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Background
There is a great awareness that effective verbal communication among team members in emergency situations
plays an important role in the teams performance [14].
However, non-verbal communication must also be taken
into consideration since it represents more than 65 % of
the communication [5]. Leadership has been described
* Correspondence: maria.hargestam@umu.se
1
Department of Nursing, Ume University, S-90187 Ume, Sweden
2
Department of Surgical and Perioperative Sciences, Ume University,
S-90185 Ume, Sweden
Full list of author information is available at the end of the article
2016 Hrgestam et al. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Hrgestam et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2016) 24:37
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Methods
Participants
Hrgestam et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2016) 24:37
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Results
The team leaders non-verbal communication is described
below in terms of position and movement in the emergency room, gaze direction, vocal nuances, and gestures.
Excerpts are inserted to illuminate the leaders communication and how they used vocal nuances to emphasize
their message.
Position around the patient in the emergency room
Hrgestam et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2016) 24:37
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time while assessing and examining the patient simulator (Table 1). In team A, the leader gazed towards the
patient simulator and monitor 92 % of the time, while in
teams C and E the leaders gazed in this direction about
58 % of the time. It was notable that the team members
rarely made eye contact during the performance. Mutual
gaze was established when the leader was discussing the
priority of actions or treatment with the anaesthesiologist. Generally, the tasks were distributed by calling out,
without directing the commands to specific team members (but rather to someone) and without establishing
eye contact. A few leaders gazed around at the team,
Fig. 3 The leader has moved to the end of the bed; in this position,
their assessment is impeded. AN = anaesthesiologist, L = leader,
RN = registered nurse
Hrgestam et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2016) 24:37
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Table 1 The proportion of time (%) during team training when the team leaders gaze was directed toward the patient/monitor or
around at the team members in the emergency room, when the leader was silent or speaking, and when the leader used gestures
during silence or during speech
Team
Silence %
Speech %
Gestures during
silence %
Gestures during
speech %
Team A
92
37
63
74
85
Team B
63
37
74
26
44
41
Team C
58
42
60
40
45
28
Team D
78
22
83
17
51
36
Team E
58
42
56
44
43
82
Team F
85
15
61
39
28
79
Team G
81
19
76
24
68
31
Team H
73
27
73
27
56
62
Team I
68
32
94
42
57
Team J
72
28
46
54
60
30
Team K
69
31
66
34
67
18
Team L
86
14
78
22
63
34
Team M
86
14
73
27
30
24
Team N
73
27
84
16
36
33
Team O
89
11
75
25
77
Team P
67
33
67
33
63
27
Team R
70
30
80
20
12
15
Team S
56
44
70
30
58
43
Excerpt 1
Enrolled nurse from ED: Shall we insert the catheter?
Leader: Well insert ca-/yes we should not insert the
catheter, we can do that in theatre, this patient is still
bleeding, the most important thing is to go to
theatre and gain control of the bleeding (pause) but
no bleeding out, we see that he has a fast pulse, hes
bleeding internally and we have no idea what it looks
like (pause) an obvious case of laparotomy so the
Fig. 4 The leader uses a gesture (holding one hand up) to emphasize
that the team should not insert the catheter. An = anaesthesiologist,
L = leader, RN = registered nurse, RNA = registered nurse anaesthetist
Hrgestam et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2016) 24:37
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Hrgestam et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2016) 24:37
Discussion
The team leaders who gained control over the inner circle used clear non-verbal communication and positioned
themselves as heads of the team. They solidified their
verbal messages using gaze direction, vocal nuances, and
gestures. Team leaders who positioned themselves (or
were positioned) outside the inner circle were quiet,
gazed around at the team members, and made little use
of vocal nuances and gestures.
The inner circle is the most important space in the
emergency room. In this space, the leader can see both
the patient simulator and the monitor displaying vital
signs. In teams where the leader had control over the
inner circle, the members seemed to have an awareness
of each others roles and tasks, knowing when in time
and where in space these tasks needed to be executed.
This has also been described in surgical teams, where
coordination behaviours increased in critical situations
[22, 23]. The coordination between the scrub nurse and
the surgeon did not always involve verbal communication; rather, changes in the surgeons tone of voice and
body shifts indicated a change in the urgency of the patients status [22]. Changes in the surgical intervention
led to exchange of roles in the theatre. Moore et al [23]
described how the senior surgeon changed position and
took the intended role as the responsible surgeon when
the registrar stretched and distanced himself away from
the wound. According to the authors, understanding the
nuances of non-verbal communication could not only
improve teamwork but also increase patient safety, and
team members who are aware of how they use their
body to communicate can fine tune their performance
[23]. The results from an observational study on anaesthesia crews showed that the crew members adapted
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Hrgestam et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2016) 24:37
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This study has identified deficiencies in leaders nonverbal communication that lead to ambiguity in the teamwork and probably delay the care of the severely injured
patient. Communication cannot be taken for granted; it
needs to be practiced regularly just as technical skills need
to be trained. Simulation training provides healthcare
professionals as well as medical and nursing students the
opportunity to put both verbal and non-verbal communication in focus, in order to improve patient safety. It is
therefore important to further study trauma team communication, preferably during real emergency events.
There is a lack of studies on how characteristics such as
profession, gender, and ethnicity affect the communication
(both verbal and non-verbal) in interdisciplinary teams.
More studies are needed, preferably performed during real
emergency cases, to verify our results.
Limitations of the study
Hrgestam et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2016) 24:37
8.
Conclusions
The main conclusion in this study is that non-verbal communication reinforced the team-leaders communication.
Team leaders with access to the inner circle used gestures
to reinforce and emphasize their verbal communication,
in contrast to the leaders who were silent, and did not use
gestures, and were positioned and/or positioned themselves outside the inner circle. There is already a great
awareness of the importance of verbal communication in
trauma teams. This study deepens our understanding of
the importance of non-verbal communication, and shows
that non-verbal communication should also be taken into
consideration in the education of trauma team leaders.
The non-verbal communication also reinforced the team
leaders deficient verbal communication.
10.
Competing interests
The authors declare that they have no competing interests.
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Authors contributions
All authors were involved in the design of the study. MHm and MHn
collected the data, and MHm and MJ analysed the video-recorded material.
The results were fully discussed by all authors. All authors worked on the
preparation of the manuscript, and all approved the final manuscript.
Acknowledgements
This study was a part of Nordic Safety and Security (NSS), a project
sponsored by the European Union regional fund. The project was a
collaboration between Ume University, Vsterbotten County Council, Lule
Technical University, and the Swedish Defence Research Agency (FOI). The
study was also supported in part by the Laerdal Foundation and the County
Council of Vsterbotten (grant number VLL-154071).
Author details
1
Department of Nursing, Ume University, S-90187 Ume, Sweden.
2
Department of Surgical and Perioperative Sciences, Ume University,
S-90185 Ume, Sweden. 3Department of Social Work, Ume University,
S-90187 Ume, Sweden.
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