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Engaging Team Members
MellissaWard, LauraMorrison, CherylFfrench,
andDebrahWirtzfeld
10
Activation of the trauma team brings together a complex
assortment of individuals who need to come together under
high anxiety and stress in a fast-paced environment. It is
imperative that each person knows their role in caring for the
trauma patient. Trauma Systems Management has advanced
the knowledge of best practices to enhance survival and
decrease morbidity. An important aspect of trauma team
management is in engaging team members toward a common goal and keeping them focused on attaining these
important objectives. Engaging team members should be
considered as an important and strategic tactic for enhancing
overall individual and team performance. This chapter will
provide a cohesive and comprehensive approach to acquisition of skills to engage team members and enhance overall
team performance.
How toApproach This Chapter
Successfully engaging team members is achieved through
integrating new habits, purposefully relinquishing old habits,
and a developing a different way of seeing things. As such,
adoption of the ten principles of engaging team members
will require persistence and a shift in mindset. Reading this
chapter and being able to recite the important principles of
M. Ward (*)
Department of Surgery, University of Manitoba,
Winnipeg, MB, Canada
L. Morrison
Department of Surgery, Cumming School of Medicine,
University of Calgary, Calgary, AB, Canada
e-mail: laura.morrison1@ucalgary.ca
C. Ffrench
Department of Emergency Medicine, University of Manitoba,
Winnipeg, MB, Canada
D. Wirtzfeld
Department of Surgery, Faculty of Medicine and Dentistry
University of Alberta, Edmonton, AB, Canada
engaging team members is not enough. Engagement can
only be successfully achieved through repeated practice of
the principles outlined in this chapter. Leaders need to communicate what they require from team members, understand
what team members need from them, and be invested in the
time and dedication it will require to reach peak
performance.
The Dierence Between aGroup
ofIndividuals andaTeam
When a trauma code is activated, healthcare providers from
different disciplines come together for a common purpose: to
save a patient’s life. It is this unifying goal that distinguishes
these individuals as a team, rather than a group. A group is a
collection of individuals gathered or classed together, while
a team is a collection of individuals, each with independent
yet complementary talents, who share a clear and common
purpose [1]. The shared goal is distinct and specic to all
team members. At any given time in the emergency department, there are groups of doctors, nurses, respiratory therapists, healthcare aides, lab and radiology technicians,
orthopedic technicians, prehospital personnel, and more who
are working in concert with one another, yet may have separate goals. These same individuals become a team in the
moment a trauma code is activated. They are unied in the
goal of resuscitating a trauma patient, and each member of
the team has a distinct skillset which is essential for team
success. Although the make-up of the trauma team can vary
depending on the human resources available at the time, or at
the site, they share the same common goal during the time
the resuscitation is taking place.
Training and education of the trauma team have historically focused on task work — specically responsibilities of
each team member — with little emphasis on team development and management [2]. There is a pervasive belief that
effective team dynamics will naturally develop in a healthcare setting. This mentality is not seen in other professional
© Springer Nature Switzerland AG 2025
L. Marshall Gillman, S. Widder (eds.), Trauma Team Dynamics, https://doi.org/10.1007/978-3-031-86312-7_10
55
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M. Ward et al.
settings, which require the coordinated efforts of a team,
such as software development companies [2]. These organizations place team training around engagement and communication front and center in order to ensure organizational
goals are met and that teams succeed. The trauma team is a
unique entity in that it can change from day-to-day or even
from code to code in the same day. Each new team has to
function at its full potential in order to meet the patient’s
needs. For this reason, every member who participates in a
trauma code should be familiar with effective team dynamics. Effective teams have a designated leader; they trust their
members to perform their designated roles, and they often
oscillate from individual to team effort without direction [3,
4]. For example, the trauma team leader may rely on the
anesthesiologist to simultaneously assess and manage the
patient’s airway without giving specic directions on how or
what to do. At the same time, the lab technician may be preparing their supplies to draw blood from the patient while the
radiology technician is positioning the patient for an x-ray.
While tasks are being individually, yet simultaneously performed, the trauma team leader may then bring the team
back to a unied moment in order to review the current ndings and upcoming plan. The important skills of engaging
team members toward a common goal are not inherent; they
should be taught as a part of any trauma training.
What Do Leaders Require fromTheir Teams?
Ability toMeet Team Goals
Leaders, in the most general sense, want high levels of performance to achieve common goals. The overarching goal
for the trauma team is to salvage the patient and preserve
function [3]. There are a number of metrics used to measure
achievement of these goals through trauma care processes
and patient outcome measures. The most obvious patient
outcome is mortality. Other metrics include complication
rates, hospital readmissions, and length of stay. These metrics reect not just the trauma team care but also care
throughout their stay. Process measures can be more specic
to the trauma team and include securing the airway in low
GCS patients, reducing joint dislocation in under 1hour, and
transfer to ICU or surgery under 1hour, where needed [3].
Together these outcome and process metrics form the basis
of quality improvement programs [4]. Quality improvement
will be discussed further in Chaps. 27 and 28.
Achieving quality patient care relies on an expert team
with effective communication, efcient feedback, and team
member cohesion. These non-technical skills are more difcult to measure directly during trauma resuscitation and
patient care but are important markers of team function and
are necessary to achieve a shared goal [5]. Team performance
has been enhanced through video review of simulated resuscitations with established non-technical scoring systems [6].
Video-facilitated feedback is widely used in simulation and
has been demonstrated to improve future performance [7].
Further, the use of video-recording resuscitations in the clinical setting allows for review of real-life team performance
and may improve team clinical performance [8]. Time to
critical interventions such as establishing a denitive airway,
CT scanning, and transfer to the operating room are improved
[9]. Simulation-based training leads to a reduction in resuscitation time and time to task completion. However, use of this
tool has been limited, likely due to a combination of legal and
ethical issues associated with the inability to obtain patient
and provider consent in the setting of an acute trauma. Video
review of trauma will be discussed further in Chap. 15.
Team Cohesion andRelationship Building
High-functioning teams focus not only on their deliverables
or objectives but also on the team as an entity unto itself,
which must be developed and fostered [10]. When there is
strong group cohesion, there is a willingness to collaborate
and share ideas and feedback. Strong cohesion is associated
with both improved perceived team effectiveness and better
patient outcomes [11]. Cohesion develops when there are
shared goals, a shared commitment to accomplishing team
tasks, and a belief that teammates are trustworthy [12].
Trauma teams can improve their communication, commitment, and ultimately teamwork through simulation [13, 14].
Important to team cohesion is psychological safety, a culture where all team members feel comfortable speaking up
[15]. When team members feel safe speaking up, problems
can be addressed, and the positive reinforcement helps maintain the safety and cohesion within the group. When working
as a team, the result of any conversation or team interaction
will build the relationship capital necessary to future team
performance. These two aspects cannot happen in isolation,
rather they must happen in parallel. Successful trauma teams
epitomize this construct.
What Do Team Members Need fromTheir
Leaders?
A Sense ofBelonging
Diversity can be dened as the ways in which we are all different [16]. This denition does not attempt to dene a specic dominant group as the norm and others as being a
deviation from that. It denes all people as being important
entities unto themselves with differences which make them
unique. Inclusivity is how the voices and thoughts of the
10 Engaging Team Members
57
group are heard [16]. If diversity is the “what,” inclusivity is
the “how.” An inclusive environment in turn fosters each
individual’s sense of belonging which is felt when an individual experiences that their social group identity is both
connected with and accepted in an organization. Medicine
and surgery have typically placed value on hierarchical systems in both educational pathways and the clinical practice
environment. These types of leadership structures can introduce fear and anxiety in less empowered members of the
team and lead to detrimental divisions in the group dynamic.
More horizontal team structures, where every member of the
team feels valued, have been found to improve performance.
Furthermore, the best results stem from diverse teams; teams
that include members with differing viewpoints and perspectives [17]. Acceptance of diverse views is strengthened by
the degree of respect given to each perspective.
Respect
Respect is an offshoot of belonging that involves recognizing
each member for their specic strengths and contributions.
Specically, it is operationalized when an individual experiences a “culture of civility and positive regard for diverse
perspectives and ways of knowing” [16]. Not only does a
member of the team feel that they are accepted, they also
believe that their opinions and ideas are regarded with high
value. When an individual is respected, a psychologically
safe space is created for new ideas to be brought forward
which have the capacity to improve team performance.
Due to the high stakes environment of a trauma resuscitation, presenting new ideas can be challenging. Hjortdal etal.
conducted a series of interviews with trauma team members
at four different hospitals to obtain a deeper understanding of
the non-technical skills that are important to team members
[18]. They found that maintaining the authority of leadership
while providing constructive feedback or new ideas was
essential to preserving team condence. For example, feedback can be formulated as a question or a proposal: “What do
you think about the patient’s blood pressure?” In this way,
the team member can feel safe to make a contribution while
both being respected and respecting the leader.
information from the primary survey, inputs from the trauma
team) and relay ndings to the team in a calm, cool, and
condent manner. The ability of the leader to radiate condence in communication was highly regarded by team members, as it instilled condence in the whole team. This circles
back to the distinction of the trauma team as a team rather
than a group. The leader needs to be in frequent communication with the members of the team because their role may be
affected by ongoing developments. For example, if the leader
nds the patient to have a pneumothorax, the anesthesiologist should be aware of a possible impending compromise to
ventilation, the medical assistant can begin preparing a chest
tube kit, and the radiology technician can start setting up for
a post-procedural x-ray. Communication is vital to synchronizing the team’s efforts to save the patient.
Opportunities forContinued Growth
The transient nature of a trauma team allows one to conceptualize each trauma team activation as a single project. Each
trauma team activation should therefore culminate with a
review of successes and failures [19]. This can be done in the
form of an “after-action review” or a debrief. This stage is
key to not only highlighting excellence but serves as a time
to reect on possible areas of learning to enhance future performance. In the Advanced Trauma Life Support Training
model, the optimal time for the debrief is immediately after
the patient is transferred to denitive care. Effective team
behavior should be reinforced, and areas of excellence
should be highlighted. For example, the trauma team leader
might say, “I think we all did a great job minimizing extraneous noise in this code, let’s keep that up next time.”
Furthermore, this is an opportunity to openly share opinions
and discuss how the code went. General questions to consider include: What could we have done differently? What
have we learned for next time? Are there any actions we need
to take before our next trauma team activation? If a culture of
psychological safety and respect has been adequately developed in the team environment, the ow of feedback can be
multidirectional. The members will look for opportunities
for continued growth, as will the team leader. Chapter 63 will
discuss debrieng strategies further.
Bidirectional andOpen Communication
Critical to the success of any team, but distinctly important
in a trauma setting, is the ability of the leader to communicate effectively. In the interview series by Hjortdal etal., participants indicated that they appreciated leaders with the
ability to communicate distinctly and clearly [18]. The leader
must have the capacity to analyze multiple sources of information (e.g., handover from the emergency transport team,
Resources
In order to sustain a culture of continued growth, team members should have access to a number of resources. Most notably, within a trauma team activation, the availability of
adequately trained human resources is of utmost importance
[20]. This includes an experienced trauma team leader and a
full complement of team members, each with a clear
58
9
Competence
Time
M. Ward et al.
understanding of their roles. In addition, physical resources
to perform the resuscitation should be readily available and
accessible. Petroniak etal. analyzed the trafc patterns of
clinicians performing an emergency cricothyroidotomy during simulation and found that decreased travel was associated with a faster time-to-completion of the emergency
procedure. Analysis of the simulation revealed that the clinician with the most efcient performance used a pre-prepared
airway kit and delegated roles which included travelling to
obtain more equipment. This is an example of effective use
of resources in the trauma setting. Trauma bay design will be
covered further in Chap. 24. Furthermore, all members who
participate in trauma team activations should have the opportunity to engage in ongoing training which could include
specialty seminars, simulation-based training, and video
review [21].
The Four Stages ofCompetence
In the acquisition of skills and formation of new habits associated with the successful engagement of team members, one
moves from unconscious incompetence through various
stages until they nally arrive at a state of unconscious competence [22]. When someone initially takes on a new task,
they are not aware they do not possess the skills, habits, and
mindset required to be successful. This is the state of unconscious incompetence (Fig.10.1). Over time and with repeated
practice, they will eventually become aware they are incompetent and move into a state of conscious incompetence.
With this awareness, and further practice, often associated
with repeated failures and revisions, one moves into a state
of conscious competence where skills and tools are practiced
with intent. This requires conscious awareness and effort that
newly acquired skills and habits need to be continuously
practiced. One is consciously competent. Finally, one moves
to a state of skillful performance without having to devote
intentional energy and focus on their performance. This is
the state of unconscious competence and the end goal of
expertise.
The movement from unconscious incompetence to unconscious competence is not achieved solely by the acquisition
of new skills and habits. It often requires that old ways of
doing things need to be consciously forgotten. If your preferred approach in a trauma setting has been to assume the
position of an expert to whom everyone else on the team
defers, it will take effort to “get rid” of this old habit in addition to developing new habits which will more effectively
support successful team engagement. This is often the place
where the transition to new practices fail as people are willing to incorporate new skills but they are unable to give up
their old way of doing things. This is why it is important to
reect on old habits and how they detract from the goal of
engaging team members. Reversion to old habits should not
be seen as a failure and a signal that one cannot change. It
should be seen for just that—a reversion to an old, comfortable way of doing things. The goal is to move from a situation where time is spent in old habits and skills to one where
time is dedicated to new habits and skills. It takes time for
the brain to be rewired in this way as one moves through
from unconscious incompetence to a nal state of unconscious competence.
Fig. 10.1 Curtiss and Warren’s four stages of
competence model. (Modied from Curtiss and
Warren [22, p.89])
8
7
6
5
4
3
2
1
0
Unconscious
incompetence
Conscious
Incompetence
Conscious
Competence
Unconscious
Competence
10 Engaging Team Members
59
Ten Principles ofEngaging Team Members
There are ten principles behind engaging team members. In
moving from unconscious incompetence through to unconscious competence, leaders will need to make their teams
aware that engaging the team is an important goal of the
leader, as it should be for all team members. Open and frank
discussion about how to best engage the team will enhance
overall success.
1. Engage in Self-Reection
Self-reection can be undertaken as a series of conscious
questions one asks themselves during the attainment of new
skills. These questions include:
1. What happened during the trauma team activation and
resuscitation?
2. What was the result or impact?
3. What was the intended result or impact?
4. Why did I handle it that way (especially when one reverts
to old habits)?
5. How will I handle it in the future? What specic strategies will I employ?
An important aspect of reection is to ask what internal or
external aspects are continuing to support old habits. For
example, if seeing yourself as the team leader with the expertise to which everyone must defer is part of how you see
yourself, it will be important to recognize that this internal
vision which supports old habits must be altered. In the
moment, it will be important to remember that altering this
vision will lead to enhanced benets for the team, its individual members, and ultimately the patient.
2. Practice Active Listening
Active listening is a conscious activity whereby one focuses
on correctly interpreting what the other person is saying. The
distinction is found in hearing someone speak, but not understanding what is being said. This is a failure of listening, not
of hearing. All of the principles involved in engaging team
members can be tied back to active listening.
The components of active listening include the following
[23]:
1. Paying attention by blocking out distractions and refrain-
ing from preparing a rebuttal while the other person is
speaking,
2. Showing you are listening through open posture and eye
contact
3. Providing feedback by paraphrasing and asking questions
to clarify meaning
4. Deferring judgement by letting the other person nish
what they are saying and responding in turn
5. Responding appropriately by showing respect and being
open and honest in your responses
Active listening involves seeking to understand what the
other person is saying over waiting until they nish so you
can state your case. It is all about the other person.
3. Mentor Critical Thinking
To effectively engage their teams, leaders must ensure that
all members feel valued. A leader’s ability to mentor critical
thinking and allow members to develop and showcase their
strengths will signicantly enhance engagement [24]. The
concept of distributed leadership speaks to allowing all team
members to lead where their strengths permit. This requires
the leader to know their team members and be champions of
inclusivity on the team. This will allow the team to expand
the scope of their inuence and limit the effect of their weaknesses on the successful completion of team objectives. It is
the leader’s responsibility to ensure that team members know
their strengths in the team and that they are being supported
to lead in these areas. For example, team members should
have condence in their own abilities and be able to identify
when it is appropriate to act independently in pursuit of the
team goal. Exemplary critical thinking includes identifying
best evidence, addressing assumptions and biases, and critically appraising one’s own leadership styles within the team.
4. Provide Constructive Feedback
Providing feedback is essential to team engagement.
Feedback can be dened as specic information about the
comparison between an individual’s observed performance
and a recognized and known standard [25]. Leaders should
look for opportunities where feedback can be given, in the
moment, and with the intent to improve the overall performance of the individual and enhance team performance. It
should be encouraging, and if an error or mistake is made,
the leader should seek to determine what led to the error and
how things could be done differently next time. Feedback
should be coached in “I” statements about what was observed
and should recommend specic actionable behavior for
improvement. For example, the leader might say, “I noticed
you were standing behind everyone as you attempted to
monitor the patient’s vitals. I believe you were pushed aside
because your name tag was not visible. Next time, ensure
you speak up and that your name tag is visible. It will
improve the function of the team.” The feedback provided
should promote specic aspects of performance to be maintained (if the behavior enhances team function) or redirect
specic aspects performance in the future (if a change is nec-
60
M. Ward et al.
essary to improve team performance). This type of feedback,
known as directive feedback, is useful for small, simple
corrections. For more complex tasks and decision-making
inquiring about the person’s frame of reference when making
that choice can be more enlightening and help facilitate better discussion, engaging the team more effectively. This type
of technique is termed advocacy inquiry and will be discussed further in Chap. 63. An example might be “I noticed
you chose not to immediately intubate the patient on arrival.
I was concerned that he might obstruct his airway and I wondered if this should be done immediately. How did you see
your priorities at that moment?”. It may be that the leader
had a very rational thought process as to why that should be
delayed and if not inquired properly may never come to light.
5. Adopt a Spirit of Servant Leadership
Servant leadership, popularized by Robert K.Greenleaf, is a
style of leadership which serves others rst. He rst described
servant leadership as the natural feeling that one wants to
serve followed by a conscious choice to lead [26]. This distinction, which the leader is rst a servant and then a leader,
emphasizes the value of those being led. The leader’s primary job is to foster, nurture, and nourish the team members
to be the best they can be. Servant leaders work closely with
the members of their team to recognize strengths and weaknesses and to facilitate continuous improvement. This individual relationship building ultimately serves to strengthen
the team’s function as a whole. When members of the trauma
team are led by a servant leader, they recognize their importance within the team and will be motivated to perform at a
high level. Servant leadership also necessitates that all voices
are heard, communicated, and disseminated within the team
[27]. A spirit of servant leadership essentially labels that the
leader will focus on what the team needs: a sense of belonging, respect, open communication, opportunities for growth,
and necessary resources to succeed.
6. Offer Continual Encouragement
Team members must receive encouragement in order to be
motivated toward the goals or objectives of the team and as a
means of developing team relationships and supporting
cohesion among team members. Positive or re-enforcing
encouragement promotes self-efcacy, which supports
development of team relationships and cohesion among
members [28]. Continual surveillance of the situation for
opportunities to encourage successful performance will
enhance the overall function of the team. Unlike feedback,
encouragement does not necessarily need to be tagged to a
specic aspect of performance, rather it supports overall performance. It should also be used to recognize team members’ strengths and their necessary inclusion among those
with whom the team interacts. In the trauma team setting,
this may include recognition by the patient or the patient’s
family. Encouragement, like feedback, is time sensitive and
should be given only where appropriate.
7. Engage in Successful Dialogue
Engaging in dialogue is an active process, which requires
concentration through undivided attention, listening to body
language, and avoiding distractions [29]. It is estimated that
over 50% of the meaning of a conversation is conveyed
through non-verbal communication or body language [24].
Think about what it might mean if someone rolls their eyes,
looks or moves away, or crosses their arms during a conversation. More subtle aspects of body language might include
certain gestures others make when they anxious or nervous,
the speed or cadence of spoken language, or posture.
Dialogue is a way of communicating where the primary
aim is to seek to understand the other person rst—nothing
more and certainly nothing less. This can best be achieved
through active listening, which involves seeking clarication, asking questions to promote understanding, and paraphrasing [30]. It entails listening when one wants to speak,
especially when they feel the need to aggressively defend
their position though interrupting or speaking over others
[31]. Holding a successful dialogue is the rst element in
resolving conict effectively.
8. Resolve Conict Effectively
The rst step in resolving conict effectively is in recognizing that a leader must know what each side wants and they
must be willing to engage in a dialogue to establish common
ground [32]. A leader will need to shift from caring about
what they are saying, and in some situations interrupting to
get their point across, to actively listening to understand
what the other person is saying. Resolving conict is coached
in the ability to separate your interpretation of the events,
your story, from the actual facts of the situation [33]. Team
leaders must be able to get to a state of mutually agreeable
goals and ultimately, and they must be invested in a good
outcome for all parties. Often teams will have difculty
resolving conict because they have not dened a mutually
agreeable goal. In trying to develop ideas and strategies,
there is an inability to come to a consensus. For example, if
there are multiple people around the table and some of them
are interested in furthering the ability of the team to function
as a whole while others are interested in avoiding a lawsuit,
it may be difcult to come up with strategies which will actually achieve both. It must be recognized that active listening
and establishing a dialogue is paramount [32].
9. Set Realistic Expectations
The process of setting expectations is a dynamic and inclusive process [34]. Leaders must be willing to consult with
other team members to ensure that expectations align with
recognized personal strengths of team members and with the
10 Engaging Team Members
61
team’s needs as a whole. There must be a common understanding of why certain expectations exist and how they
align with the overall objectives of the team. Leaders should
consider delegating the development of expectations to others, especially to those whom the expectations will apply. In
the same way, responsibility for ensuring expectations are
met should be a joint responsibility of leaders, those to whom
the expectations apply, and the team as a whole as they seek
to dene where best to employ each member’s strengths.
There may be situations in which expectations need to be
achieved within a short time frame, and trauma teams are
commonly in this position. In these situations, it is important
that expectations of all members and the entire team are realistic and known in advance. We would not expect a very junior
member of the team to support the airway without appropriate
guidance and this should be clear to everyone on the team.
Expectations should be set before the situation arises where
they will need to be enacted. Unclear or unrealistic expectations will threaten the function of the team, engagement of
team members, and ultimately patient outcomes.
10. Look for Opportunities
Self-reection and actively listening, like other skills involved
in engaging teams, require one to look for opportunities. They
require conscious performance when one is in a space of
unconscious incompetence and through to unconscious competence. These skills require time and effort when one is rst
seeking to practice them consistently. The propensity to fall
back to bad habits will need to be specically kept in check in
strengthening these basic tenets, which are necessary for
addressing the ten principles of engaging team members.
Engaging Virtual Teams
Engaging virtual teams is become increasingly more important during COVID-19. Although trauma teams may not
engage virtually at the time of a trauma, some of the relationship building and simulation exercises may move to a virtual
format. Leaders need to recognize that within the environment of virtual teams all processes must be simplied,
clearly dened, and delegated appropriately [35]. It is the
responsibility of the leader to set the parameters with clear
direction and a shared mental model, including the roles to
be taken on by team members in the virtual setting. When
individuals understand their roles and other’s contributions
to the team, they are able to anticipate activities which can
decrease the effort needed to coordinate the team.
For a virtual team to function equivalently to a face-toface team requires more time and effort on the part of the
leader [36]. This is challenging in a traditional hierarchical
leadership model and can be supplemented with structural
supports such as routines and reward systems as well as
shared team leadership. This would include collaborative
decision-making, where appropriate, and shared responsibility, both of which contribute to trust and group cohesion.
Through frequent communication and shared responsibility,
leaders can adapt and effectively engage with virtual teams.
One of the ways of achieving this is through the development
of a communication charter.
Develop aCommunication Charter
One of the important challenges in virtual teams is the loss of
informal communication, including access to non-verbal cues,
meetings within meetings, and attention to emotional aspects
of the environment, which normally function to establish trust
through connectedness [37]. To overcome the loss of informal
communication, leaders can create prompts and rules to guide
discussion. A formal communication charter should be established which outlines how communication will take place in
the virtual setting such that all voices are heard and timely
discussions related to issues can be held [35]. A team charter
can also help maintain a common understanding of group purpose, which is a marker of a healthy team [38].
Virtual Water Cooler
In-person meetings and interactions are inclusive of the opportunity for team members to interact and strengthen team relationships and support cohesion [35]. This is an aspect which
has traditionally been missing from virtual interactions. An
example of introducing the opportunity for informal interaction into the virtual team setting has been to establish a virtual
water cooler [39]. Purposeful scheduling of white time as the
start of a meeting can allow people to interact outside of the
context of the meeting agenda. Allowing for informal break
out rooms can strengthen this concept.
Together, a communication charter and virtual water
cooler help to engage teams and create connectedness that
forms the basis of team trust. Addressing the challenges of
trust and informal communication help to create norms and
cohesion, which are essential to effective team function [35].
The Role ofSimulation in“Engaging Team
Members” Skill Development
Overall enhancement of patient care in the trauma team setting can be achieved through the acquisition of effective
team leadership skills, including engaging team members, in
a simulation-based environment [40]. Simulation-based
leadership development for trauma team leaders has been
employed with emergency medicine residents with self-
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M. Ward et al.
perceived improvements in pre-arrival brief and prioritization of tasks, both through enhanced communication and
engagement of team members. These results were found to
be maintained up to 24 months following the simulation
training. Patient outcomes were not specically evaluated.
Simulation can be used to dene team member roles and
allow communication around how to enhance efciencies,
enhance communication, and enhance empathy for the challenges of other members of the team [41]. For example, more
junior members can be provided with information on the role
they will play and what they need to focus on to be successful
and procient in that role. They can even be introduced to
slightly more complex roles, both in terms of specic tasks and
communication with other team members, and come to understand the impact they have on other team members and their
roles. The simulation setting is particularly responsive to learner’s needs and can help to develop a shared purpose of what it
means to engage teams in communication and collaboration.
Simulated trauma situations can be used to specically
dene the educational goals related to engaging team members [41]. Conict can be built into the situation by “planting
a mole” to evaluate and teach constructs related to the ten
principles of engagement, including speaking up in the face
of conict and providing effective feedback. A mole or confederate is a member of the simulation team who is instructed
to perform in a certain manner, without the knowledge of the
rest of the team members, in order to ensure the team reaches
a specic learning goal. The design of simulation scenarios
and curricula can be found in Chaps. 61 and 62. Simulation
is especially well suited to providing feedback in the moment
around specic educational goals, with the opportunity to
cement concepts through participation in an immediate second simulation following an effective debrief.
The debrief is an exceptionally important part of the simulation experience [42–45]. As such, those undertaking the
debrief must be trained in how best to perform this part of the
simulation. The debrief must be formative for learners and
identify what went well, what areas must be improved upon,
and how the learner can enhance their education to become
more procient. The debrieng process itself must be seen as
a way to continue to engage members involved in the simulation experience. Importantly, those performing the debrief
must be open to receiving feedback on their own debrieng
techniques in order to enhance the experience for future
learners. An introduction to basic debrieng techniques can
be found in Chap. 63.
Conclusion
Engaging team members is of primary importance to optimal
performance of the trauma team. Trauma teams are not static;
each activation will result in a team whose membership is dif-
ferent from the last. As such, trauma team leaders must recognize that their members will be at different points in
understanding their roles, interacting in teams, and responding under stress. The leadership skills involved in engaging
team members can be acquired, with simulation-based scenarios followed by appropriate debrieng being paramount.
Engagement of team members and ensuring appropriate team
function are as important to limiting morbidity and mortality
in the acute trauma setting as learning the ABCs of trauma.
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The Trouble withTeams: Practical Tools
forComplex Trauma Team Dynamics
ChristopherHicks andAndrewPetrosoniak
None of us is as smart as all of us.
– Ken Blanchard
11
Anyone who has worked in the complex ecosystem of teambased trauma resuscitation can attest to the notion that effective
teamwork is not intuitive, that a team of experts does not make
an expert team and that to function as a cohesive interprofessional is a unique and specic skill set separate but not
divorced from content or procedural knowledge. Exactly what
that skill set looks like can be difcult to pinpoint: At any given
time in a resuscitation, team members may be called upon to
speak up, to keep quiet, to act, to remain hands off, to work
together, to work independently, to work quickly or to slow
things down. That the issue is complex does not mean that solutions have to be—in effect, good team behaviors can be scaffolded along a set of practical and tangible concepts, and then
shaped by local, cultural and domain- specic understanding to
create elite, high reliability, expert- level group performance.
Implicit Coordination
At the summit of our understanding of elite team performance is the concept of implicit coordination, or the ability
to anticipate the needs of other team members in concert
with carrying out your own role without an excess amount of
chatter and cross-talking [1]. Effective teams tend to be surprisingly quiet, a concept that runs counter the Crisis
Resource Management (CRM) principle of verbalizing
thoughts or notion of “ying the patient”—a concept borrowed from aviation that describes the act of speaking aloud
your thought process for the rest of the team members to hear
[2]. Indeed, there is a time for speaking up, and a series of
concepts to support doing so effectively (discussed subsequently), but the concept of implicit communication is nonetheless a cornerstone of expert team performance. Implicit
coordination can be measured by way of an anticipation
ratio (AR), the frequency with which information is offered
compared to the frequency with which it is requested [3].
The implication is that if team members are provided the
information they need to carry out their roles without having
to ask (AR>1), the team is demonstrating implicit coordination by anticipating the needs of their fellow team members.
This is important because it suggests that a team has a shared
sense of situation awareness, current priorities, and anticipated next steps.
Implicit coordination is in turn predicated on the notion of
shared mental models: the idea that all team members have a
shared understanding of both team and task-based process for
a given clinical scenario [4]. Experimental studies in combat
aviation and military teams demonstrate that the degree to
which team members share mental models is directly correlated with mission success [5]. This is particularly relevant in
trauma resuscitation, where competing priorities can create
confusion and interfere with one another, predisposing to consequential delays as well as errors of omission and commission. The concepts that follow are selected deliberately to
facilitate the creation of shared, exible, and accurate mental
models for team-based trauma resuscitation, with the goal of
building capacity for implicit coordination.
The authors attest to having no relevant conicts of interest to declare.
Psychological Safety andEmotional
Contagion
C. Hicks (*) · A. Petrosoniak
St. Michael’s Hospital, Li Ka Shing Knowledge Institute,
Toronto, ON, Canada
Department of Medicine, University of Toronto,
Toronto, ON, Canada
e-mail: christopher.hicks@unityhealth.to
© Springer Nature Switzerland AG 2025
L. Marshall Gillman, S. Widder (eds.), Trauma Team Dynamics, https://doi.org/10.1007/978-3-031-86312-7_11
In order to function cohesively under stressful, timepressured conditions, team members need to be reassured
that they have the permission to ask questions, admit mistakes, or challenge the team leader. The key to facilitating
65