Elsevier

Journal of Surgical Education

Volume 73, Issue 1, January–February 2016, Pages 31-39
Journal of Surgical Education

Original Reports
A Video Analysis of Intra- and Interprofessional Leadership Behaviors Within “The Burns Suite”: Identifying Key Leadership Models

https://doi.org/10.1016/j.jsurg.2015.09.011Get rights and content

Objective

Leadership is particularly important in complex highly interprofessional health care contexts involving a number of staff, some from the same specialty (intraprofessional), and others from different specialties (interprofessional). The authors recently published the concept of “The Burns Suite” (TBS) as a novel simulation tool to deliver interprofessional and teamwork training. It is unclear which leadership behaviors are the most important in an interprofessional burns resuscitation scenario, and whether they can be modeled on to current leadership theory. The purpose of this study was to perform a comprehensive video analysis of leadership behaviors within TBS.

Methods

A total of 3 burns resuscitation simulations within TBS were recorded. The video analysis was grounded-theory inspired. Using predefined criteria, actions/interactions deemed as leadership behaviors were identified. Using an inductive iterative process, 8 main leadership behaviors were identified. Cohen’s κ coefficient was used to measure inter-rater agreement and calculated as κ = 0.7 (substantial agreement). Each video was watched 4 times, focusing on 1 of the 4 team members per viewing (senior surgeon, senior nurse, trainee surgeon, and trainee nurse). The frequency and types of leadership behavior of each of the 4 team members were recorded. Statistical significance to assess any differences was assessed using analysis of variance, whereby a p < 0.05 was taken to be significant. Leadership behaviors were triangulated with verbal cues and actions from the videos.

Results

All 3 scenarios were successfully completed. The mean scenario length was 22 minutes. A total of 362 leadership behaviors were recorded from the 12 participants. The most evident leadership behaviors of all team members were adhering to guidelines (which effectively equates to following Advanced Trauma and Life Support/Emergency Management of Severe Burns resuscitation guidelines and hence “maintaining standards”), followed by making decisions. Although in terms of total frequency the senior surgeon engaged in more leadership behaviors compared with the entire team, statistically there was no significant difference between all 4 members within the 8 leadership categories. This analysis highlights that “distributed leadership” was predominant, whereby leadership was “distributed” or “shared” among team members. The leadership behaviors within TBS also seemed to fall in line with the “direction, alignment, and commitment” ontology.

Conclusions

Effective leadership is essential for successful functioning of work teams and accomplishment of task goals. As the resuscitation of a patient with major burns is a dynamic event, team leaders require flexibility in their leadership behaviors to effectively adapt to changing situations. Understanding leadership behaviors of different team members within an authentic simulation can identify important behaviors required to optimize nontechnical skills in a major resuscitation. Furthermore, attempting to map these behaviors on to leadership models can help further our understanding of leadership theory. Collectively this can aid the development of refined simulation scenarios for team members, and can be extrapolated into other areas of simulation-based team training and interprofessional education.

Introduction

Key leadership attributes are well defined in the literature and in the context of surgery encompass multiple virtues, which include technical competence, professionalism, motivation, innovation, teamwork, effective communication, emotional competence, and teaching; they can be developed through observation, experience, and education.1 Leadership is particularly important in complex highly interprofessional health care contexts involving a number of staff, some from the same specialty (intraprofessional), and others from different specialties (interprofessional). Recently interprofessional teamwork has become an important aspect of work in health care.2 Maximizing patient safety and reducing medical errors depends not only on technical expertise but also on how decisions are made and how relevant information is communicated and tasks are coordinated.

It is well established that simulation can play a powerful role in clinical training.3 Educational theory highlights the importance of contextualized simulation for effective learning.4 An important aspect of surgical practice is the ability to function effectively in a setting where team members share responsibility of the patient during a procedure.3 Such elements are more complex and much harder to define than technical skills. Often they are invisible when working well, surfacing only when things go wrong. A more satisfactory conception of effective simulation may therefore highlight it as a spectrum of resources alongside clinical care to complement its richness. Within the appropriate context and design, simulation may therefore provide a unique opportunity to help trainees/residents develop adequate leadership skills, within the surgical environment. Simulation-based team training (SBTT) and debriefing is an evolving educational strategy that encourages work-based learning, collaboration, and teamwork.5 Current SBTT programs often include targets and feedback focused on the whole team or leader or both, ignoring the “follower” as a unique entity. Such programs do not fully appreciate and recreate the dynamic realities and complexities of team leadership, where the follower is as important or leadership is “shared.”6

Dedicated simulation facilities are scarce, expensive, and resource intensive. To maximize the value of immersive simulation, it should be available to all those who require it. A novel, low-cost, high-fidelity, portable, immersive simulation environment (referred to as distributed simulation or DS) has recently been developed.3 This concept has been shown to be effective for the delivery of burns education to both surgical experts and novices within an acute resuscitation scenario, denoted as “The Burns Suite” (TBS).7 TBS was also shown to be a novel simulation tool to deliver interprofessional training and SBTT in a burns resuscitation scenario comprising doctors and nurses.8

Over the last decade there has been an interest in exploring leadership behaviors of trauma resuscitation teams9, 10, 11, 12 and surgeons.13, 14, 15 Künzle et al.12 examined intraprofessional leadership behaviors of anesthetists within a simulated airway induction on a mannequin in the operating room. They reported the effectiveness of shared (or distributed) leadership in situations with high task complexity and indicated that a clear distribution of content-oriented and structuring leadership of team members is an effective strategy. Henrickson Parker et al.13 have recently published the Surgeon’s Leadership Inventory (SLI) to rate surgeon’s intraoperative leadership behaviors. This was proposed following an in-depth analysis of the surgical and leadership literature, combined with data from focus group interviews with expert surgeons. They reported 8 domains for the SLI: maintaining standards, making decisions, managing resources, directing, training, supporting others, communicating, and coping with pressure. Although the SLI domains primarily indicate behaviors observed in the operating room, potentially they may be explored for use in working environments such as the resuscitation room (where, although the procedure is not an actual technical operation, the behaviors required to achieve a successful resuscitation require a combination of technical and nontechnical skills).

The dynamics of a team within a resuscitation scenario can be complex. It is unknown which leadership behaviors are the most important and whether they can be modeled on to current leadership theory. Exploring this may inform the development of future leadership scenarios within TBS, specifically if the use of TBS were to further expand into the delivery of “nontechnical skills.” Given the fact that TBS is a novel realistic simulation modality comprising an immersive portable simulation environment and authentic clinical scenario, the purpose of this study was to perform a comprehensive video analysis of leadership behaviors within TBS, to explore whether SBTT within TBS can elaborate on key leadership theories, and which leadership models appeared predominant within TBS.

Section snippets

Materials and Methods

This study had approval from the Imperial College London ethics committee. Using a wide-angle Sony HD camcorder, 3 burns resuscitation simulations within TBS were recorded and were available for analysis. The inclusion criteria were (1) a complete (i.e., start to finish) scenario recording and (2) clear audio quality requisite to capturing all communication between the burns resuscitation team. All 3 videos met these criteria and were scrutinized.

A total of 12 participants (6 doctors and 6

Results

All 3 scenarios were successfully completed. A total of 68 minutes of video recordings was reviewed, with a mean scenario duration of 23 minutes. A total of 362 leadership behaviors of the 12 participants were identified in all 3 videos. Table 3 summarizes the frequency of the 8 identified leadership behaviors by each of the 4 team member categories (i.e., senior surgeon, trainee surgeon, senior nurse, and trainee nurse). Although it appeared that senior surgeons displayed the greatest number

Discussion

This study reports a detailed video analysis of leadership behaviors within 3 authentically replicated burns simulation resuscitation scenarios in TBS. The results suggest that although the senior surgeon followed by the senior nurse displayed the highest frequency of leadership behaviors, statistically there was no difference in frequency of leadership behaviors of participants, i.e., effectively they showed a similar number of behaviors. It must be noted that frequency of specific leadership

Conclusions

Effective leadership is essential for successful functioning of work teams and accomplishment of task goals.33, 34 As the resuscitation of a patient with major burns is a dynamic event, team leaders require flexibility in their leadership behaviors to effectively adapt to changing situations. Understanding leadership behaviors of different team members within an authentic simulation can identify important behaviors required to optimize nontechnical skills in a major resuscitation, and it can be

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