International Emergency Nursing 23 (2015) 37

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International Emergency Nursing

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The effect of a nurse team leader on communication and leadership in

major trauma resuscitations
Alana Clements RN, MEmergNurs (Clinical Nurse Consultant) a,*,
Kate Curtis RN, PhD (Clinical Nurse Consultant, Associate Professor) a,b,c,d,
Leanne Horvat RN, MN(NursPrac) (Clinical Stream Manager) e,
Ramon Z. Shaban RN, PhD (Professor) f
a

Trauma Service, St George Hospital, NSW, Australia

Sydney Nursing School, University of Sydney, Australia
c The George Institute for Global Health, Australia
d Faculty of Medicine, St George Clinical School, University of NSW, Australia
e South Eastern Sydney Local Health District, Australia
f
Centre for Health Practice Innovation, School of Nursing and Midwifery, Grith Health Institute, Grith University, Australia
b

A R T I C L E

I N F O

Article history:
Received 11 September 2013
Received in revised form 13 January 2014
Accepted 30 April 2014
Keywords:
Trauma
Leadership
Resuscitation
Nursing
Emergency
Communication

A B S T R A C T

Background: Effective assessment and resuscitation of trauma patients requires an organised, multidisciplinary team. Literature evaluating leadership roles of nurses in trauma resuscitation and their effect
on team performance is scarce.
Aim: To assess the effect of allocating the most senior nurse as team leader of trauma patient assessment and resuscitation on communication, documentation and perceptions of leadership within an Australian emergency department.
Methods: The study design was a pre-post-test survey of emergency nursing staff (working at resuscitation room level) perceptions of leadership, communication, and documentation before and after the
implementation of a nurse leader role. Patient records were audited focussing on initial resuscitation assessment, treatment, and nursing clinical entry. Descriptive statistical analyses were performed.
Results: Communication trended towards improvement. All (100%) respondents post-test stated they
had a good to excellent understanding of their role, compared to 93.2% pre-study. A decrease (58.1
12.5%) in intimidating personality as a negative aspect of communication. Nursing leadership had a 6.7%
increase in the proportion of those who reported nursing leadership to be good to excellent. Accuracy
of clinical documentation improved (P = 0.025).
Conclusion: Trauma nurse team leaders improve some aspects of communication and leadership. Development of trauma nurse leaders should be encouraged within trauma team training programmes.
Crown Copyright 2014 Published by Elsevier Ltd. All rights reserved.

1. Introduction
Traumatic injury accounts for 11% of global mortality and is a
leading cause of disability (Peden et al., 2002). Trauma affects society
on a physical, psychological and economical level (Lyons et al., 2010),
and in Australia injuries are one of the most costly disease groups
(Australian Institute of Health and Welfare, 2010).

AC, KC, and LH conceived and designed the study; AC, KC developed the study
protocol, designed and tested the study instruments; AC, KC and LH supervised
data collection; RS analysed the data; All authors prepared and approved the
manuscript.
* Corresponding author. Tel.: +61 02 9947 9865; fax: +61 02 9947 9879.
E-mail address: alana.clements@sesiahs.health.nsw.gov.au
http://dx.doi.org/10.1016/j.ienj.2014.04.004
1755-599X/Crown Copyright 2014 Published by Elsevier Ltd. All rights reserved.

Quality trauma care requires an integrated and resourced trauma

system. The aim of a trauma system is to facilitate the timely treatment of severely injured patients where resources are available for
their optimal management and rehabilitation. Trauma systems have
signicantly reduced trauma patient mortality in Australia (Cameron
et al., 2008; Curtis et al., 2012) and internationally (Celso et al., 2006;
Twijnstra et al., 2010).
Once the trauma patient has arrived at the trauma centre, inhospital trauma systems, such as trauma teams, are activated and
facilitate systematic clinical assessment and ongoing patient care
(Liberman et al., 2005; Teixeira et al., 2007). Quality and effective
initial assessment and resuscitation of trauma patients require a multidisciplinary trauma team led by medical and nursing staff (Cole
and Crichton, 2006; Georgiou and Lockey, 2010). Adopting a structured team-based approach to trauma care in resuscitation allows

A. Clements et al./International Emergency Nursing 23 (2015) 37

for simultaneous inputs to address the need for rapid resuscitation, stabilisation and to prioritise ongoing patient care (Georgiou
and Lockey, 2010).
Leadership, documentation (Calleja et al., 2011) and communication are an integral part of trauma team success in major trauma
resuscitation (Capella et al., 2010). As a matter of course, the
assessment and resuscitation of trauma patients at the study site
are initially managed by emergency physicians. A senior nurse with
resuscitation and training experience is allocated to each emergency department (ED) resuscitation room for the shift, and others attend
and assist when required for a resuscitation, such as a major trauma.
When a trauma call is activated, nurses are allocated to either the
airway, breathing and circulation or scribe roles. The resuscitation
nurse was traditionally assigned the role of airway nurse. The airway
nurses ability to maintain a comprehensive overview of their patients treatment and understanding of the denitive care plan, which
they were expected to contribute to, as well as provide a comprehensive clinical handover to other clinicians can be dicult when
focussed on particular tasks, such as airway management. Anecdotally, this lack of awareness of the patient process and plan created
frustration among the nursing staff and could potentially inhibit
patient care. There was also no formal nursing team leader, who
would delegate nursing roles and interventions in conjunction with
the medical team leader.
Nurses are integral to trauma and resuscitation in the ED, and
their contribution through quality clinical care in addition to effective communication, leadership, and team work ultimately enables
quality patient outcomes (Clements and Curtis, 2012). However, literature evaluating the role allocation of nurses in trauma resuscitation and their effect on team performance is scarce. We
hypothesised that allocating the most senior nurse as scribe and enhancing the role to include nursing leadership would improve
nursing documentation, awareness of the patients clinical condition, ongoing patient management plans by facilitating prioritisation
of nursing intervention and overall effective communication among
team members. This role would see the medical trauma team leader
and the nurse team leader work collaboratively in major trauma
resuscitations.
2. Aim
The aim of this study is to assess the effect of allocating the most
senior nurse as nurse team leader and scribe on effective communication, documentation, and perceptions of leadership in major
trauma resuscitations.
3. Methods
A pre-post test design was used employing survey and audit
methods. The study was conducted from March 2011 (pre-test),
implementation (AprilMay 2011) to July 2011 (post-test) at St
George Hospital a major trauma centre in Sydney, Australia. St George
Hospital is the fourth busiest in NSW and treated 66,507 patients
in 2012. Over 1700 trauma patients presented in 2012, and of those
over 350 were severely injured (injury severity score >12) are admitted annually.
3.1. Data collection tools
Two tools were developed to test the hypothesis. A staff survey
to determine perceptions of leadership, effective communication and
awareness of patient plan and a medical record audit form to determine the quality of the documentation.
The survey was developed using an expert group of four trauma
and emergency resuscitation nurse clinicians and nurse academics. Survey questions were developed using the expert group con-

sensus and were based on key positive and negative leadership

concepts described in the literature, such as decision making, instruction, effective communication, intimidation, knowledge, and
initiation of treatment (Cole and Crichton, 2006; Cooper and
Wakelam, 1999). These themes were identied from a formal literature review around nursing leadership and resuscitation
(Clements and Curtis, 2012). The survey had 10 questions using a
variety of response formats: Likert scale, checklist, and openended questioning (Table 1). For example,
When you are the resuscitation nurse in a major trauma how
aware are you of the injuries?
Participants were able to provide written comment after each
question. The survey was piloted by ve clinicians for feedback on
usability and content validity. Survey results were compared pre and
post implementation of the nurse team leader role.
Patient medical records underwent a retrospective documentation audit using a modication of a validated tool to compare completeness and detail of nursing documentation (Calleja et al., 2011).
The audit tool enabled data extraction from three aspects of the
trauma resuscitation episode of care. These were (1) initial resuscitation assessment and patient demographics (such as mechanism of injury, vital signs, demographics and medical history), (2)
resuscitation treatment (e.g. medication/intravenous uid administration, investigations and interventions) and (3) the clinical nursing
entry (that describes a summary of the patient assessment, patient
progress and management plan). All these components were reviewed as being complete or incomplete, including the nursing entry
which was assessed for clarication of the patient assessment, progress and plan which are integral components of trauma patient care
documentation.
3.2. Participants
Following ethics approval, all emergency nursing staff working
at resuscitation room level were invited to participate in the study
(pre n = 57, post n = 52). The survey was limited to nursing staff as
this was a nursing role change, nurses are the consistent workforce in the ED, and the intent of the role change was to improve
nursing communication.
3.3. Data collection process
A survey was placed in their staff pigeonhole/mailbox before the
implementation of the new role. The pre-survey was available for
staff completion 2 months before the trauma nurse leader role was
implemented. An introduction letter explained the purpose, anonymity, voluntary nature and dissemination intent of the research. A survey box was placed in the ED staffroom for completed
survey forms. The surveys were collected regularly during the
2 month period.
The medical records for audit were identied using the St George
Hospital trauma database. Trauma data are collected prospectively on all trauma patient presentations and include demographics,
length of stay, injury severity score (ISS) and complications.
This database enabled the identication of patients that were classied as a major trauma (ISS >12) and received a trauma team
activation.
3.4. Role implementation
A process of engagement and consultation with the ED and
trauma service nursing and medical consultants resulted in the
formalisation of a nurse trauma team leader role. The senior nurse
role became scribe and nurse team leader for trauma and resuscitation. The scribe component of the role ensured the nurse leader

A. Clements et al./International Emergency Nursing 23 (2015) 37

Table 1
Perceptions of leadership and communication in major trauma survey results*.
Question

Pre (n = 31)
n (%)

Post (n = 24)
n (%)

I understand what my role is during a major trauma resuscitation?

Poor/average
Good/very good/excellent
How well do you think nurses lead an after hours major trauma resuscitation in the traumas you have been involved in?
Poor/average
Good/very good/excellent
When you are the resuscitation nurse in a major trauma how aware are you of the injuries?
Never/rarely/sometimes
Most of the time/always
How do you rate the overall level of verbal communication regarding the patient management plan and
progress between all members of the trauma team in a major trauma resuscitation?
Poor/average
Good/very good/excellent
Of the choices below what do you feel are negative aspects of communication that occur in a major trauma
resuscitations you have been involved in?
Intimidating personality
No identication team member
Unclear instructions
No documentation
Language barrier
Workload
Absent verbal patient plan
Of the choices below what do you feel are positive aspects of communication in a major trauma resuscitation?
Approachable personality
Clear instructions
Verbal patient plan
Audible instruction
Dened team leader
Identication of team members
Clear documentation
How do you rate the overall level of communication between nursing staff in an after hours major trauma
resuscitations you have been involved in?
Poor
Average
Good
Very good
Excellent

(n = 31)
2 (6.5)
29 (93.5)
(n = 29)
13 (44.8)
16 (55.2)
(n = 31)
2 (6.5)
29 (93.5)
(n = 30)

(n = 24)
0 (0)
24 (100.0)
(n = 21)
8 (38.1)
13 (61.9)
(n = 23)
0 (0.0)
23 (100.0)
(n = 20)

8 (26.7)
22 (73.3)

4 (20.0)
16 (80.0)

18 (58.1)
18 (58.1)
16 (51.6)
11 (35.5)
3 (9.7)
10 (32.3)
19 (61.3)

3 (12.5)
10 (41.7)
19 (79.2)
10 (41.7)
3 (12.5)
11 (45.8)
17 (70.8)

20 (64.5)
23 (74.2)
19 (61.3)
20 (64.5)
20 (64.5)
16 (51.6)
22 (71.0)
(n = 29)

18 (75.0)
18 (75.0)
14 (58.3)
17 (70.8)
18 (75.0)
10 (41.7)
13 (54.2)
(n = 22)

0 (0)
1 (3.5)
11 (37.9)
11 (37.9)
6 (20.7)

0 (0)
2 (9.1)
5 (22.7)
11 (50.0)
4 (18.2)

* Cell sizes were too small (n < 5) to perform McNemars Chi square or Wilcoxon singed-rank tests on the majority of items. No signicant relationships were seen for
those items containing larger cell sizes.

had a comprehensive, real time overview of patient care. The leadership component of the role then enabled the nurse leader to work
in conjunction with the medical team leader, prioritise nursing interventions and facilitate effective team communication. While the
medical team leader has overarching responsibility, the medical and
nurse team leaders work collaboratively. Education was provided
to nurses working at resuscitation level over a 2 month period on
the roles and responsibilities of being a nurse team leader. This education included leadership skills, clinical care, conict management, and graded assertiveness by formal and informal education
methods, regular in-service and mentoring during a resuscitation.
Prior to the implementation of the new role, resuscitation nursing
staff completed an in-service on the denition, purpose and responsibilities involved in the role. During the implementation, the
trauma and emergency nurse consultants and educators mentored
nurses in their new role by using a shadow strategy during a major
trauma resuscitation to provide expert advice and guidance.
3.5. Data analysis
The data were obtained in a de-identied form and only aggregate data are reported. Data were entered into excel and imported
into SPSS Version 20.0 (Statistical Package for the Social Sciences
(SPSS), 2010) for analysis. Analysis of the survey results was restricted due to the small variable cell sizes. Due to the condential
and non-identiable nature of data, it is not known if the same participants completed the pre and post questionnaires, although

it is likely that a proportion did. For this reason it has been assumed
that data samples are matched, dependent data and a pre-post analysis was conducted. All binary (yes/no) data were analysed using
McNemars chi square analysis. Ordinal data were analysed using
the Wilcoxon signed-rank test. Medical Record documentation
audits used independent samples and were analysed using
Chi-square analysis.
4. Results
4.1. Survey
In this study, 31 (55%) nurses completed the pre-test survey and
24 the post-test survey (48%). Communication trended towards improvement with the nursing team leader role implementation. There
were 73% (pre) compared to 80% (post) felt that overall communication was good to excellent, and the incidence of very good to excellent nursing communication increased from 58.6% (pre) to 68.2%
(post). All respondents post-test stated they had a good to excellent understanding of their role, compared to 93.2% prior. Post intervention there was a decrease in intimidating personality as a
negative aspect of communication and leadership in major trauma
resuscitation, from 58.1% (n = 18) to 12.5% (n = 3) and a decrease in
no team member identication (from 58% to 42%).
Nursing leadership improved post implementation of the nurse
team leader role. There was a 6.8% decrease in respondents who
felt nursing leadership was poor/average and a 6.7% increase in the

A. Clements et al./International Emergency Nursing 23 (2015) 37

Table 2
Documentation quality pre and post nurse leader role implementation.

Trauma admission sheet (answer of

yes to the following:)
(a) MOI
(b) MOI specics (e.g. height of fall,
speed of MVC)
(c) Ambulance treatment
(d) Initial obs (complete)
(e) Initial BP manual
(f) 15 min obs per protocol for 1st hour
(g) First hourly temperature
(h) Patient details name, age, DOB
(i) Patient med history
Resuscitation ow chart
(a) Allergies
(b) IV access identication
(c) Medication charted
(d) Fluids charted
(e) Investigations documented
(f) Chart singed by MO
Clinical notes nursing entry
(a) MOI
(b) Primary survey ndings
(c) Injuries
(d) Investigations
(e) Interventions
(f) Patient plan

Pre
n (%)*
(n = 40)

Post
n (%)*
(n = 40)

Sig (P)

40 (100.0)
37 (92.5)

39 (97.5)
37 (92.5)

37 (92.5)
36 (90.0)
8 (20.0)
30 (78.9)
18 (47.4)
40 (100.0)
36 (90.0)

33 (82.5)
37 (92.5)
19 (47.5)
27 (69.2)
22 (56.4)
38 (95.0)
33 (82.5)

30 (90.9)
29 (87.9)
32 (100.0)
28 (96.6)
19 (59.4)
11 (33.3)

30 (93.8)
33 (97.1)
33 (100.0)
26 (92.9)
18 (52.9)
17 (50.0)

36 (90.0)
34 (85.0)
15 (37.5)
34 (85.0)
33 (82.5)
34 (85.0)

37 (92.5)
33 (82.5)
25 (62.5)
31 (77.5)
36 (94.7)
30 (75.0)

0.009
0.331
0.427

0.599
0.167

0.762
0.025
0.390

0.264

* Percentages are based on numbers of responders.

Cell sizes were too small (n < 5) to perform analyses on these items.

proportion of those who felt nursing leadership was good to excellent. One participant recorded on their survey responses when
asked how aware they were of the patients injuries and plan:
In the leadership and/or scribe role I am very aware. As the airway
nurse variably as you can get tunnel vision in the role or[only] just
hear due to softly spoken voices or just general noise. Another nurse
commented that knowledge of the patients injury and condition
improved with a nurse leader in charge of the trauma and resuscitation: The primary nurse knows about the patients injuries and
treatment plan properly.
Prior to the nurse team leader role, respondents noted that communication was poor and problematic. As one respondent noted:
Often there is simply too much noise and therefore poor communication and interaction. We all need clear direction on any given resus[citation] and effective communication. Participant A.
4.2. Medical records audit
There was an improvement in the recording of the rst blood
pressure being performed manually rather than with an automated device (2(1) = 6.765, P = 0.009). The clinical nursing entry
that describes a summary of the patient assessment, patient progress and plan was improved in terms of the accuracy of injuries
(2(1) = 5.00, P = 0.025). No other signicant changes were seen
(Table 2).
5. Discussion
The results of this study reinforce the evidence that nurses contribute to the effective communication and functioning of the trauma
team. The introduction of a nurse team leader improved perceptions of nursing leadership in our ED. The leadership role required
the nurse to oversee the trauma resuscitation in conjunction with
the medical team leader. The overseeing concept enables the leader
to compile a structured team which is known to work more har-

moniously and perform the tasks of resuscitation more effectively

(Cooper and Wakelam, 1999). Leadership along with competence,
communication and the status of the patient inuences the culture
of the trauma team (Cole and Crichton, 2006). Wurster et al. (Wurster
et al., 2009) suggested that advanced autonomous trauma nurses
who are able to identify and resolve issues in the trauma room
improve team performance for trauma patients, enhance group cohesion, communication and documentation. The development of
trauma nurse team leaders should be encouraged within trauma
team training programmes.
The allocation of an experienced emergency nurse to this role
is supported by Cudmore (Cudmore, 1996) who reported that nurses
working with trauma patients are most condent when they have
more than 2 years trauma experience. Experience, condence and
knowledge within the resuscitation team environment are assisted by targeted team training and contribute to the development of leadership skills (Mahoney, 2008). Capella (Capella et al.,
2010) demonstrated that trauma team training signicantly improves team performance and ecacy of patient care, although the
contribution of the nurse was not examined independently. Team
dynamics are subject to constant change in relation to human factors
such as personalities, experience and communication skills which
impedes robust investigation into individual roles. Further, as is
typical in any ED, a wide variety of patient presentations and injuries can affect a teams performance which results in study design
complexities (Yun et al., 2005).
Verbal and written communication directly relate to patient outcomes (Hindle et al., 2005). The main issues around trauma care communication processes include a lack of clarity during clinical
handovers including missing or inaccurate information given and
poorly documented care (Calleja et al., 2011). The implementation
of a nurse team leader improved verbal communication in major
trauma resuscitations in our ED and to a lesser degree written communication. This study could be explained by the small sample size,
the pre-existing high quality of documentation, patient stability or
a lack of resources equating to time constraints and the nurse
prioritising verbal communication and patient care above written
documentation, all of which are known barriers (Calleja et al., 2010).
An increase in nurse patient ratios may go some way to address this
(Dueld et al., 2011), although the onus remains on nurses to be
proactive in ascertaining and communicating information regarding patient care (Curtis et al., 2011). For example, these ndings are
applicable to other resuscitation contexts, for example a rapid response nurse. A rapid response nurse is a member of a team who
responds to deteriorating patients outside of the ED or ICU environment has been shown to be effective in leadership, improving
team dynamics, the identication of patient deterioration, improving patient outcomes and communication (Gilligan et al., 2005; Jolley
et al., 2007). The trauma leadership role could be further enhanced by extending the leadership role past the ED to the inpatient setting. Fecura (Fecura et al., 2008) demonstrated that trauma
nurse coordinators in the military setting showed improved performance in trauma care by improving patient care processes, policy
renements, and clinical practice guidelines implementation. The
military setting and trauma case management model are known to
reduce inpatient complication rates while improving communication (Curtis et al., 2006).
This study was limited by the small sample size necessitated by
a single site and specic population. Further research is required to
evaluate this role with the medical team members and its effect on
patient outcomes.
6. Conclusion
Trauma nurse team leaders improve leadership and communication in trauma resuscitations. The knowledge, trauma

A. Clements et al./International Emergency Nursing 23 (2015) 37

experience and assertiveness of senior nurses contribute to the effective functioning of the trauma team. The development of trauma
nurse leaders should be encouraged within trauma team training
programmes.

Acknowledgement
The authors acknowledge Kerri Holzhauser for her assistance with
survey design and preliminary analyses and Pauline Calleja for
sharing her trauma medical record audit.

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