Leadership Spotlight

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Emergency Room Observations

When patients arrive at the trauma resuscitation unit, they are immediately seen by a team of specialists that includes an attending surgeon (the most experienced surgical member of the team), a surgical fellow (the second most experienced surgical member), one or more surgical or emergency medical residents, an anesthesiologist, a registered nurse and a trauma technician.

The composition of the team changes frequently "as the individual members cycle on and off the team. Team members work shifts of differing lengths. Thus, the make-up of the team that assembles to treat one patient may differ from the make-up of a team that assembles to treat a second patient one hour later," the authors note in their paper. Team composition also shifts from day to day, week to week, and month to month especially as team members complete their trauma unit rotations and others begin. The lifetime of a team is short, usually 15 to 60 minutes—about the time it takes to stabilize the patient.

As part of their initial data collection, the researchers interviewed more than 30 members of the trauma unit and spent more than 150 hours observing the treatment of approximately 100 patients, including observation of operating room procedures. (One anesthesiologist said to Klein, as she was suiting up in surgical scrubs to observe an operation: "I am going to introduce you as Dr. Klein. Don't touch anything.") The researchers supplemented their interviews and observations with additional data, such as an analysis of the 184-page Resident Training Manual, a study of orientation meetings and interview transcriptions from other researchers.

Their initial goal was to answer two questions: "Who is the leader of the trauma unit team? And what leadership functions does this individual fulfill?" Although Klein and her colleagues had assumed that each trauma unit team had a leader, "we were wrong. Not only does leadership not reside in a single person, it does not reside in a single position," the authors write. Rather, trauma unit team leadership resides in a hierarchy of three positions: the top-ranked position, held by the "attending" surgeon, followed by second-ranked "fellow" position, followed by the third-ranked "admitting resident." According to the authors, "The active leadership role shifts frequently and fluidly among the three individuals who occupy the team's three key leadership positions."

The researchers also wondered how leadership shifts from one position to another, when and why it shifts, and why such a system does not result in "chaos, conflict and error."

Among their findings: The system of investing leadership in three key positions "accommodates frequent changes in team composition. Individual leaders come and go but the leadership positions remain. Second, it creates redundancy, enhancing the reliability of patient care ... Finally it allows relatively novice leaders (i.e., the admitting residents) to assume a primary leadership role in a setting that affords them and their patients, protection and support."

The researchers note that trauma unit leaders perform three key functions: They provide strategic direction, monitor the performance of the team, and teach team members by providing instruction—all tasks that match those the researchers identified in the functional team leadership literature and which are applicable to business settings. (The fourth function of the trauma unit leaders, providing hands-on treatment of the patient, could refer to situations where leaders, instead of just supervising team members in key tasks, actually jump in to perform those tasks when the need arises, as in the idea of a store manager helping to ring up customers.)

Two functions that are referred to frequently in leadership research—"ensuring that team members are motivated and engaged, and establishing norms and routines that enable a positive and safe climate"—are not part of the trauma unit approach, for two reasons. One, the team's efforts to save patients' lives is "inherently motivating." Two, because the trauma unit teams change so frequently, there is little time to develop norms and routines. "More influential are the norms of the trauma unit as an institution," the researchers note.

Passing the Baton

While this description of the trauma unit suggests a shifting leadership structure, it nevertheless is based on a clear pecking order. As the researchers note, the attending, the fellow and the resident "are ranked in a clear and rigid hierarchy," with the attending having more expertise, experience, status and power than the fellow, and the fellow having more than the resident. The leadership role changes essentially because the attending allows it to, depending on the circumstances of the individual case.

"Leadership ... seems to be a baton, whose possession is controlled by the most senior members of the hierarchy," the researchers write. "These individuals may assume control, taking possession of the baton, at any time. Yet, often they relinquish possession of the baton to those lower in the hierarchy." These shifts of leadership are based on such factors as the patient's condition and the personal styles of the doctors (for example, "hands-on" vs. "laidback").

While the researchers use the baton image to describe the active leadership role, the trauma unit leadership system as a whole, they suggest, is ultimately better described "not as a relay race, but as a dance in which the three team leaders step forward or back in response to the patient's changing condition and to the actions, competence, and confidence of others in the leadership hierarchy. The picture that emerges from this description is far more dynamic than that of traditional leadership models. In the trauma unit, leadership is ... a system, or dance, of moving parts."

In looking at the treatment of patients in the trauma unit, the researchers also wondered why there were so few errors and conflicts, especially given the very real pressure to act quickly and competently during the first few minutes of patient treatment. The researchers attribute this to a set of "enabling conditions," including such things as expert support staff (the nurses), the awareness among the fellows and residents that they are only in the unit for a short time (which makes it easier for junior leaders to accept the intervention of senior leaders) and the strong role that routines, tradition, and values play in the unit.

For example, "the initial treatment of patients is guided by routines or protocols that organize and prescribe the team's activities, protocols which the personnel observe and also teach to others." One attending anesthesiologist described the Advanced Trauma Life Support manual as "the handbook we are singing from during the first ten minutes of any resuscitation." Another fellow, referring to the manual's "ABC's of patient care," said: "To an outsider looking in, it looks like chaos. But everything is done in an orderly fashion. So, when a patient comes in, airway's first (A), breathing's second (B), circulation's third (C) ... It all looks unorganized, but it's organized."