269 Factors Affecting Leadership Style in Trauma Teams: A Qualitative Analysis

Abstract

The most recent American Trauma Life Support guidelines have emphasized the importance of strong leadership in trauma teams. Prior research has shown that strong leadership improves processes of care. However, the optimal leadership style for trauma is largely unstudied. In this study, we seek to understand the perceived optimal leadership style for trauma resuscitations, and the factors the impact these perceptions. We conducted semi-structured interviews with 23 members of trauma teams (emergency physicians, trauma surgeons, and emergency nurses) at a large, urban level 1 trauma center. With a modified grounded theory approach and the qualitative analysis program Dedoose, we developed a set of 27 codes describing the phenomena of leadership in trauma resuscitations. Two researchers coded the transcripts independently using a rigorous coding system. After 4 rounds of coding, we developed our final codebook, which demonstrated excellent agreement (pooled K=0.83). Transcripts were analyzed in an iterative process until broad categorical themes arose from the initial codes. We reviewed over 250 pages of transcripts line by line. In an iterative process over 4 rounds, we developed a code book with 26 codes describing the phenomena of leadership in trauma care. From the data, patient acuity emerged as the factor that most affected the participants’ perception of ideal leadership style. With severely injured patients, interviewees perceived that leadership style should be more direct and leaders in these cases should be more hands-on and use simple commands. The time to be collegial or to allow for other team members to propose care plans was considered detrimental to patient care. For example: “With the critical patients, the patients that are sickest, and that I am the most worried about, that's when I'm gonna be the most direct, have a very low threshold to speak in more of a direct tone to my colleagues, ER and trauma included.” (Trauma Fellow) “The patient condition essentially dictates if I need to have a direct style, and how direct I need to be... if the patient is a trauma, then there’s got to be a direct leadership style and if the patient is acutely crashing and I am getting ready to do an ED thoracotomy, then it’s even more direct, so, definitely I think the patient condition dictates.” (Trauma Fellow) “With any high acuity situation is, if the person who is in charge doesn’t make it known that they are in charge, then it kind of falls to pieces, then other people start trying⋯ to fill the silence, and then that kind of make confusion happen.” (ED Attending) With stable patients, interviewees perceived that leadership style should be more empowering, allowing time for collaboration and joint decisionmaking, which was recognized to have benefits. “Well, I think it depends on the patient, how sick the patient is. You know, for a very stable trauma, everyone kind of works together - usually it's really quick. So when everyone knows their role, we all work together, people chime out, chime in and out as far as what the patient has or is presented with and then sometimes you can wrap it up.” (ED Nurse) Trauma providers perceive that the injury level of the patient affects the ideal leadership style. More severely injured patients require a direct style while less severely injured patients can be managed with a collaborative style. Leaders should consider modifying their management style based on the patient’s injury status.