S, Wakelam A. Leadership of resuscitation teams: "Lighthouse Leadership'.

Resuscitation 1999;42:27-45.

13. Mishra A, Catchpole K, Dale T, McCulloch P. The influence of non-technical

performance on technical outcome in laparoscopic cholecystectomy. Surg Endosc

2008;22:68-73.

14. Burke CS, Salas E, Wilson-Donnelly K, Priest H. How to turn a team of experts into an

expert medical team: guidance from the aviation and military communities. Qual Saf

Health Care 2004;13:I96-I104.

15. Salas E, Wilson KA, Murphy CE, King H, Salisbury M. Communicating, coordinating,

and cooperating when lives depend on it: tips for teamwork. Jt Comm J Qual Patient

Saf 2008;34:333-41.

16. Lingard L, Espin S, Rubin B, Whyte S, Colmenares M, Baker GR, et al. Getting teams

to talk: development and pilot implementation of a checklist to promote

interprofessional communication in the OR. Qual Saf Health Care 2005;14:340-6.

17. Lingard L, Regehr G, Orser B, Reznick R, Baker GR, Doran D, et al. Evaluation of a

preoperative checklist and team briefing among surgeons, nurses, and anesthesiologists

to reduce failures in communication. Arch Surg 2008;143:12-7

Page 23 of 25


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from



23

18. Helmreich RL, Merritt AC, Wilhelm JA. The evolution of crew resource management

training in commercial aviation. International Journal of Aviation Psychology

1999;9:19-32.

19. Sexton JB, Helmreich RL. Analyzing cockpit communications: the links between

language, performance, error, and workload. Hum Perf Extrem Environ 2000;5:63-8.

20. Jacobsson M, Hargestam M, Hultin M, Brulin C. Flexible knowledge repertoires;

communication by leaders in trauma teams. Scand J Trauma Resusc Emerg Med

2012;20:44.

21. Wilson KA, Salas E, Priest HA, Andrews D. Errors in the heat of battle: taking a closer

look at shared cognition breakdowns through teamwork. Hum Factors 2007;49:243-56.

22. Bowers CA, Jentsch F, Salas E, Braun CC. Analyzing communication sequences for

team training needs assessment. Hum Factors 1998;40:672-9.

23. Siassakos D, Bristowe K, Draycott TJ, Angouri J, Hambly H, Winter C, et al. Clinical

efficiency in a simulated emergency and relationship to team behaviours: a multisite

cross-sectional study. Br J Obstet Gynaecol 2011;118:596-607.

24. Andersen PO, Jensen MK, Lippert A, Ostergaard D. Identifying non-technical skills and

barriers for improvement of teamwork in cardiac arrest teams. Resuscitation

2010;81:695-702.

25. Rall M, Gaba D. Patients simulators. In: Miller RD, Afton-Bird G, editors. Anesthesia

Vol 2. 6. ed. New York: Elsevier/Churchill Livingstone; 2005. p. xviii, 1617-3203 s.,

lix.

26. Issenberg SB, McGaghie WC, Hart IR, Mayer JW, Felner JM, Petrusa ER, et al.

Simulation technology for health care professional skills training and assessment. JAMA

: the journal of the American Medical Association 1999;282:861-6.

27. Salas E, Sims DE, Burke CS. Is there a "big five" in teamwork? Small Group Research

2005;36:555-99.

28. American College of Surgeons Committee on Trauma. ATLS : Advanced Trauma Life

Support Program for Doctors. 7th ed. Chicago, IL: American College of Surgeons;

2004.

29. Riksföreningen för sjuksköterskor inom Trauma (RST), Emergency Nurses Association.

TNCC manual : Trauma nursing core course. 5. uppl., ed. Bälinge: Riksföreningen för

sjuksköterskor inom Trauma; 2003.

30. National Association of Emergency Medical Technicians (U.S.). Pre-Hospital Trauma

Life Support Committee., American College of Surgeons. Committee on Trauma.

PHTLS : prehospital trauma life support. Military 7th ed. St. Louis, MO: Mosby

Jems/Elsevier; 2011.

31. Parker SH, Yule S, Flin R, McKinley A. Surgeons' leadership in the operating room: an

observational study. Am J Surg 2012;204:347-54.

32. Holcomb JB, Dumire RD, Crommett JW, Stamateris CE, Fagert MA, Cleveland JA, et

al. Evaluation of trauma team performance using an advanced human patient simulator

for resuscitation training. J Trauma. 2002;52:1078-85; discussion 85-6. PubMed PMID:

12045633. Epub 2002/06/05. eng.

33. Lee SK, Pardo M, Gaba D, Sowb Y, Dicker R, Straus EM, et al. Trauma assessment

training with a patient simulator: a prospective, randomized study. J Trauma.

2003;55:651-7. PubMed PMID: 14566118.

34. Brindley PG, Reynolds SF. Improving verbal communication in critical care medicine. J

Crit Care 2011;26:155-9.

Page 24 of 25


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from



24

35. Siassakos D, Draycott T, Montague I, Harris M. Content analysis of team

communication in an obstetric emergency scenario. J Obstet Gynaecol 2009;29:499-

503.

36. Klein KJ, Ziegert JC, Knight AP, Xiao Y. Dynamic delegation: Hierarchical, shared and

deindividualized leadership in extreme action teams. Adm Sci Q 2006;51:590-621.

37. Sinclair TD. The role of the rapid response nurse: hospitalwide and in trauma

resuscitations. J trauma nurs: the official journal of the Society of Trauma Nurses

2006;13:175-7.

38. Wurster LA, Coffey C, Haley K, Covert J. The role of the trauma nurse leader in a

pediatric trauma center. J trauma nurs: the official journal of the Society of Trauma

Nurses 2009;16:160-5.

39. Fairclough N. Language and power. London: Longman; 1989.

40. Mishler EG. The discourse of medicine : dialectics of medical interviews. Norwood,

N.J.: Ablex; 1984.

Figure legends

Figure 1. Description of closed-loop communication. The sender (S) transmits the message, call-out (CO), the

receiver (R) acknowledge the message by check-back (2). The sender verifies that the message is interpreted

correctly: closed-loop communication (CLC) is obtained (3).

Page 25 of 25


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from




Exploring closed-loop communication during in-situ trauma

team training

Journal: BMJ Open

Manuscript ID: bmjopen-2013-003525.R1

Article Type: Research

Date Submitted by the Author: 09-Sep-2013

Complete List of Authors: Härgestam, Maria; Umeå University, Department of Nursing; Umeå University, Department of Surgical and Perioperative Sciences, Anaesthesiology and Intensive Care Lindkvist, Marie; Umeå University, Department of Statistics, Umeå School of Business and Economics Brulin, Christine; Umeå University, Department of Nursing Jacobsson, Maritha; Umeå University, Department of Social Work Hultin, Magnus; Umeå University, Department of Surgical and Perioperative Sciences, Anaesthesiology and Intensive Care

<b>Primary Subject Heading</b>:

Emergency medicine

Secondary Subject Heading: Communication, Anaesthesia, Medical education and training

Keywords: ACCIDENT & EMERGENCY MEDICINE, ANAESTHETICS, MEDICAL EDUCATION & TRAINING


BMJ Open on A

ugust 2, 2021 by guest. Protected by copyright.

http://bmjopen.bm

j.com/

BM

J Open: first published as 10.1136/bm

jopen-2013-003525 on 21 October 2013. D

ownloaded from



1

Communication in interdisciplinary teams: Exploring closed-loop communication during in-situ trauma team training

Maria Härgestam1,4



3 & Magnus Hultin

4










Sweden. [email protected]

phone number +46907869068, fax number +46907869169


Word count: 3576

Page 1 of 99


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from



2

ARTICLE SUMMARY

Article focus:

• The challenge and necessity to improve communication skills in interdisciplinary

teams in order to secure patient safety.



• Communication is complicated and several factors have influence on the team

members communication and it is therefore of great importance to study this

communication model in practice.

Key message:

• Despite the explicit focus on the importance of communication in terms of CO and

CLC, the difficulty in establishing a safe and reliable form of verbal communication

within the interdisciplinary team remained.

• There was a limited use of CLC in the teams during the in-situ trauma team training.

This indicates the need for validated training models combined with implementation

studies.


• The team members participated in their own roles in their standard positions at the

emergency department. Efforts were made to ensure the simulation training was as

authentic as possible.



• The limited use of CO and CLC in the teams makes it difficult to draw general

conclusions. However, this study point out important issues for further studies, which

Page 2 of 99


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from



3

should pay attention to establishing safe forms of verbal communication and practical

implementation of learning objectives for non-technical skills in clinical practice.

Page 3 of 99


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from



4

ABSTRACT



years in profession, educational experience, work experience, and leadership style.


Setting: In-situ simulator-based interdisciplinary team training using trauma cases at an

emergency department.

Participants: The result was based on 16 trauma teams with totally 96 participants. Each

team consisted of two physicians, two registered nurses and two enrolled nurses, identical to a

standard trauma team.

Results: The results in this study showed that the use of CO and CLC in trauma teams was

limited, with an average of 20 CO and 2.8 CLC per team. Previous participation in trauma

team training did not increase the frequency of use of CLC while ≥2 structured trauma

courses correlated with increased use of CLC (RR 3.17, CI 1.22 to 8.24). All professions in

the trauma team were observed to initiate and terminate CLC (except for the enrolled nurse

from the OT). The frequency of team members’ use of CLC significantly increased with

egalitarian leadership style (RR 1.14, CI 1.04 to 1.26).

Conclusion: This study showed that despite focus on the importance of communication in

terms of CO and CLC, the difficulty in achieving a safe and reliable verbal communication

within the interdisciplinary team remained. This finding indicates the need for validated

training models combined with further implementation studies.


Page 4 of 99


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from



5

INTRODUCTION


into focus by the Institute of Medicine at the end of 1990s [1]. When things go wrong it is


rather than the result of a single mistake by an individual [2-5]. The change from reliance on

vigilant health care providers to the systematic prevention of errors is a challenge in the

future.


is the hand-over between and/or within departments [4 6-8]. Shortcomings also occur within

the interdisciplinary team where misunderstandings, language difficulties, interruptions and

hesitation to speak up (against authority) have been reported [3 6 9-11]. Communication has

been shown to be an important prerequisite for the team’s structure, collaboration and task

performance [9 12 13].


and reduce the risk of miscommunication resulting in team breakdowns [14-17]. Experience

from the field of aviation has led to major changes with the development of team training

concepts to increase safety, e.g. Crew Resource Management [18-20]. Closed-loop

communication (CLC), including call-out (CO), is an important part of the concept based on

the assumption that safe communication in an emergency situation is achieved by

standardized terminology and procedures [14 15]. CO is the first verbalisation of an

observation and makes the team aware of important changes, particularly when something

appears to be wrong. CLC can be described as a transmission model where verbal feedback is

Page 5 of 99


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from



6

of great importance to ensure that the team members correctly understand the message. The

communication strategy involves three steps; (1) the sender transmits a message: the call-out

(CO), (2) the receiver accepts the message and acknowledges its receipt; the check-back, and

(3) the sender verifies that the message has been received and interpreted correctly (i.e. the

loop is closed) (Figure 1) [14 21]. This advocated model assumes that communication is

simple and clear. In practice communication is more complicated and several other factors

affect the transmission [22 23]. It is therefore of great importance to study if this

communication model, suggested among educators, is useful in complicated practical

situations.

Insert Figure 1 about here, please.



more frequently and repeated commands more often than low-performing teams [24]. Similar

results were found when studying teams during simulation training in cases of emergency

obstetric care. Teams that described in clear terms the emergency (CO) and used feedback

(CLC) were more efficient in completing critical tasks (administering Mg infusion during an

eclamptic event) than were teams that were ambiguous in their communication [25]. This

highlight that CLC skills might be transferred from the training environment to clinical praxis,

and that use of CO followed by CLC probably increase patient safety [26].

In addition to the fact that communication according to CO as well as CLC is of importance to

optimize patient safety, also the leaders’ communication styles influence the teams’ task

execution. In a previous study we showed that trauma team leaders used a mix of

authoritarian and egalitarian leadership styles in order to achieve common goals [20].

Page 6 of 99


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from



7

Leadership style determines the culture within the team and can in turn influence when and

how often team members speak up when unexpected and urgent changes in a patient’s

condition occur [11].

In sum; in order to prevent errors in health care CLC has been assumed to be a necessary

component to ensure and facilitate safe team communication [27 28].

Since communication is more complicated than just sending a message between individuals

(se figure 1), the purpose of this exploratory study was to investigate the communication

during in-situ trauma team training, more specific; the use of CO and CLC during a simulated

emergency scenario, and (2) its relation to profession, age, gender, ethnicity, years in

profession, educational experience, work experience, and leadership style.

METHODS

Participants


training. Two of the teams were excluded from this analysis due to technical problems with

the recording equipment and one team was incomplete. Thus, the reported results are based on

16 teams with 96 participants in total (S n=16, AN n=16, RN n=16, RNA n=16, ENED n=16

and ENOT n=16). Before the training session, the participants were informed that the

recorded material would be treated in confidence and that they could leave the session

whenever they wished to. Individual informed consent was obtained before the start of each

training session.

Research setting

Page 7 of 99


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from



8




regular emergency room (ER) in the ED with the trauma team composed as according to the

trauma team manual currently in use at the ED. An advanced patient simulator (PS) was pre-



attending the training, the participants were asked to view a five-minute introductory video

about teamwork in emergency settings, with focus on collaboration and communication. In

this introductory video the importance of using CLC by giving feed back to the sender was

highlighted, e.g. when prescribing drugs or fluids or when asking for help with a pre-assigned

task.












Page 8 of 99


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from



9







Life Support programme (ATLS) [29] and the equivalent courses for nurses: the Trauma

Nursing Core Course (TNCC) [30] and Pre-Hospital Trauma Life Support (PHTLS) [31].To

increase the task load, systolic blood pressure was decreased to 48 mmHg when the PS was

transferred to the stretcher. The length of the simulation scenario was designed to last for 15

minutes before the instructor interrupted the session.

Data collection






The communication in the team was transcribed and categorized using the data analysis

software program NVivo 9. The communication was then quantified as CO (only step one

included) and CLC (all three steps included) (Figure 1), according to definitions set out in

advance [14 21]. The categorization and quantifications in the total number of CLC vs. CO in

each team were made by two of the authors and then discussed in the research group. The

Page 9 of 99


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from



10

number of CO and CLC initiated by the different individual team members in each team was

analyzed in relation to the independent variables.











by the leader (coercive, discussing, educating and negotiating cf. [32]) in each training session

was counted. The variable Authoritarian leadership style is the sum of coercive (orders,

commands) and educating (transferring knowledge) turn-constructional units [20]. Since the

variable is the sum of turn-constructional units it is a continuous variable and can vary

between 0 - ∞. In this study the variable Authoritarian leadership style varied between 0-20.

The variable Egalitarian leadership style is the sum of discussing (involved team members

agree in the decision-making process) and negotiating (disagreements between team members

in the decision-making process) turn-constructional units [20]. The variable is a continuous

variable, the sum of turn-constructional units, and can vary between 0 - ∞. In this study the

variable Egalitarian leadership style varied between 2-16.

Page 10 of 99


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from



11
















RESULTS




residents. All RNAs had postgraduate diploma in Specialist Nursing in Anaesthesia Care,

while only three of the RNs had a postgraduate diploma (in Pre-hospital Emergency Care).

The participants’ previous education and work experience are shown in Table 2.

Page 11 of 99


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from



12


Profession

Gender

male/female, n/n

Age

median (Q1, Q3)

Years in profession

median (Q1, Q3)

S 11/5 40 (30, 55) 4 (2, 23)

AN 10/6 40 (35, 45) 11 (4, 16)

RN 8/8 31 (30, 34) 5 (1, 6)

RNA 7/9 39 (34, 45) 10 (5, 16)

ENED 2/14 45 (37, 51) 17 (10, 30)

ENOT 2/14 50 (32, 55) 24 (6, 30)

Total 40/56 39 (32, 48) 9 (3, 18)



Work experience






n (%)



None 1 ≥2


S 6(37) 6(37) 4(25) 1(6) 11(69) 4 (25) 6(37) 6(37) 4(25)

AN 1(6) 6(37) 9(56) 3(19) 10(62) 3(19) 1(6) 9(56) 6(37)

RN 7(44) 5(31) 4(25) 8(50) 6(38) 2(12) 2(12) 9(56) 5(31)

RNA 2(12) 9856) 5(31) 4(25) 9(56) 3(19) 2(12) 9(56) 5(31)

ENED* 2(12) 4(25) 8(50) 9(56) 5(31) - 3(19) 9(56) 2(12)

ENOT 2(12) 10(62) 4(25) 7(44) 9(56) - 5(31) 6(37) 5(31)

Total* 20(21) 40(42) 34(35) 32(33) 50(52) 12(12) 19(20) 48(50) 27(28) *2 missing







Page 12 of 99


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from



13


Profession

CLC

n (%)

CO

n (%)

CLC/CO

% S 21 (47) 151 (47) 14

AN 12 (27) 93 (29) 13

RN 1 (2) 22 (7) 4

RNA 10 (22) 43 (14) 23

ENED 1 (2) 6 (2) 17

ENOT - 4 (1) -

Total 45 (100) 319 (100)









Page 13 of 99


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from



14


CO full model CO final model

RR 95 % CI p RR 95 % CI P

Profession

S 40.48 (26.28, 62.36) .000 32.63 (18.04, 59.00) .000

AN 21.76 (11.80, 40.11) .000 17.47 (8.99, 33.94) .000

RN 5.88 (3.08, 11.22) .000 5.36 (2.84, 10.14) .000

RNA 9.04 (4.49, 18.21) .000 8.17 (4.08, 16,34) .000

EN 1 1

Gender

Male .82 (0.56, 1.21) .310

Female 1

Ethnicity

Scandinavian 1.44 (0.82, 2.54) .203

Non-scandinavian 1

Leadership style

Authoritarian .99 (0.96, 1.04) .856

Egalitarian 1.01 (0.97, 1.05) .613

Age

Years 1.01 (0.97, 1.04) .678

Years in profession

≥11 years 1.28 (0.72, 2.29) .394 1.51 (1.10, 2.06) .011

≤10 years 1 1

Trauma course

≥2 .98 (0.65, 1.47) .925

1 .77 (0.53. 1.13) .184

None 1

Simulation training

≥2

1.17

(0.85, 1.61)

.348

1 1.10 (0.63, 1.92) .742

None 1

Most recent experience of trauma

≥1 year .86 (0.47, 1.58) .656 .93 (.60, 1.45) .761

<1 year 1.33 (0.83, 2.14) .298 1.43 (1.03, 1.99) .034

None 1 1

Page 14 of 99


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from



15















Page 15 of 99


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from



16


CLC full model CLC final model

RR 95 % CI p RR 95 % CI p

Profession

S 36.59 (4.21, 318.32) .001 34.87 (4.24, 286.94) .001

AN 19.36 (2.17, 172.99) .008 17.92 (2.36, 136.22) .005

RN 1.87 (0.13, 27.75) .649 1.42 (0.09, 23.36) .805

RNA 17.29 (1.89,158.07) .012 13.39 (1.62,110.54) .016

EN 1 1

Gender

Male 1.26 (0.66, 2.38) .481

Female 1

Ethnicity

Scandinavian 5.33 (1.49, 19.01) .010 4.46 (1.87, 10.65) .001

Non-

scandinavian

1 1

Leadership style

Authoritarian .84 (0.76, 0.94) .002 .85 (0.77, 0.93) .000

Egalitarian 1.61 (1.04, 1.31) .012 1.14 (1.04, 1.26) .007

Age

Years 1.02 (0.95, 1.10) .53

Years in

profession

≥11 years .97 (0.28, 3.32) .96

≤10 years 1

Trauma course

≥2 2.31 (0.70, 7.68) .171 3.17 (1.22, 8.24) .018

1 1.01 (0.28, 3.60) .991 1.67 (0.38, 3.60) .789

None 1 1

Simulation

training

≥2 .97 (0.41, 2.30) .951

1 .84 (0.36, 1.98) .686

None 1

Most recent

experience of

trauma

≥1 year .58 (0.12, 2.79) .494

<1 year 1.18 (0.41, 3.44) .760

None 1

Page 16 of 99


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from



17

DISCUSSION

Despite the explicit focus on the importance of communication in terms of CO and CLC, we

found that the difficulty in establishing a safe and reliable form of verbal communication

within the interdisciplinary team remained. We also found a limitation in usage of CLC in the

trauma teams, only one of seven CO led to a completed CLC and less than three CLC were

completed per team training session. Finally, we found that education in accordance with

trauma courses increased the use of CLC.






emphasized. Apparently there seems to be a gap between evidence-based knowledge in using

communication to obtain safety and practical implementation of the communication model in

team training. Similar results were found in resuscitation teams that successfully used CLC in

order to give verbal feedback in training situations, but the participants did not apply these

skills in cardiac arrest situations [26]. The content, didactics and learning objectives of the

training in communication are important to consider when trying to remedy this. The

participants’ main focus in our study was on completing their assigned tasks, and

communication appeared to be of minor importance. However, complex tasks require a more

distinct communication, which could be lost or misunderstood if the focus is mainly on the

tasks.

Page 17 of 99


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from



18




aware of completed tasks or important changes [33]. When there are too many call-outs being

sent out to no one in particular, there is a risk that the commands given will not make



compared to commands called out "in the air” that were less likely to lead to action [34].


members of resuscitations teams, thus having a negative influence on team performance [26].





members to speak up (cf [11 35]). An authoritarian leadership style meant a less common use

of CLC in the trauma teams. Speaking up is an important issue in interdisciplinary teams

where power conflicts between professionals (nurses and doctors) and within professions

(junior and senior doctors) can obstruct the delivery of crucial information about the patient to

the team.




Page 18 of 99


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from



19


with PS before this session and had also participated in more structured trauma courses.

In this study, having attended ≥ 2 structured trauma courses were associated with higher

frequency of initiating the use of CLC. Even though it is the ABCDE principles that are

trained during structured life support courses like ATLS, PHTLS and TNCC, repeated

training might provide a solid foundation for trauma care. The observed improved

performance in usage of CLC in an emergency situation after structured trauma courses might

in line with other studies showing that deliberate practice is key to excellence [36-38].

Confidence in how to manage a case medically might allow for better teamwork.

Studying leadership behaviours in the operating theatre, Parker, Yule, Flin and McKinley

found that communication were focused at optimizing technical skill performance rather than

ensure the team teambuilding [39]. Perhaps this reflects a common perception that

communication is something that can be taken for granted and therefore not necessarily needs

to be practiced. Asymmetrical power relations in interdisciplinary teams have been discussed

to influence the interaction and inhibit safety [3], In order to further investigate those factors

already described as being important for team communication, the effects of gender, ethnicity,

and years in profession were studied. In this study, it was having a Scandinavian background,

not one’s gender or years in the profession that determined a significant increase in the team

members’ use of CLC. In this study, all leaders in the trauma teams spoke Swedish fluently,

some leaders with an accent, which otherwise would have caused difficulties for the team

members. In general, language is an important factor for gaining and keeping power in

conversation [23], and a focus of research in the contexts of doctor-patient communication

Page 19 of 99


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from



20

[22]. Communication is complex and simple models might not solve the multi-faceted

problems interdisciplinary teams. Empirical studies of interdisciplinary teams are needed in

order to further study the factors influencing communication.

Limitations











CONCLUSIONS








Page 20 of 99


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from



21



Acknowledgements




Funding



Contributors



by MHa and ML.

Competing interests


Ethics approval

Page 21 of 99


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from



22


(Reg. no 09-106M).

References


Washington, D.C.: National Academy Press, 2000.

2. Lingard L, Espin S, Whyte S, et al. Communication failures in the operating room: an observational

classification of recurrent types and effects. Qual Saf Health Care 2004;13(5):330-4 doi:

13/5/330 [pii]

10.1136/qhc.13.5.330[published Online First: Epub Date]|.

3. Sutcliffe KM, Lewton E, Rosenthal MM. Communication failures: an insidious contributor to

medical mishaps. Acad Med 2004;79(2):186-94

4. Arora V, Johnson J, Lovinger D, et al. Communication failures in patient sign-out and suggestions

for improvement: a critical incident analysis. Qual Saf Health Care 2005;14(6):401-7 doi:

14/6/401 [pii]

10.1136/qshc.2005.015107[published Online First: Epub Date]|.

5. Reason J. Human error: models and management. BMJ 2000;320(7237):768-70

6. Gawande AA, Zinner MJ, Studdert DM, et al. Analysis of errors reported by surgeons at three teaching hospitals. Surgery 2003;133(6):614-21 doi: 10.1067/msy.2003.169[published Online

First: Epub Date]|.

7. Rabol LI, Andersen ML, Ostergaard D, et al. Descriptions of verbal communication errors between

staff. An analysis of 84 root cause analysis-reports from Danish hospitals. BMJ Qual Saf

2011;20(3):268-74 doi: DOI 10.1136/bmjqs.2010.040238[published Online First: Epub Date]|.

8. Nagpal K, Arora S, Vats A, et al. Failures in communication and information transfer across the

surgical care pathway: interview study. BMJ Qual Saf 2012;21(10):843-9 doi: 10.1136/bmjqs-

2012-000886[published Online First: Epub Date]|.

9. Lingard L, Whyte S, Espin S, et al. Towards safer interprofessional communication: constructing a model of "utility" from preoperative team briefings. J Interprof Care 2006;20(5):471-83 doi:

W32032851J855928 [pii]

10.1080/13561820600921865[published Online First: Epub Date]|.

10. Bergs EAG, Rutten FLPA, Tadros T, et al. Communication during trauma resuscitation: do we

know what is happening? Injury 2005;36(8):905-11 doi:

10.1016/j.injury.2004.12.047[published Online First: Epub Date]|.

11. Edmondson AC. Speaking up in the operating room: How team leaders promote learning in

interdisciplinary action teams. Journal of Management Studies 2003;40(6):1419-52

12. Cooper S, Wakelam A. Leadership of resuscitation teams: "Lighthouse Leadership'. Resuscitation 1999;42(1):27-45

13. Mishra A, Catchpole K, Dale T, et al. The influence of non-technical performance on technical

outcome in laparoscopic cholecystectomy. Surg Endosc 2008;22(1):68-73 doi:

10.1007/s00464-007-9346-1[published Online First: Epub Date]|.

Page 22 of 99


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from



23

14. Burke CS, Salas E, Wilson-Donnelly K, et al. How to turn a team of experts into an expert medical

team: guidance from the aviation and military communities. Qual Saf Health Care

2004;13:I96-I104 doi: 10.1136/qshc.2004.009829[published Online First: Epub Date]|.

15. Salas E, Wilson KA, Murphy CE, et al. Communicating, coordinating, and cooperating when lives depend on it: tips for teamwork. Jt Comm J Qual Patient Saf 2008;34(6):333-41

16. Lingard L, Espin S, Rubin B, et al. Getting teams to talk: development and pilot implementation of

a checklist to promote interprofessional communication in the OR. Qual Saf Health Care 2005;14(5):340-6 doi: 14/5/340 [pii]


17. Lingard L, Regehr G, Orser B, et al. Evaluation of a preoperative checklist and team briefing

among surgeons, nurses, and anesthesiologists to reduce failures in communication. Arch Surg

2008;143(1):12-7; discussion 18 doi: 143/1/12 [pii]

10.1001/archsurg.2007.21[published Online First: Epub Date]|. 18. Helmreich RL, Merritt AC, Wilhelm JA. The evolution of crew resource management training in

commercial aviation. International Journal of Aviation Psychology 1999;9(1):19-32

19. Sexton JB, Helmreich RL. Analyzing cockpit communications: the links between language,

performance, error, and workload. Hum Perf Extrem Environ 2000;5(1):63-8

20. Jacobsson M, Hargestam M, Hultin M, et al. Flexible knowledge repertoires; communication by

leaders in trauma teams. Scand J Trauma Resusc Emerg Med 2012;20(1):44 doi:

10.1186/1757-7241-20-44[published Online First: Epub Date]|.

21. Wilson KA, Salas E, Priest HA, et al. Errors in the heat of battle: taking a closer look at shared

cognition breakdowns through teamwork. Hum Factors 2007;49(2):243-56 22. Mishler EG. The discourse of medicine : dialectics of medical interviews. Norwood, N.J.: Ablex,

1984.

23. Fairclough N. Language and power. London: Longman, 1989.

24. Bowers CA, Jentsch F, Salas E, et al. Analyzing communication sequences for team training needs

assessment. Hum Factors 1998;40(4):672-79

25. Siassakos D, Bristowe K, Draycott TJ, et al. Clinical efficiency in a simulated emergency and

relationship to team behaviours: a multisite cross-sectional study. Br J Obstet Gynaecol 2011;118(5):596-607 doi: 10.1111/j.1471-0528.2010.02843.x[published Online First: Epub

Date]|.

26. Andersen PO, Jensen MK, Lippert A, et al. Identifying non-technical skills and barriers for improvement of teamwork in cardiac arrest teams. Resuscitation 2010;81(6):695-702 doi:

10.1016/j.resuscitation.2010.01.024[published Online First: Epub Date]|.

27. Rall M, Gaba D. Patients simulators. In: Miller RD, Afton-Bird G, eds. Anesthesia Vol 2. 6. ed. New York: Elsevier/Churchill Livingstone, 2005:xviii, 1617-3203 s., lix.


2005;36(5):555-99 doi: Doi 10.1177/1046496405277134[published Online First: Epub Date]|.

29. American College of Surgeons Committee on Trauma. ATLS : Advanced Trauma Life Support

Program for Doctors. 7th ed. Chicago, IL: American College of Surgeons, 2004.

30. Riksföreningen för sjuksköterskor inom Trauma (RST), Emergency Nurses Association. TNCC

manual : Trauma nursing core course. 5. uppl., ed. Bälinge: Riksföreningen för

sjuksköterskor inom Trauma, 2003.

31. National Association of Emergency Medical Technicians (U.S.). Pre-Hospital Trauma Life Support Committee., American College of Surgeons. Committee on Trauma. PHTLS :

prehospital trauma life support. Military 7th ed. St. Louis, MO: Mosby Jems/Elsevier, 2011.

32. Corbin JM, Strauss AL. The articulation of work through interaction. Sociol Quart 1993;34(1):71-83

33. Brindley PG, Reynolds SF. Improving verbal communication in critical care medicine. J Crit Care

2011;26(2):155-9 doi: 10.1016/j.jcrc.2011.03.004[published Online First: Epub Date]|.

Page 23 of 99


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from



24

34. Siassakos D, Draycott T, Montague I, et al. Content analysis of team communication in an

obstetric emergency scenario. J Obstet Gynaecol 2009;29(6):499-503 doi: Doi

10.1080/01443610903039153[published Online First: Epub Date]|.

35. Klein KJ, Ziegert JC, Knight AP, et al. Dynamic delegation: Hierarchical, shared and deindividualized leadership in extreme action teams. Adm Sci Q 2006;51(4):590-621

36. Holcomb JB, Dumire RD, Crommett JW, et al. Evaluation of trauma team performance using an

advanced human patient simulator for resuscitation training. J Trauma 2002;52(6):1078-85; discussion 85-6

37. Lee SK, Pardo M, Gaba D, et al. Trauma assessment training with a patient simulator: a

prospective, randomized study. J Trauma 2003;55(4):651-7 doi: 10.1097/01.TA.0000035092.83759.29[published Online First: Epub Date]|.

38. Ericsson K, Krampe R, Teschromer C. The role of deliberate practice in the acquisition of expert

performance. Psychological Review 1993;100(3):363-406 doi: 10.1037/0033-

295X.100.3.363[published Online First: Epub Date]|.

39. Parker SH, Yule S, Flin R, et al. Surgeons' leadership in the operating room: an observational

study. Am J Surg 2012;204(3):347-54 doi: DOI 10.1016/j.amjsurg.2011.03.009[published Online First: Epub Date]|.

Figure legends

Figure 1. Description of closed-loop communication. The sender (S) transmits the message,

call-out (CO), the receiver (R) acknowledge the message by check-back (2). The sender

verifies that the message is interpreted correctly: closed-loop communication (CLC) is

obtained (3).

Page 24 of 99


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from



Figure 1

1 - Call-out

2 - Check-back

3 - Closed-loop

S R

Page 25 of 99


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from



1

Communication in interdisciplinary teams: Exploring closed-loop communication during emergency situationsin-situ trauma team training

Maria Härgestam1,4



3 & Magnus Hultin

4










Sweden. [email protected],[email protected]

phone number +46-90786906846907869068, fax number +46 90786 91 6946907869169


Word count: 3422 3576

Formatted: English (U.K.)


Formatted: Font: Italic, English (U.K.)


Formatted: Font: +Body (Calibri), English(U.K.)

Formatted: Space After: 0 pt, Line spacing: Double

Formatted: Font: +Body (Calibri), Not Italic,English (U.K.)

Formatted: Font: +Body (Calibri), 11 pt, NotItalic, English (U.K.)

Formatted: Font: +Body (Calibri), 11 pt,English (U.K.)



Formatted: Font: Font color: Black, English(U.K.)


Page 26 of 99


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from



2

ARTICLE SUMMARY

Article focus:

• The challenge and necessity to improve communication skills in interdisciplinary

teams in order to secure patient safety.



• Structured team training focused on CRM-principles including COCommunication is

complicated and CLC are assumed to facilitate and increase safer communication in

trauma team during emergency situation.

• Profession, age, gender, ethnicity, years in profession, educational experience, work

experience and leadership style may affect several factors have influence on the team

members usecommunication and it is therefore of CLCgreat importance to study this

communication model in practice.

Key message:

• Previous participation in trauma team training with learning goals including the use of

CO and CLC did not increase the frequency of use of CLC.

• Having participated in two or more structured trauma courses (e.g. ATLS, TNCC and

PTHLS) correlated with increased use of CLC.

• The observed gap between having been taught and application of the communication

model emphasizesDespite the explicit focus on the importance of communication in

terms of CO and CLC, the difficulty in establishing a safe and reliable form of verbal

communication within the interdisciplinary team remained.

• There was a limited use of CLC in the teams during the in-situ trauma team training.

This indicates the need for validated training models combined with implementation

studies.













Formatted: Font: (Intl) Arial Unicode MS,English (U.K.)

Page 27 of 99


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from



3


• The team members participated in their own roles in their standard workingpositions

at the emergency department. Efforts were made to ensure the simulation training was

as authentic as possible.



• The limited use of CO and CLC in the teams makes it difficult to draw general

conclusions, but indicate. However, this study point out important issues for further

studies, especially the difficulties inwhich should pay attention to establishing safe

forms of verbal communication and the practical implementation of learning

objectives for non-technical skills in clinical practice.


Formatted: imported-Normal


Formatted: List Paragraph, None, Bulleted +Level: 1 + Aligned at: 0.25" + Indent at: 0.5"




Page 28 of 99


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from



4

Page 29 of 99


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from



5

ABSTRACT



years in profession, educational experience, work experience, and leadership style.


Setting: Trauma team training sessions during inIn-situ simulator-based interdisciplinary

team training using trauma cases at an emergency department.

Participants: The reported result was based on 16 trauma teams with totally 96 participants.

Each team consisted of two physicians, two registered nurses and two enrolled nurses. ,

identical to a standard trauma team.

Results: The results in this study showed that the use of CO and CLC in trauma teams was

limited, with an average of 20 CO and 2.8 CLC per team. Previous participation in trauma

team training did not increase the frequency of use of CLC while ≥2 structured trauma

courses correlated with increased use of CLC (RR 3.17, CI 1.22 to 8.24). All professions in

the trauma team were observed to initiate and terminate CLC (except for the enrolled nurse

from the OT). The frequency of team members’ use of CLC significantly increased with

egalitarian leadership style (RR 1.14, CI 1.04 to 1.26).

Conclusion: This study investigatesshowed that despite focus on the useimportance of

communication in terms of CO and CLC in trauma teams and factors that may increase, the

use amongdifficulty in achieving a safe and reliable verbal communication within the

interdisciplinary team members. The observed gap between what has been taught and the

practical use of the communication model emphasizesremained. This finding indicates the

need for validated training models combined with further implementation studies.






Formatted: Font: (Intl) Times New Roman,English (U.K.)







Page 30 of 99


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from



6



Exploring closed-loop communication during emergency situations

INTRODUCTION


into focus by the Institute of Medicine at the end of 1990s (1).[1]. When things go wrong it is


rather than the result of a single mistake by an individual (2-5).[2-5]. The change from

reliance on vigilant health care providers to the systematic prevention of errors has just

startedis a challenge in the future.


is the hand-over between and/or within departments (4, 6-8).[4 6-8]. Shortcomings also occur

within the interdisciplinary team where misunderstandings, language difficulties, interruptions

and hesitation to speak up (against authority) have been reported (3, 6, 9-11).[3 6 9-11].

Communication has been shown to be an important prerequisite for the team’s structure,

collaboration and task performance (9, 12, 13).[9 12 13].


and reduce the risk of miscommunication resulting in team breakdowns (14-17).[14-17].

Experience from the field of aviation has led to major changes with the development of team

Formatted: Font: Font color: Auto, English(U.K.)


Formatted: Font: Calibri, 11 pt, Not Bold,English (U.K.)















Page 31 of 99


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from



7

training concepts to increase safety, e.g. Crew Resource Management (18-20).[18-20].

Closed-loop communication (CLC), including call-out (CO), is an important part of the

concept based on the assumption that safe communication in an emergency situation is

achieved by standardized terminology and procedures (14, 15).[14 15]. CO is the first

verbalisation of an observation and makes the team aware of important changes, particularly

when something appears to be wrong. CLC can be described as a transmission model where

verbal feedback is of great importance to ensure that the team members correctly understand

the message. The communication strategy involves three steps; (1) the sender transmits a

message: the call-out (CO), (2) the receiver accepts the message and acknowledges its receipt;

the check-back, and (3) the sender verifies that the message has been received and interpreted

correctly (i.e. the loop is closed) (Figure 1) (14, 21). the loop is closed) (Figure 1) [14 21].

This advocated model assumes that communication is simple and clear. In practice

communication is more complicated and several other factors affect the transmission [22 23].

It is therefore of great importance to study if this communication model, suggested among

educators, is useful in complicated practical situations.

Insert Figure 1 about here, please.



more frequently and repeated commands more often than did low-performing teams (22).low-

performing teams [24]. Similar results were found when studying teams during simulation

training in cases of emergency obstetric care. Teams that described in clear terms the

emergency (CO) and used feedback (CLC) were more efficient in completing critical tasks

(administering Mg infusion during an eclamptic event) than were teams that were ambiguous

Formatted: Font: English (U.K.)


Formatted: Font: (Default) Times NewRoman, 12 pt, Font color: Auto, English (U.K.)



Formatted: Default Paragraph Font, Font:Times New Roman, 10 pt, English (U.K.)






Page 32 of 99


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from



8

in their communication (23). However, there might be a problem with transferring[25]. This

highlight that CLC skills might be transferred from the training environment to clinical praxis

(24)., and that use of CO followed by CLC probably increase patient safety [26].

The leaders’ communication styles influence the team’s task execution. In a previous study

we showed that trauma team leaders used a mix of authoritarian and egalitarian leadership

styles in order to achieve common goals (20). Leadership style is important as it determines

the culture within the team and can in turn influence how often team members speak up when

unexpected and urgent changes in a patient’s condition occur (11).

Errors occur frequentlyIn addition to the fact that communication according to CO as well as

CLC is of importance to optimize patient safety, also the leaders’ communication styles

influence the teams’ task execution. In a previous study we showed that trauma team leaders

used a mix of authoritarian and egalitarian leadership styles in order to achieve common goals

[20]. Leadership style determines the culture within the team and can in turn influence when

and how often team members speak up when unexpected and urgent changes in a patient’s

condition occur [11].

In sum; in order to prevent errors in health care and root cause analysis have pointed to

failures in team communication as being one of the major contributors to these (1). Team

training with patient simulators and facilitated debriefing with a focus on CRM have been

suggested as one remedy (25, 26). CLC has been assumed to be a necessary

elementcomponent to ensure and facilitate safe team communication (25, 27).[27 28].











Page 33 of 99


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from



9

TheSince communication is more complicated than just sending a message between

individuals (se figure 1), the purpose of this exploratory study was to investigate (1)the

communication during in-situ trauma team training, more specific; the use of CO and CLC

during a simulated emergency scenario, and (2) its relation to profession, age, gender,

ethnicity, years in profession, educational experience, work experience, and leadership style.

METHODS

Participants


training. Two of the teams were excluded from this analysis due to technical problems with

the recording equipment and one team was incomplete. Thus, the reported results are based on

16 teams with 96 participants in total (S n=16, AN n=16, RN n=16, RNA n=16, ENED n=16

and ENOT n=16). Before the training session, the participants were informed that the

recorded material would be treated in confidence and that they could leave the session

whenever they wished to. Individual informed consent was obtained before the start of each

training session.

Research setting
















Page 34 of 99


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from



10

regular emergency room (ER) in the ED. with the trauma team composed as according to the

trauma team manual currently in use at the ED. An advanced patient simulator (PS) was pre-



attending the training, the participants were asked to view ana five-minute introductory video

about teamwork in emergency settings, with the focus on collaboration and communication.

In this introductory video the importance of using CLC by giving feed back to the sender was

highlighted, e.g. when prescribing drugs or fluids or when asking for help with a pre-assigned

task.






















Page 35 of 99


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from



11





Life Support programme (ATLS) (28) and the equivalent courses for nurses: the Trauma

Nursing Core Course (TNCC) (29) and Pre-Hospital Trauma Life Support (PHTLS) (30). [29]

and the equivalent courses for nurses: the Trauma Nursing Core Course (TNCC) [30] and Pre-

Hospital Trauma Life Support (PHTLS) [31].To increase the task load, systolic blood

pressure was decreased to 48 mmHg when the PS was transferred to the stretcher. The length

of the simulation scenario was designed to last for 15 minutes before the instructor interrupted

the session.

Data collection






Closed-loopThe communication in the team was transcribed and categorized using the data

analysis software program NVivo 9. The communication was then quantified as CO (only

step one included) and CLC (all three steps included) (Figure 1), according to definitions set

out in advance (14, 21). Preliminary[14 21]. The categorization and quantifications in the total

number of CLC vs. CO in each team were made by two of the authors (MHa and MHu) and


















Page 36 of 99


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from



12

then discussed in the research group. The number of CO and CLC initiated by the different

individual team members in each team was analyzed in relation to the independent variables.











by the leader (coercive, discussing, educating and negotiating) in each training session was

counted (cf.(20)). cf. [32]) in each training session was counted. The variable Authoritarian

leadership style is the sum of coercive (orders, commands) and educating (transferring

knowledge) turn-constructional units (20).[20]. Since the variable is the sum of turn-

constructional units it is a continuous variable and can vary between 0 - ∞. In this study the

variable Authoritarian leadership style varied between 0-20. The variable Egalitarian

leadership style is the sum of discussing (involved team members agree in the decision-

making process) and negotiating (disagreements between team members in the decision-

making process) turn-constructional units (20).[20]. The variable is a continuous variable, the

sum of turn-constructional units, and can vary between 0 - ∞. In this study the variable

Egalitarian leadership style varied between 2-16.










Page 37 of 99


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from



13

Page 38 of 99


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from



14
















RESULTS




residents. All RNAs had postgraduate diploma in Specialist Nursing in AnesthesiaAnaesthesia

Care, while only three of the RNs had a postgraduate diploma (in Pre-hospital Emergency

Care). The participants’ previous education and work experience are shown in Table 2.






Formatted: Font: Bold, English (U.K.)




Formatted: Font: Font color: Auto, English

(U.K.)

Page 39 of 99


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from



15


Profession

Gender

male/female, n/n Age

median (Q1, Q3)

Years in profession

median (Q1, Q3)

S 11/5 40 (30, 55) 4 (2, 23)

AN 10/6 40 (35, 45) 11 (4, 16)

RN 8/8 31 (30, 34) 5 (1, 6)

RNA 7/9 39 (34, 45) 10 (5, 16)

ENED 2/14 45 (37, 51) 17 (10, 30)

ENOT 2/14 50 (32, 55) 24 (6, 30)

Total 40/56 39 (32, 48) 9 (3, 18)



Work experience






n (%)



None 1 ≥2


S 6(37) 6(37) 4(25) 1(6) 11(69) 4 (25) 6(37) 6(37) 4(25)

AN 1(6) 6(37) 9(56) 3(19) 10(62) 3(19) 1(6) 9(56) 6(37)

RN 7(44) 5(31) 4(25) 8(50) 6(38) 2(12) 2(12) 9(56) 5(31)

RNA 2(12) 9856) 5(31) 4(25) 9(56) 3(19) 2(12) 9(56) 5(31)

ENED* 2(12) 4(25) 8(50) 9(56) 5(31) - 3(19) 9(56) 2(12)

ENOT 2(12) 10(62) 4(25) 7(44) 9(56) - 5(31) 6(37) 5(31)

Total* 20(21) 40(42) 34(35) 32(33) 50(52) 12(12) 19(20) 48(50) 27(28)

*2 missing

Formatted ... [1]

Formatted ... [2]

Formatted Table ... [3]

Formatted ... [4]

Formatted ... [5]

Formatted ... [6]

Formatted ... [7]

Formatted ... [8]

Formatted ... [9]

Formatted ... [10]

Formatted ... [11]

Formatted ... [12]

Formatted ... [13]

Formatted ... [14]

Formatted ... [15]

Formatted ... [16]

Formatted ... [17]

Formatted ... [18]

Formatted ... [19]

Formatted ... [20]

Formatted ... [21]

Formatted ... [22]

Formatted ... [23]

Formatted ... [24]

Formatted ... [25]

Formatted ... [26]

Formatted ... [27]

Formatted ... [28]

Formatted ... [29]

Formatted ... [30]

Formatted ... [31]

Formatted ... [32]

Formatted ... [33]

Formatted ... [34]

Formatted ... [35]

Formatted ... [36]

Formatted ... [37]

Formatted ... [38]

Formatted ... [39]

Formatted ... [40]


Formatted ... [42]

Formatted ... [43]

Formatted ... [44]

Formatted ... [45]

Formatted ... [46]

Formatted ... [47]

Formatted ... [48]

Formatted ... [49]

Formatted ... [50]

Formatted ... [51]

Formatted ... [52]

Formatted ... [53]

Formatted ... [54]

Formatted ... [55]

Formatted ... [56]

Formatted ... [57]

Formatted ... [58]

Formatted ... [59]

Formatted ... [60]

Page 40 of 99


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from



16








Profession

CLC

n (%)

CO

n (%)

CLC/CO

%

S 21 (47) 151 (47) 14

AN 12 (27) 93 (29) 13

RN 1 (2) 22 (7) 4

RNA 10 (22) 43 (14) 23

ENED 1 (2) 6 (2) 17

ENOT - 4 (1) -

Total 45 (100) 319 (100)





Formatted ... [124]

Formatted ... [125]



Formatted Table


Formatted ... [126]

Formatted ... [127]

Formatted ... [128]

Formatted ... [129]

Formatted ... [130]

Formatted ... [131]

Formatted ... [132]

Formatted ... [133]

Formatted ... [134]

Formatted ... [135]

Formatted ... [136]

Formatted ... [137]

Formatted ... [138]

Formatted ... [139]


Formatted ... [140]

Formatted ... [141]

Formatted ... [142]

Formatted ... [143]

Formatted ... [144]

Formatted ... [145]

Formatted ... [146]

Formatted ... [147]

Formatted ... [148]

Formatted ... [149]

Formatted ... [150]

Formatted ... [151]

Formatted ... [152]

Formatted ... [153]

Formatted ... [154]

Formatted ... [155]

Formatted ... [156]

Formatted ... [157]

Formatted ... [158]


Formatted ... [159]

Formatted ... [160]

Page 41 of 99


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from



17






Formatted: Space After: 10 pt, Line spacing: Double, Tab stops: 1.9", Left

Page 42 of 99


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from



18


CO Fullfull model

CO Finalfinal model


Formatted: Font: 10 pt, English (U.K.)


Inserted Cells

Formatted Table

Formatted: Underline, English (U.K.)




Page 43 of 99


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from



19

Variable

Profession

S

AN

RN

RN

A

EN

Gender Mal

e

Fem

ale

Ethnicity

Scan

dina

vian

Non-

scan

dina

vian

Leadership style

Aut

horit

aria

n

Egal

itari

an

Age

Years in profession

≥11

years ≤10

years

Trauma course

≥ 2

1

Non

e

Simulation training

≥2

1

Non

e

Most recent

experience of

trauma

≥1ye

ar

<1

year

None

RR

95 % CI p RR 95 % CI pP Split Cells

Formatted Table
















Page 44 of 99


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from



20

Profession

S 40.48 (26.28, 62.36) .000 32.63 (18.04, 59.00) .000

AN 21.76 (11.80, 40.11) .000 17.47 (8.99, 33.94) .000

RN 5.88 (3.08, 11.22) .000 5.36 (2.84, 10.14) .000

RNA 9.04 (4.49, 18.21) .000 8.17 (4.08, 16,34) .000

EN 1 1

Gender Male .82 (0.56, 1.21) .310

Female 1

Ethnicity

Scandinavian 1.44 (0.82, 2.54) .203

Non-scandinavian 1

Leadership style

Authoritarian .99 (0.96, 1.04) .856

Egalitarian 1.01 (0.97, 1.05) .613

Age

Years 1.01 (0.97, 1.04) .678

Years in profession

≥11 years 1.28 (0.72, 2.29) .394 1.51 (1.10, 2.06) .011

≤10 years 1 1

Trauma course

≥2 .98 (0.65, 1.47) .925

1 .77 (0.53. 1.13) .184

None 1

Simulation training

≥2

1.17

(0.85, 1.61)

.348

1 1.10 (0.63, 1.92) .742

None 1

Most recent experience of trauma

≥1 year .86 (0.47, 1.58) .656 .93 (.60, 1.45) .761 <1 year 1.33 (0.83, 2.14) .298 1.43 (1.03, 1.99) .034

None 1 1

Split Cells ... [161]


Formatted ... [163]

Formatted ... [164]

Formatted ... [165]

Formatted ... [166]

Formatted ... [167]

Formatted ... [168]

Formatted ... [169]

Formatted ... [170]

Formatted ... [171]

Formatted ... [172]

Formatted ... [173]

Formatted ... [174]

Formatted ... [175]

Formatted ... [176]

Formatted ... [177]

Formatted ... [178]

Formatted ... [179]

Formatted ... [180]

Formatted ... [181]

Formatted ... [182]

Formatted ... [183]

Formatted ... [184]

Formatted ... [185]

Formatted ... [186]

Formatted ... [187]

Formatted ... [188]


Formatted ... [190]


Formatted ... [192]

Formatted ... [193]

Formatted ... [194]

Formatted ... [195]

Formatted ... [196]



Formatted ... [199]

Formatted ... [200]

Formatted ... [201]

Formatted ... [202]

Formatted ... [203]


Formatted ... [205]


Formatted ... [207]

Formatted ... [208]

Formatted ... [209]

Formatted ... [210]

Formatted ... [211]

Formatted ... [212]

Formatted ... [213]



Formatted ... [216]

Formatted ... [217]

Formatted ... [218]


Formatted ... [220]

Page 45 of 99


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from



21

Page 46 of 99


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from



22
















Page 47 of 99


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from



23


CLC Fullfull model

CLC Finalfinal model

Variable

Profession

S

AN

RN

RNA

EN

Gender

M

al

e F

e

m

al

e

Ethnicity

S

c

a

nd

i

n

a

v

ia

n

N

o

n

-

sc

a

n

d

i

na

v

ia

n

Leadership style

A

RR 95 % CI

p RR 95 % CI

p


Inserted Cells

Formatted Table





Split Cells

Formatted Table











Page 48 of 99


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from



24

u

t

h

o

ri

tari

a

n

E

g

al

it

a

ri

a

n

Age

Years in

profession

≥

1

1

y

e

a

rs

≤

1

0

ye

a

rs

Trauma course

≥2

1

N

o

n

e

Simulation

training

≥

2

1 N

o

n

e

Most recent

experience of





Page 49 of 99


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from



25

trauma

≥

1

y

e

ar

<

1

y

e

a

r

None

Profession

S 36.59 (4.21, 318.32) .001 34.87 (4.24, 286.94) .001 AN 19.36 (2.17, 172.99) .008 17.92 (2.36, 136.22) .005

RN 1.87 (0.13, 27.75) .649 1.42 (0.09, 23.36) .805

RNA 17.29 (1.89,158.07) .012 13.39 (1.62,110.54) .016

EN 1 1

Gender

Male 1.26 (0.66, 2.38) .481

Female 1

Ethnicity

Scandinavian 5.33 (1.49, 19.01) .010 4.46 (1.87, 10.65) .001

Non-

scandinavian

1 1

Leadership style

Authoritarian .84 (0.76, 0.94) .002 .85 (0.77, 0.93) .000

Egalitarian 1.61 (1.04, 1.31) .012 1.14 (1.04, 1.26) .007

Age

Years 1.02 (0.95, 1.10) .53

Years in

profession

≥11 years .97 (0.28, 3.32) .96

≤10 years 1

Trauma course

≥2 2.31 (0.70, 7.68) .171 3.17 (1.22, 8.24) .018 1 1.01 (0.28, 3.60) .991 1.67 (0.38, 3.60) .789

None 1 1

Simulation

training

≥2 .97 (0.41, 2.30) .951

Formatted ... [274]



Formatted ... [277]

Formatted ... [278]

Formatted ... [279]

Formatted ... [280]

Formatted ... [281]

Formatted ... [282]

Formatted ... [283]

Formatted ... [284]

Formatted ... [285]

Formatted ... [286]

Formatted ... [287]

Formatted ... [288]

Formatted ... [289]

Formatted ... [290]

Formatted ... [291]

Formatted ... [292]

Formatted ... [293]

Formatted ... [294]

Formatted ... [295]

Formatted ... [296]

Formatted ... [297]

Formatted ... [298]

Formatted ... [299]

Formatted ... [300]

Formatted ... [301]

Formatted ... [302]


Formatted ... [304]


Formatted ... [306]

Formatted ... [307]

Formatted ... [308]

Formatted ... [309]

Formatted ... [310]



Formatted ... [313]

Formatted ... [314]

Formatted ... [315]

Formatted ... [316]

Formatted ... [317]

Formatted ... [318]

Formatted ... [319]

Formatted ... [320]

Formatted ... [321]


Formatted ... [323]


Formatted ... [325]

Formatted ... [326]

Formatted ... [327]

Formatted ... [328]

Formatted ... [329]

Formatted ... [330]

Formatted ... [331]

Formatted ... [332]

Formatted ... [333]

Page 50 of 99


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from



26

1 .84 (0.36, 1.98) .686

None 1

Most recent

experience of

trauma

≥1 year .58 (0.12, 2.79) .494

<1 year 1.18 (0.41, 3.44) .760

None 1






Split Cells

Formatted Table










Page 51 of 99


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from



27

DISCUSSION

The main results in this study show that the use of CLC in the trauma teams was limited.

OnlyDespite the explicit focus on the importance of communication in terms of CO and CLC,

we found that the difficulty in establishing a safe and reliable form of verbal communication

within the interdisciplinary team remained. We also found a limitation in usage of CLC in the

trauma teams, only one of seven CO led to a completed CLC and less than three CLC were

completed per team training session. Finally, we found that education in accordance with

trauma courses increased the use of CLC.






emphasized. Apparently there seems to be a gap between theoreticalevidence-based

knowledge in using communication to obtain safety and the practical implementation of the

communication model in team training. Similar results were found in resuscitation teams that

successfully used CLC in order to give verbal feedback in training situations, but the

participants did not apply these skills in cardiac arrest situations (24).[26]. The content,

didactics and learning objectives of the training in communication are important to consider

when trying to remedy this. The present study found that despite the explicit focus on the

importance of communication in terms of CO and CLC, the difficulty in establishing a safe

and reliable form of verbal communication within the interdisciplinary team remained. The

participants’ main focus in our study was on completing their assigned tasks, and

communication appeared to be of minor importance. Studying leadership behaviors in the










Page 52 of 99


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from



28

operating theatre, Parker, Yule, Flin and McKinley found that collaboration and

communication were focused at optimizing technical skill performance rather than on

intentional teambuilding (31). Perhaps this reflects a common perception that communication

is something that canHowever, complex tasks require a more distinct communication, which

could be taken for granted and therefore not necessary to practice. lost or misunderstood if the

focus is mainly on the tasks.

In this study, having attended ≥ 2 structured trauma courses were associated with more

initiation of more CLC. Even though it is the ABCDE principle that are trained during

structured life support courses this repeated training may provide a solid foundation for

trauma care. Better performance in emergency situations are thus in line with other studies

showing that deliberate practice is key to excellence (32, 33).




aware of completed tasks or important changes (34).[33]. When there are too many call-outs

being sent out to no one in particular, there is a risk that the commands given will not make



compared to commands called out "in the air” that were less likely to lead to action (35).[34].


members of resuscitations teams, thus having a negative influence on team performance

(24).[26].




Formatted: Font: Times New Roman, 12 pt,English (U.K.)




Page 53 of 99


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from



29





members to speak up (cf (11, 36)).[11 35]). An authoritarian leadership style meant a less

common use of CLC in the trauma teams. Speaking up is an important issue in

interdisciplinary teams where power conflicts between professionals (nurses and doctors) and

within professions (junior and senior doctors) can obstruct the delivery of crucial information

about the patient to the team.





with PS before this session and had also participated in more structured trauma courses. As

has already been mentioned, the nurses’ vital role in a resuscitation team depends on (37, 38);

good communication skills, the ability to work independently and to prioritize tasks. These

skills, which develop with experience, improve the team's performance.

In this study, having attended ≥ 2 structured trauma courses were associated with higher

frequency of initiating the use of CLC. Even though it is the ABCDE principles that are

trained during structured life support courses like ATLS, PHTLS and TNCC, repeated

training might provide a solid foundation for trauma care. The observed improved

performance in usage of CLC in an emergency situation after structured trauma courses might


Formatted: Font color: Red, English (U.K.)

Page 54 of 99


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from



30

in line with other studies showing that deliberate practice is key to excellence [36-38].

Confidence in how to manage a case medically might allow for better teamwork.

Studying leadership behaviours in the operating theatre, Parker, Yule, Flin and McKinley

found that communication were focused at optimizing technical skill performance rather than

ensure the team teambuilding [39]. Perhaps this reflects a common perception that

communication is something that can be taken for granted and therefore not necessarily needs

to be practiced. Asymmetrical power relations in interdisciplinary teams mayhave been

discussed to influence the interaction and inhibit safety (3).[3], In order to further investigate

those factors already described as being important for team communication, the effects of

gender, ethnicity, and years in profession were studied. In this study, it was having a

Scandinavian background, not one’s gender or years in the profession that determined a

significant increase in the team members’ use of CLC. In this study, all leaders in the trauma

teams spoke Swedish fluently, some leaders with an accent, which otherwise would have

caused difficulties for the team members. In general, language is an important factor for

gaining and keeping power in conversation (39),[23], and a focus of research in the contexts

of doctor-patient communication (40).[22]. Communication is complex and simple models

might not solve the multi-faceted problems interdisciplinary teams. Empirical studies of

interdisciplinary teams are needed in order to further study the factors influencing

communication.







Page 55 of 99


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from



31

Limitations











CONCLUSIONS













Page 56 of 99


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from



32

Acknowledgements




Funding



Contributors



by MHa and ML.

Competing interests


Ethics approval


(Reg. no 09-106M).




Formatted: None, Space After: 10 pt, Linespacing: 1.5 lines


Page 57 of 99


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from



33

REFERENCES


Washington, D.C.: National Academy Press; 2000.

2. Lingard L, Espin S, Whyte S, Regehr G, Baker GR, Reznick R, et al. Communication

failures in the operating room: an observational classification of recurrent types and

effects. Qual Saf Health Care 2004;13:330-4.

3. Sutcliffe KM, Lewton E, Rosenthal MM. Communication failures: an insidious

contributor to medical mishaps. Acad Med 2004;79:186-94.

4. Arora V, Johnson J, Lovinger D, Humphrey HJ, Meltzer DO. Communication failures

in patient sign-out and suggestions for improvement: a critical incident analysis. Qual

Saf Health Care 2005;14:401-7.

5. Reason J. Human error: models and management. BMJ 2000;18: 768-70.

6. Gawande AA, Zinner MJ, Studdert DM, Brennan TA. Analysis of errors reported by

surgeons at three teaching hospitals. Surgery 2003;133:614-21.

7. Rabol LI, Andersen ML, Ostergaard D, Bjorn B, Lilja B, Mogensen T. Descriptions of

verbal communication errors between staff. An analysis of 84 root cause analysis-

reports from Danish hospitals. BMJ Qual Saf 2011;20:268-74.

8. Nagpal K, Arora S, Vats A, Wong HW, Sevdalis N, Vincent C, et al. Failures in

communication and information transfer across the surgical care pathway: interview

study. BMJ Qual Saf 2012;21:843-9.

9. Lingard L, Whyte S, Espin S, Baker GR, Orser B, Doran D. Towards safer

interprofessional communication: constructing a model of "utility" from preoperative

team briefings. J Interprof Care 2006;20:471-83.

10. Bergs EAG, Rutten FLPA, Tadros T, Krijnen P, Schipper IB. Communication during

trauma resuscitation: do we know what is happening? Injury 2005;36:905-11.

11. Edmondson AC. Speaking up in the operating room: How team leaders promote

learning in interdisciplinary action teams. Journal of Management Studies

2003;40:1419-52.

12. Cooper S, Wakelam A. Leadership of resuscitation teams: "Lighthouse Leadership'.

Resuscitation 1999;42:27-45.

13. Mishra A, Catchpole K, Dale T, McCulloch P. The influence of non-technical

performance on technical outcome in laparoscopic cholecystectomy. Surg Endosc

2008;22:68-73.

14. Burke CS, Salas E, Wilson-Donnelly K, Priest H. How to turn a team of experts into an

expert medical team: guidance from the aviation and military communities. Qual Saf

Health Care 2004;13:I96-I104.

15. Salas E, Wilson KA, Murphy CE, King H, Salisbury M. Communicating, coordinating,

and cooperating when lives depend on it: tips for teamwork. Jt Comm J Qual Patient

Saf 2008;34:333-41.

16. Lingard L, Espin S, Rubin B, Whyte S, Colmenares M, Baker GR, et al. Getting teams

to talk: development and pilot implementation of a checklist to promote

interprofessional communication in the OR. Qual Saf Health Care 2005;14:340-6.

17. Lingard L, Regehr G, Orser B, Reznick R, Baker GR, Doran D, et al. Evaluation of a

preoperative checklist and team briefing among surgeons, nurses, and anesthesiologists

to reduce failures in communication. Arch Surg 2008;143:12-7

Page 58 of 99


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from



34

18. Helmreich RL, Merritt AC, Wilhelm JA. The evolution of crew resource management

training in commercial aviation. International Journal of Aviation Psychology

1999;9:19-32.

19. Sexton JB, Helmreich RL. Analyzing cockpit communications: the links between

language, performance, error, and workload. Hum Perf Extrem Environ 2000;5:63-8.

20. Jacobsson M, Hargestam M, Hultin M, Brulin C. Flexible knowledge repertoires;

communication by leaders in trauma teams. Scand J Trauma Resusc Emerg Med

2012;20:44.

21. Wilson KA, Salas E, Priest HA, Andrews D. Errors in the heat of battle: taking a closer

look at shared cognition breakdowns through teamwork. Hum Factors 2007;49:243-56.

22. Bowers CA, Jentsch F, Salas E, Braun CC. Analyzing communication sequences for

team training needs assessment. Hum Factors 1998;40:672-9.

23. Siassakos D, Bristowe K, Draycott TJ, Angouri J, Hambly H, Winter C, et al. Clinical

efficiency in a simulated emergency and relationship to team behaviours: a multisite

cross-sectional study. Br J Obstet Gynaecol 2011;118:596-607.

24. Andersen PO, Jensen MK, Lippert A, Ostergaard D. Identifying non-technical skills and

barriers for improvement of teamwork in cardiac arrest teams. Resuscitation

2010;81:695-702.

25. Rall M, Gaba D. Patients simulators. In: Miller RD, Afton-Bird G, editors. Anesthesia

Vol 2. 6. ed. New York: Elsevier/Churchill Livingstone; 2005. p. xviii, 1617-3203 s.,

lix.

26. Issenberg SB, McGaghie WC, Hart IR, Mayer JW, Felner JM, Petrusa ER, et al.

Simulation technology for health care professional skills training and assessment. JAMA

: the journal of the American Medical Association 1999;282:861-6.


2005;36:555-99.

28. American College of Surgeons Committee on Trauma. ATLS : Advanced Trauma Life

Support Program for Doctors. 7th ed. Chicago, IL: American College of Surgeons;

2004.

29. Riksföreningen för sjuksköterskor inom Trauma (RST), Emergency Nurses Association.

TNCC manual : Trauma nursing core course. 5. uppl., ed. Bälinge: Riksföreningen för

sjuksköterskor inom Trauma; 2003.

30. National Association of Emergency Medical Technicians (U.S.). Pre-Hospital Trauma

Life Support Committee., American College of Surgeons. Committee on Trauma.

PHTLS : prehospital trauma life support. Military 7th ed. St. Louis, MO: Mosby

Jems/Elsevier; 2011.

31. Parker SH, Yule S, Flin R, McKinley A. Surgeons' leadership in the operating room: an

observational study. Am J Surg 2012;204:347-54.

32. Holcomb JB, Dumire RD, Crommett JW, Stamateris CE, Fagert MA, Cleveland JA, et

al. Evaluation of trauma team performance using an advanced human patient simulator

for resuscitation training. J Trauma. 2002;52:1078-85; discussion 85-6. PubMed PMID:

12045633. Epub 2002/06/05. eng.

33. Lee SK, Pardo M, Gaba D, Sowb Y, Dicker R, Straus EM, et al. Trauma assessment

training with a patient simulator: a prospective, randomized study. J Trauma.

2003;55:651-7. PubMed PMID: 14566118.

34. Brindley PG, Reynolds SF. Improving verbal communication in critical care medicine. J

Crit Care 2011;26:155-9.

Page 59 of 99


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from



35

35. Siassakos D, Draycott T, Montague I, Harris M. Content analysis of team

communication in an obstetric emergency scenario. J Obstet Gynaecol 2009;29:499-

503.

36. Klein KJ, Ziegert JC, Knight AP, Xiao Y. Dynamic delegation: Hierarchical, shared and

deindividualized leadership in extreme action teams. Adm Sci Q 2006;51:590-621.

37. Sinclair TD. The role of the rapid response nurse: hospitalwide and in trauma

resuscitations. J trauma nurs: the official journal of the Society of Trauma Nurses

2006;13:175-7.

38. Wurster LA, Coffey C, Haley K, Covert J. The role of the trauma nurse leader in a

pediatric trauma center. J trauma nurs: the official journal of the Society of Trauma

Nurses 2009;16:160-5.

39. Fairclough N. Language and power. London: Longman; 1989.

40. Mishler EG. The discourse of medicine : dialectics of medical interviews. Norwood,

N.J.: Ablex; 1984.

References

1. Kohn LT, Corrigan J, Donaldson MS. To err is human : building a safer health system. Washington, D.C.: National Academy Press, 2000.

2. Lingard L, Espin S, Whyte S, et al. Communication failures in the operating room: an observational classification of recurrent types and effects. Qual Saf Health Care 2004;13(5):330-4 doi:

13/5/330 [pii]

10.1136/qhc.13.5.330[published Online First: Epub Date]|.

3. Sutcliffe KM, Lewton E, Rosenthal MM. Communication failures: an insidious contributor to

medical mishaps. Acad Med 2004;79(2):186-94 4. Arora V, Johnson J, Lovinger D, et al. Communication failures in patient sign-out and suggestions

for improvement: a critical incident analysis. Qual Saf Health Care 2005;14(6):401-7 doi: 14/6/401 [pii]


5. Reason J. Human error: models and management. BMJ 2000;320(7237):768-70

6. Gawande AA, Zinner MJ, Studdert DM, et al. Analysis of errors reported by surgeons at three

teaching hospitals. Surgery 2003;133(6):614-21 doi: 10.1067/msy.2003.169[published Online

First: Epub Date]|.

7. Rabol LI, Andersen ML, Ostergaard D, et al. Descriptions of verbal communication errors between staff. An analysis of 84 root cause analysis-reports from Danish hospitals. BMJ Qual Saf

2011;20(3):268-74 doi: DOI 10.1136/bmjqs.2010.040238[published Online First: Epub Date]|. 8. Nagpal K, Arora S, Vats A, et al. Failures in communication and information transfer across the

surgical care pathway: interview study. BMJ Qual Saf 2012;21(10):843-9 doi: 10.1136/bmjqs-2012-000886[published Online First: Epub Date]|.

Page 60 of 99


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from



36

9. Lingard L, Whyte S, Espin S, et al. Towards safer interprofessional communication: constructing a

model of "utility" from preoperative team briefings. J Interprof Care 2006;20(5):471-83 doi: W32032851J855928 [pii]

10.1080/13561820600921865[published Online First: Epub Date]|. 10. Bergs EAG, Rutten FLPA, Tadros T, et al. Communication during trauma resuscitation: do we

know what is happening? Injury 2005;36(8):905-11 doi:

10.1016/j.injury.2004.12.047[published Online First: Epub Date]|.

11. Edmondson AC. Speaking up in the operating room: How team leaders promote learning in

interdisciplinary action teams. Journal of Management Studies 2003;40(6):1419-52

12. Cooper S, Wakelam A. Leadership of resuscitation teams: "Lighthouse Leadership'. Resuscitation

1999;42(1):27-45

13. Mishra A, Catchpole K, Dale T, et al. The influence of non-technical performance on technical

outcome in laparoscopic cholecystectomy. Surg Endosc 2008;22(1):68-73 doi:

10.1007/s00464-007-9346-1[published Online First: Epub Date]|. 14. Burke CS, Salas E, Wilson-Donnelly K, et al. How to turn a team of experts into an expert medical

team: guidance from the aviation and military communities. Qual Saf Health Care 2004;13:I96-I104 doi: 10.1136/qshc.2004.009829[published Online First: Epub Date]|.

15. Salas E, Wilson KA, Murphy CE, et al. Communicating, coordinating, and cooperating when lives

depend on it: tips for teamwork. Jt Comm J Qual Patient Saf 2008;34(6):333-41

16. Lingard L, Espin S, Rubin B, et al. Getting teams to talk: development and pilot implementation of

a checklist to promote interprofessional communication in the OR. Qual Saf Health Care

2005;14(5):340-6 doi: 14/5/340 [pii]

10.1136/qshc.2004.012377[published Online First: Epub Date]|. 17. Lingard L, Regehr G, Orser B, et al. Evaluation of a preoperative checklist and team briefing

among surgeons, nurses, and anesthesiologists to reduce failures in communication. Arch Surg 2008;143(1):12-7; discussion 18 doi: 143/1/12 [pii]

10.1001/archsurg.2007.21[published Online First: Epub Date]|.

18. Helmreich RL, Merritt AC, Wilhelm JA. The evolution of crew resource management training in

commercial aviation. International Journal of Aviation Psychology 1999;9(1):19-32

19. Sexton JB, Helmreich RL. Analyzing cockpit communications: the links between language,

performance, error, and workload. Hum Perf Extrem Environ 2000;5(1):63-8

20. Jacobsson M, Hargestam M, Hultin M, et al. Flexible knowledge repertoires; communication by leaders in trauma teams. Scand J Trauma Resusc Emerg Med 2012;20(1):44 doi:

10.1186/1757-7241-20-44[published Online First: Epub Date]|. 21. Wilson KA, Salas E, Priest HA, et al. Errors in the heat of battle: taking a closer look at shared

cognition breakdowns through teamwork. Hum Factors 2007;49(2):243-56 22. Mishler EG. The discourse of medicine : dialectics of medical interviews. Norwood, N.J.: Ablex,

1984. 23. Fairclough N. Language and power. London: Longman, 1989.

24. Bowers CA, Jentsch F, Salas E, et al. Analyzing communication sequences for team training needs

assessment. Hum Factors 1998;40(4):672-79

25. Siassakos D, Bristowe K, Draycott TJ, et al. Clinical efficiency in a simulated emergency and

relationship to team behaviours: a multisite cross-sectional study. Br J Obstet Gynaecol

2011;118(5):596-607 doi: 10.1111/j.1471-0528.2010.02843.x[published Online First: Epub Date]|.

26. Andersen PO, Jensen MK, Lippert A, et al. Identifying non-technical skills and barriers for improvement of teamwork in cardiac arrest teams. Resuscitation 2010;81(6):695-702 doi:

10.1016/j.resuscitation.2010.01.024[published Online First: Epub Date]|. 27. Rall M, Gaba D. Patients simulators. In: Miller RD, Afton-Bird G, eds. Anesthesia Vol 2. 6. ed.

New York: Elsevier/Churchill Livingstone, 2005:xviii, 1617-3203 s., lix.

Page 61 of 99


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from



37


2005;36(5):555-99 doi: Doi 10.1177/1046496405277134[published Online First: Epub Date]|. 29. American College of Surgeons Committee on Trauma. ATLS : Advanced Trauma Life Support

Program for Doctors. 7th ed. Chicago, IL: American College of Surgeons, 2004. 30. Riksföreningen för sjuksköterskor inom Trauma (RST), Emergency Nurses Association. TNCC

manual : Trauma nursing core course. 5. uppl., ed. Bälinge: Riksföreningen för

sjuksköterskor inom Trauma, 2003.

31. National Association of Emergency Medical Technicians (U.S.). Pre-Hospital Trauma Life

Support Committee., American College of Surgeons. Committee on Trauma. PHTLS :

prehospital trauma life support. Military 7th ed. St. Louis, MO: Mosby Jems/Elsevier, 2011.

32. Corbin JM, Strauss AL. The articulation of work through interaction. Sociol Quart 1993;34(1):71-

83

33. Brindley PG, Reynolds SF. Improving verbal communication in critical care medicine. J Crit Care

2011;26(2):155-9 doi: 10.1016/j.jcrc.2011.03.004[published Online First: Epub Date]|. 34. Siassakos D, Draycott T, Montague I, et al. Content analysis of team communication in an

obstetric emergency scenario. J Obstet Gynaecol 2009;29(6):499-503 doi: Doi 10.1080/01443610903039153[published Online First: Epub Date]|.

35. Klein KJ, Ziegert JC, Knight AP, et al. Dynamic delegation: Hierarchical, shared and

deindividualized leadership in extreme action teams. Adm Sci Q 2006;51(4):590-621

36. Holcomb JB, Dumire RD, Crommett JW, et al. Evaluation of trauma team performance using an

advanced human patient simulator for resuscitation training. J Trauma 2002;52(6):1078-85;

discussion 85-6

37. Lee SK, Pardo M, Gaba D, et al. Trauma assessment training with a patient simulator: a

prospective, randomized study. J Trauma 2003;55(4):651-7 doi: 10.1097/01.TA.0000035092.83759.29[published Online First: Epub Date]|.

38. Ericsson K, Krampe R, Teschromer C. The role of deliberate practice in the acquisition of expert performance. Psychological Review 1993;100(3):363-406 doi: 10.1037/0033-

295X.100.3.363[published Online First: Epub Date]|.

39. Parker SH, Yule S, Flin R, et al. Surgeons' leadership in the operating room: an observational

study. Am J Surg 2012;204(3):347-54 doi: DOI 10.1016/j.amjsurg.2011.03.009[published

Online First: Epub Date]|.

Figure legends

Figure 1. Description of closed-loop communication. The sender (S) transmits the message,

call-out (CO), the receiver (R) acknowledge the message by check-back (2). The sender

verifies that the message is interpreted correctly: closed-loop communication (CLC) is

obtained (3).

Formatted: Line spacing: Multiple 1.15 li


Formatted: Font: Not Bold, English (U.K.)


Formatted: Space After: 10 pt, Line spacing: Double, Font Alignment: Auto


Page 62 of 99


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from



38

Page 63 of 99


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from



9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

Page 64 of 99


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from



9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

Page 65 of 99


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from



9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

Page 66 of 99


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from



9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

Page 67 of 99


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from



9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

Page 68 of 99


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from



9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

Page 69 of 99


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from



9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

Page 70 of 99


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from



9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

Page 71 of 99


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from



9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

Page 72 of 99


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from



9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

Page 73 of 99


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from



9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

Page 74 of 99


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from



9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

Page 75 of 99


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from



9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

Page 76 of 99


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from



9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

Page 77 of 99


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from



9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

Page 78 of 99


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from



9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

Page 79 of 99


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from



9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

Page 80 of 99


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from



9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

Page 81 of 99


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from



9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

Page 82 of 99


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from



9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

Page 83 of 99


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from



9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

Page 84 of 99


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from



9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

Page 85 of 99


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from



9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

Page 86 of 99


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from



9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

Page 87 of 99


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from



9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

Page 88 of 99


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from



9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

Right, Space After: 0 pt, Line spacing: single, Position: Horizontal: Left, Relative to: Column, Vertical: In

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

g: single, Position: Horizontal: Left, Relative to: Column, Vertical: In line,

9/7/2013 8:52:00 PM

Page 89 of 99


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from



9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

Page 90 of 99


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from



9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

Page 91 of 99


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from



9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

Page 92 of 99


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from



9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

Page 93 of 99


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from



9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

Page 94 of 99


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from



9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

Page 95 of 99


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from



9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

Page 96 of 99


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from



9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

Page 97 of 99


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from



9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

9/7/2013 8:52:00 PM

Page 98 of 99


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from



Page 99 of 99


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


ctober 2013. Dow

nloaded from


Documents

BMJ OpenMaria Härgestam1,4, Marie Lindkvist2, Christine Brulin1, Maritha Jacobsson3 & Magnus Hultin4 1Department of Nursing, Umeå University, Umeå, Sweden 2Department of Statistics,