CONDUCTING THE EMERGENCY TEAM - Beier & Larsen

F A C U L T Y O F H E A L T H A N D M E D I C A L S C I E N C E S U N I V E R S I T Y O F C O P E N H A G E N

PHDTHESISTureLarsen

CONDUCTINGTHEEMERGENCYTEAMFocusonleadership

Academicadvisors:RandiBeier-Holgersen,PeterDieckmann,DorisØstergaard

ThisthesishasbeensubmittedtotheGraduateSchooloftheFacultyofHealthandMedical

Sciences,UniversityofCopenhagen

Submitted02.01.18

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ThestudiesinthisPhDthesiswereconductedbetween2015and2017atSimNord,Nordsjællands

Hospital,UniversityofCopenhagenandtheCapitalRegionofDenmark

Forfurtherinformation,contact

TureLarsen

Oldfuxvej20

2400NV

Denmark

Mail:[email protected]

Phone:+4531127281

Website:http://turelarsen.dk/phd.html

ORCID:http://orcid.org/0000-0002-5410-6340

Front-pageillustration:

Aquicklydrawnsketchoftheparallelbetweentheconductorandtheclinicalteamleader(byTL)

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ACADEMICADVISORS

RandiBeier-Holgersen,AssociateProfessor,MD,MHPE.SeniorSurgeon,Departmentof

GastrointestinalSurgery,NordsjællandsHospital,Denmark

PeterDieckmann,PhD,Dipl.-Psych.Psychologist,SeniorScientist,CopenhagenAcademyfor

MedicalEducationandSimulation(CAMES),CapitalRegionofDenmarkandUniversityof

Copenhagen,Copenhagen,Denmark

DorisØstergaard,MD,DMSc,Professor,MHPE.HeadofInstitute,CopenhagenAcademyfor

MedicalEducationandSimulation(CAMES),CapitalRegionofDenmarkandUniversityof

Copenhagen,Copenhagen,Denmark

ASSESSMENTCOMMITTEE

JacobRosenberg,MD,DMSc,Professor,chiefsurgeon,Dept.ofSurgery,HerlevandGentofte

Hospitals,UniversityofCopenhagen,Denmark.

NielsQvist,MD,DMSc,Professor,chiefsurgeon,Dept.A.ofSurgery,OdenseUniversitetshospital,

Denmark

PeterEttrupLarsen,Dr.ofMusicalArts(DMA),Conductor,MAinMusicologyandRhetoric,

AssociateProfessorofDigitalConductingStudies,TheUniversityinStavanger,Norway

FUNDING

ThePhDprojecthasbeensupportedbyTrygFoundation,LaerdalFoundationandNordsjællands

Hospital,Denmark.

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ACKNOWLEDGEMENTS

ThankstoRandi.Thankyouforcreatingthiscrazyandinnovativeidea.Allideas,theories,views,

anddecisionswerecreatedjointlyinourresearchpartnership.Noideashaveeverbeenrejected

andallthoughtsandassociationshavebeenfollowed,understoodanddiscussedindepth,

thoroughly,seriouslyandwithlotsoflaughs.Ithasbeenagreatprivilegeandexperiencetopresent

theprojectonourmanytripsfromSingaporeoverIstanbul,andGlasgowtoToronto,Quebecand

Vancouver.

ThankyoutomycolleaguesatSimNord.ThankstoSusannetorealisethepotentialandpossibilities

inRandi’sidea.ThankstoRikkeandGitteformanydiscussions,supportandengagement.Thanksto

Lindaforalwaysbeingreadytohelp.ThankstoErikandCasperforlistening,discussingand

supporting.IhavebeenwellreceivedandfeltlikepartofSimNord.

ThanktoHRandtheResearchdepartmentatNOHforhelpingrealizingtheprojectandforfinancial

support.

ThankstoPeterforaswellsupportfortheideaaswellascriticismofmethods,methodology,

ontology,epistemology,conclusionsandwriting.Thishasonlyintensifiedmydesiretosharpenmy

workandmypoints.

ThankstoDorisforparticipatingintheprojectgroup,itishighlyappreciatedthatyouchoosetoadd

yournameandknowledgetothisdifferentresearchproject.

ThankstoJetteforhelpingwiththechallengingsearchintheliteratureaswellassupportand

inspiringdiscussions.

ThankstoSusanLaubeforproofreadingonthearticles.ThankstoNigelBarnardforproofreading

onThesis.

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TABLEOFCONTENTS

PAPERSINCLUDEDINTHETHESIS................................................................................................8

ABBREVIATIONSANDDEFINITIONS.............................................................................................9

SUMMARYOFTHETHESIS.........................................................................................................11

SAMMENFATNINGPÅDANSK....................................................................................................13

STRUCTUREOFTHETHESIS........................................................................................................15

BACKGROUND...........................................................................................................................16TheConductor..................................................................................................................................17

Emergencyinhealthcare..................................................................................................................17

AIMS.........................................................................................................................................18

CONCEPTUALFRAMEWORK.......................................................................................................18Differentontologies.........................................................................................................................18

Qualitativemethodologyconsiderations.........................................................................................19

LEARNINGTHEORYCONSIDERATIONS.......................................................................................21Theoriessupportingconceptualchangeortransformation.............................................................21

EmbodiedCognition.........................................................................................................................21

TransformativeLearningTheory......................................................................................................21

Apprenticeship.................................................................................................................................21

Flowtheory–apedagogicideal.......................................................................................................22

Anxietycounteractslearning............................................................................................................22

Thinking,fastandslow.....................................................................................................................23

Learningpyramid,NTL......................................................................................................................24

ANALYSISCONSIDERATIONSONEXTRALINGUISTICDATA.........................................................24Incongruencebetweenoralandextralinguisticcommunication....................................................24

Semiotics..........................................................................................................................................25

Multimodality(extralinguisticcommunication)..............................................................................25

Videoanalysis...................................................................................................................................26

Conductorsandvideo.......................................................................................................................26

Videoandsimulationinhealthcare..................................................................................................27

PRE-UNDERSTANDING...............................................................................................................27

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METHOD...................................................................................................................................28SystematicReview............................................................................................................................28

Qualitativecontentanalysisasamethod........................................................................................28

Video................................................................................................................................................30

Transcriptions...................................................................................................................................30

Evaluations.......................................................................................................................................30

ETHICALCONSIDERATIONS........................................................................................................31

PRESENTATIONOFTHEINCLUDEDPAPERS................................................................................32Study1..............................................................................................................................................32

Study2..............................................................................................................................................34

Study3..............................................................................................................................................36

DISCUSSION..............................................................................................................................39Developmentandconductionofacourseaddressingleadership...............................................41Feedback.......................................................................................................................................43Faculty..........................................................................................................................................44Assessmentoftheimpactofthecourse......................................................................................46

STRENGTHSANDLIMITATIONS..................................................................................................46

CONCLUSION.............................................................................................................................50

PERSPECTIVES...........................................................................................................................51

TRAININGRESIDENTSTOLEADEMERGENCYTEAMS[PARTONE]:ASYSTEMATICREVIEW........53

TRAININGRESIDENTSTOLEADEMERGENCYTEAMS[PARTTWO]..............................................79

CONDUCTINGTHEEMERGENCYTEAM:ANOVELWAYTOTRAINTHETEAM-LEADERFOREMERGENCIES...........................................................................................................................93

APPENDIX................................................................................................................................122

ONLINEAPPENDIX...................................................................................................................122

REFERENCES............................................................................................................................124

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PAPERSINCLUDEDINTHETHESIS

Paper1

TureLarsen,RandiBeier-Holgersen,JetteMeelby,PeterDieckmann,DorisØstergaard.

Trainingresidentstoleademergencyteams[PartOne]:ASystematicReview

SubmittedtoAnnalsofSurgery(December2017)

Paper2

TureLarsen,RandiBeier-Holgersen,DorisØstergaard,PeterDieckmann.

Trainingresidentstoleademergencyteams[PartTwo]:Barriers,ChallengesandLearningGoals

concerningtrainingresidentstoleademergencies:aQualitativeReview

SubmittedtoAnnalsofSurgery(December2017)

Paper3

TureLarsen,RandiBeier-Holgersen,PeterDieckmann,DorisØstergaard.

Conductingtheemergencyteam:Anovelwaytotraintheteam-leaderforemergencies

SubmittedtoLancet(December2017)

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ABBREVIATIONSANDDEFINITIONS

LBDQ LeadershipBehaviourDescriptionQuestionnaire1

NOTECHS NonTechnicalSkillsbehaviouralmarkersystem.Amethodfor

assessinganindividualpilot’snontechnicalskills(e.g.leadership,

decisionmaking,teamworking,situationawareness).2

NTL TheNationalTrainingLaboratories’averageretentionratesfor

differenttrainingandteachingmethods

PRISMA PreferredReportingItemsforSystematicReviewsandMeta-

Analyses.PRISMAisanevidence-basedminimumsetofitemsfor

reportinginsystematicreviewsandmeta-analyses3

GRADE GradingofRecommendationsAssessment,Developmentand

Evaluation.TheGRADEprocessdevelopsrecommendations,the

evidenceprofile,andSummaryofFindingstable.Gradedescribes

theprocessforframingquestionsandidentifyingoutcomes4

CASP CriticalAppraisalSkillsProgramme4

Abduction TheoryàDataßàDataàTheoryàAnalysisàConclusion

Deduction TheoryàDataàAnalysisàConclusion

Induction DataàTheoryàAnalysisàConclusion

QCA QualitativeContentAnalysis

GT GroundedTheory

Ontology Knowledgeaboutbeing(thenatureofbeing)5

Epistemology Knowledgeaboutknowledge(science/knowledge)5

Positivist:

Positivist’sontology Believesthereisonesinglerealityandbelievesinuniversal

concepts6

Positivist’sepistemology Empiricist:collecting–hypothesis–testhypothesisobjectively

usingstatistical.Nointerpretation.

Positivist’smethodology Theorydeveloping:Hypotheticdeductivemethod

Constructivist

Constructivist’sontology There’snosinglereality,realityisconstructedinthecontext7

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Constructivist’sepistemology Interpretreality(putsoneselfintheproject)

Constructivist’smethodology Inductive(lookatsinglecasesstudies)

Writtencommunication Linguisticisbasedonwordsandsentences.Thevalueofawordis

rarelycompletelyneutral,astherearetypicallyconnotationstoa

word.Furthermore,itispossibletotalkaboutthesurfacecontent

ofthetextaswellasinterpretationsoftheunderlyingmeaning8

Extralinguistics Non-verbalcommunication,pictures,videos,allmeansof

multimodalcommunication9

Oralcommunication Speaking,lectures,andpresentations:Linguistics,includingthe

possibilityofaddingextralinguistics

Facetofacecommunication Interpersonalcommunication:allcommunicatorsactively

participateandareresponsibleforitscreation.Linguistics,

includingextralinguistics

Semiotics Therangeofdifferentkindsofsignsthatcanbefoundascompared

tolanguagethatcomprisesabstractsymbols.10CharlesSanders

Peirce(1839-1914)describedthoughtsnotas’ideas’butas’signs,’

externaltotheselfandwithoutmeaningunlessinterpretedbya

subsequentthought.Hisgeneraltheoryofsigns–orsemiotic–is

especiallypertinenttomethodologiescurrentlybeingdebated11

Multimodality Describingothermeaningsthanbasedonlanguageandlinguistics.

Thereisvisuallanguage,gesturallanguage,andsoforth.Itis

sociallyproduced,culturalresourcesformakingmeaning.

Situationsaregivenwheretextonlygivesapartialaccountofwhat

isgoingon12

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SUMMARYOFTHETHESIS

Thespecificapproachtothisthesisistoexploreadifferentapproachtotraintheemergencyteam

leaderwithhelpfromanotherprofession.Furthermoreinvestigateexistingaspectsoftrainingof

theteamleaderinemergenciesinhealthcare.

Thisthesisisbasedonanabductiveapproach.Themainideaisconceivedincollaborationbetween

asurgeonandanorchestralconductorwhorealisedaparallelbetweenleadingamedicalteamand

leadinganorchestraintermsofthenon-verbalcommunicationthatdemonstratesthattheleader

hasassumedleadership.

Ithasbeendescribedintheliteratureforthelast30yearsthatthereisanurgentneedtotrain

residentsandmedicalstudentsinleadershipinacutemedicalsituations.Theliteraturedescribes

theneedfortheteamleadertorisetotheoccasionwhencalledupontoactasleadersof

emergencyteams:manyresidents/rescuersfeelunpreparedtoadopttheleadershiprolein

emergencies.Itisimportanttoassumeleadershipduringtheteamworkthattakesplaceinthe

criticalsituation,aslackofleadershipisconcludedtobeoneofthecausesofpooroutcomesfor

thecriticallyillpatient.

Theconclusionofasystematicreviewthatincludedalltheinterventionstudiesfound,focusingon

whetherornotfoundadequatetrainingintheteamleadershiproleamongresidents,is

unfortunatelythatnofocusedleadershiptraininghastakenplace.

Instead,literaturerevealedalargenumberoftaxonomiesaimingatmeasuringtheabilityof

residentstoimplementvariousprofessionalalgorithmswithoutspecificfocusontheleadership

role.Theliteraturehasdevotedtimetodevelopingmeasuringinstrumentsintheformof

taxonomiesandhasnotfocusedonthedevelopmentofleadership.Itispossibletoconcludethat

focushassubstitutedfromhowtotrainleadershiptomeasureleadership.

Inaqualitativecontentanalysisofthefoundliterature,itwasconcludedthatleadershiptrainingis

anecessitywhichisneededtobeaddressed,buteffortshassofarbeenfocusedelsewhereanda

usefulleadershiptraininginemergenciesitisstillindemand.

Byfurtherreviewandqualitativecontentanalysisoftheliterature,includingalltheopinionsand

reviewsfound,itwasidentifiedthatacrucialfactortoaddressistheanxietyresidentscan

experiencewhentheyaretotakeonleadershipinacutecriticalsituations.Theliteratureitself

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describeshowtheresidentsshouldbetrainedinmentallyassumingleadership,radiatingcalmness

andcredibilityanddemonstratingauthorityinthecriticalandchaoticsituation.Byreviewingthe

literature,learninggoalsthatshouldbethefocusofanupcomingtrainingwereidentified.Those

shouldaddresstheactualneedstheresidenthasinthesituation.

Thecoursewasdevelopedinanon-medicalchallengingcontext,butcloselyrelatedtotheclinic.

Musicalexerciseswereused,whichmadethecourseharmlesstotheindividualmedicalparticipant

whowasnotexpectedtobeabletohandlethechallengesand‘obstacles’intheexercises.

However,themusical‘obstacles’broughttheparticipantintothementallychallengingstate,

resultingthatalloftheparticipant’spersonalinappropriatenon-verbalexpressionswererevealed

inthesituation.Thisenabledtheorchestralconductortoaddressthese,givepersonalanddirect

feedbacktoparticipant,andthustheparticipantwasenabledtorecogniseownweaknessesand

guidedbytheconductorwasgivenopportunitytostrengthentheseexpressions.Inaddition,the

musicalexercisesgavetheparticipantanexperienceofflowwhenconducting,andtheindividual

participantexperiencedtheintensefeelingwhenallcommunicationtakesplacethroughtheleader.

Thecourseswereevaluatedusingvideorecordings,transcriptionsofthese,evaluationsfromthe

courseparticipants,aswellaswrittencommentsfromtwostudentswhohelpedtotranscribethe

transcriptions.Thelatterdidnotattendthecoursesandwereblindedtotheideaofthecourse.

Again,aqualitativecontentanalysiswasconductedandtheconclusionisthatthecourseisableto

supporttheindividualparticipant’sabilitytogaininsightintohis/herownleadershipchallenges

andtoprovideadviceandassistanceindevelopinghisnon-verbalappearanceandexpression.

Ingeneral,thisthesishasdescribedhowcollaborationbetweentwoverydifferentprofessionshas

managedtoexploitthevariousontologicalapproachestotheexperienceoftheworldinapositive

andconstructiveway.Itpointsoutthatitisbeneficialtoallowtoseebeyondowndomainor

profession.

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SAMMENFATNINGPÅDANSK

Formåletmeddenneafhandlingeratundersøgeomdetermuligtatbrugeenandenprofessiontil

attræneteamlederrolleniakuttemedicinsketeams.Derudoverundersøgeomderfindesandre

holdningerelleraspektervedrørendetræningafteamlederrolleniakuttesituationeriklinikken.

Denneteseerbaseretpåenabduktivtilgang.Ideenerundfangetietsamarbejdemellemenkirurg

samtenorkesterdirigent,dersåenparallelmellemdetatledeetmedicinskteamogetorkester

mht.bl.a.dennon-verbalekommunikation,derviser,atlederenharpåtagetsiglederskabet.

Detergennemdesidste30årbeskrevetilitteraturenatdereretbehovforattræneyngrelæger

ogmedicinskestudenterilederskabiakuttemedicinskesituationer.Litteraturenbeskriveretbehov

foratteamlederentræderikarakterogpåtagersiglederskabetunderdetteamsamarbejdeder

foregåridenkritiskesituation,idetmanglendelederskabkonkluderesatværeenafårsagernetil

dårligtoutcomefordenkritisksygepatient.

Konklusionenpåetsystematiskreviewmedinklusionafallefundneinterventionsstudiermedfokus

påomderfindesellerharfundetfokuseretoplæringiteam-lederrollenblandtyngrelægerer

desværre,atderikkeharfundetfokuseretledelsestræningsted.Istedetfindesilitteraturenet

stortantaltaxonomiertilmålingafyngrelægersevnetilgennemførelseafforskelligefaglige

algoritmerudenspecifiktfokuspålederrollen.Litteraturenharfokuseretpåatudvikle

måleinstrumenteriformaftaxonomierogharikkefokuseretpåudviklingafoplæringssituationeri

lederrollen.Mankankonkludereatfokusersubstitueretfrahvordantrænermanlederskabtil

hvordanmanmålerlederskab.

Vedenkvalitativindholdsanalyseafdenfundnelitteraturerkonklusionenatlederskabstræninger

etnødvendigtbehov,derskaldækkes,menatindsatsenindtilvidereharværetfokuseret

andetstedsogatdenfortsatefterspørges.

Vedyderligereengennemgang/kvalitativindholdsanalyseaflitteraturen,hvorogsåallefundne

opinionsogreviewsmedtages,findes,atdenafgørendefaktor,derskaladressereserdenangst

somyngrelægeroplever,nårdeskalpåtagesiglederskabetiakuttekritiskesituationer.Der

beskrives,hvordandeyngrelægerskaltrænesiatmentaltpåtagesiglederskabet,udstråleroog

autoritetidenkritiske/kaotiskesituation.Vedgennemgangenaflitteraturenfindeshermedde

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læringsmål,sombørværefokusienkommendetræning,hvistræningskalfokuserepådebehov

denyngrelægeharisituationen.

Kursetblevudvikletienikkemedicinskfagligkontekst,menmedtætrelationtildenmedicinske

verden.Derbenyttesmusikalskeøvelser,hvilketgørkursetufarligtfordenenkeltemedicinsk

fagligekursist,derikkeforventesatkunnehåndterede”benspænd”dereriøvelserne.Demusiske

benspændformåededogatbringekursisterneidenmentaltudfordrendetilstand,dermedførteat

alledeuhensigtsmæssigenon-verbaleudtryk,somerenudfordringvedrørendelederskabi

teamledelsen,komtiludtryk.Dettegavorkesterdirigentenmulighedforathjælpedenenkelte

kursisttilaterkende,hvoregnesvaghederfandtessamtmulighedforatarbejdemeddisse.

Derudovergavdemusiskeøvelserenoplevelseafflowiledelsessituationen,hvordenenkelte

kursistoplevededenfølelsedeter,nåralledelseforegårgennemlederen.

Kurserneblevevalueredevedhjælpafvideooptagelser,transskriptionerafdisse,evalueringerfra

kursisternesamtkommentarerfratostudenterderhjalptilmedatfortagetransskriptionerne.

Sidstnævntedeltogikkepåkurserneogvarblindedefortankernebagkurset.Igenblevgennemført

enkvalitativindholdsanalyse,ogkonklusionenpådenneer,atkursetformåratunderstøtteden

enkeltekursistsmulighedforatfåindsigtiegneudfordringerilederrollensamtatgiverådoghjælp

tilatudviklesitnon-verbaleudtryk.

Overordnethardennetesebeskrevethvordansamarbejdemellemtomegetforskellige

professionerharformåetatudnyttedeforskelligeontologisketilgangetiloplevelsenafverdenpå

enpositivogkonstruktivmåde.Denpåpegerdetfrugtbareiattilladesigatseudoveregen

faggruppe/profession.

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STRUCTUREOFTHETHESIS

Thefirstchapterpresentsthebackground.Thesecondchapterpresentstheconceptualframework;

theontologyandthemethodologyofthethesis.Furthermorethischapterpresentstheories

consideredrelevanttothethesis;learningtheories,discussiononanxietyandlearning,theintuitive

andtherationalwayofthinking,andanassessmentmodeloftheimpactoflearning.Finally,the

chapterpresentsseveralapproachestonon-linguisticorextralinguisticlanguage.Thethirdchapter

presentsthemethodsusedanddataacquisitionandanalysis.Thefourthchapterprovidesabrief

descriptionofthethreestudies.Chapterfivepresentsadiscussionoftheimplicationofthefindings

inthethesis.Chaptersixdiscussesthelimitationsinthethreestudies,andfinallyconcludesonthe

threestudies,highlightsimplicationsforpracticeandsuggestsfutureresearch.

Studyoneexaminesthemedical,pedagogicalandpsychologicaldatabasesifthereisawell-

functioningtrainingoftheclinicalteamleaderinemergencies,27articleswererelevant.In

addition,itexaminesbyaqualitativecontentanalysiswhetherthereisconsensusonthe

importanceofleadership.

Studytwoexaminesthe27articlesfoundplusadditional13articlesifitispossibletoidentify

challengesandlearninggoalsconcerningleadershiptraininginemergencies.

Studythreepresentstheinterventionofthethesis,acourseconductedanddesignedbya

conductorandaconsultantforresidents,medicalstudentsandseniornursesattheemergency

room.

Atthebackofthedissertationanonlineappendixthatpresentsthecomprehensiveresultsofthe

qualitativecontentanalysesissituated.Inaddition,alogfromthecoursecontainingfieldnotes,

transcribeddialogues,andevaluations.Finally,linkstotwodocumentspresentingvideosfromthe

courseispresent.

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BACKGROUND

Teamleadershipinemergenciesisreportedasbeingimportantforthequalityoftheperformance

ofteams13-24,forpatientoutcome,patientsafetyandpatientcare22,23,25-35.Thequalityofteam

leadershipmayeveninfluencepatientmortalityandsurvivalrates19,23,27,32.

However,manystudiesidentifythatleadershiptraininghasbeeninadequate1,16,17,23,27,29,36-39,and

arecurrentcallforaworkableleadershiptrainingprogrammehasbeenexpressedexplicitly

1,14,16,17,21-23,26,27,29,34,36-43.Thisneedhasprevailedthroughoutthe30-yearperiodaddressedinour

investigation.

Theliteratureaffirmedthattargetedleadershiptrainingisveryimportant.Itisnecessaryfor

residentstoaddressandhandleanxiety16,23,27,32,44andpanic32instressful20,22,25,27,31,32,34,41,45and

complex19-22,35,39,41situations.Therefore,inordertoprovidegoodandconvincingleadership,

residentsmustlearntobeconfident1,16,23,27,32,36,37,39,41,42,44,46,47andcalm16,30,32,44whenassuming

theleadershipinemergencies.

However,‘something’isapparentlystillmissing,andthereasonwhy‘residentsfeelunpreparedand

unsupervisedasleaders’27shouldbeexplored.

Theparallelbetweentheconductorandtheteamleaderinemergenciesinthiscontextisthehighly

intensesituationstheyworkin:bothsituationsrequireclearandconvincingleadershipandthereis

notimeorroomfordiscussions.Neithertheconcertnorthecardiacarrestcanbeinterrupted.The

leader’sguidanceandinstructionsmustbecarriedoutimmediately.

OneyearpriortothestartofthePhDstudy,apilotprojectwasconducted.Aconsultantwhoalso

wasanamateurtromboneplayerrealizedtheparallelbetweentheteamleaderandtheconductor

whenherconcertbandreceivedanewskilledconductor.Theconsultantandtheconductor

designedacourseformedicalstudentswhoparticipatedinaprogramintroducingnon-verbal

communicationandteamleadership.Theresultsfromthecourseisdescribedinthearticle“Team

Management-Canmusiccontributetobetterunderstanding?”48.(Abstractispresentedinthe

appendixsection).

Manyinitiativeshavesoughttoaddressleadershiptraininginemergencies:inparticularleadership

ispartoftheScottishinitiativeAnaesthetists’NontechnicalSkills(ANTS)49,adaptedto‘Non-

TechnicalSkillsforSurgeons’(NOTSS)38,andto‘ScrubPractitioners’ListofIntra-operativeNon-

17

TechnicalSkills’(SPLINTS)50.ThelatterreplacedNOTECHSfornurses51–whichwasalsomodified

to:OxfordNOTECHS52andamongotherthings:T-NOTECHS53,aswellastheSwissleadership

trainingprogrammebasedontheLeadershipBehaviourDescriptionQuestionnaire(LBDQ)1.These

programmesfocusondevelopingformativeassessmenttools54,behaviouralmarkers55and

taxonomiesinordertomeasure15,22,33,38leadershipskills.Since2015theliteraturehasbegunto

questionthenumberoftools–andmethodsused–inthetaxonomies34.

Handlingnegativefeelingsisnotapartofexistingprogrammes.Leadershipduringanemergency

situationinvolvesknowledgeandskills,butalsoimpliesdealingwiththepressure16,25,28,34,38,56of

beingthedecision-makerandtakingtheultimateresponsibilityforwhathappens(ordoesnot).

THECONDUCTOR

Theconductorworkspurposefullywithhispostureandappearanceinordertoeliminateanything

thatcouldpossiblypreventthemessagefrombeinginterpretedasintended.Theconductors’main

focustoachievetheauthoritytoleadanorchestra,itisimportanttoappearcalm,balanced,

competent,authentic,andcredible.Thisisthebasicstartingpointfortheconductor,when

recognised,heisablebegintoworkandchoosehisstyleofleadership57.

Thisviewsexpressingtheconductor’sreflectionsonhisworkwiththeorchestra’smusiciansare

generalanddonotreflecttheopinionsofasingleconductor.Theabovedescriptionofthe

conductorsfocusisreadbytwosymphonicconductors,anddiscussedthoroughly.Bothconductors

couldendorsethereflectionsandopinionsthatwerepresented.

Noliteratureaddressesthesecompetenciesequallyinhealthcare.

EMERGENCYINHEALTHCARE

“Emergencymedicalcareteamshave[…]littletimefordeliberateplanningandelaborate

communicationwhileprovidingcare.Second,suchteamsaregenerallyadhoc,thatis,assignedto

worktogetherineverchangingcompositions”40.‘Adhoc’teamsarealsoreferredtoas‘crash’

teams23.

Thissituationiscomplex16,19-22,24,25,29,30,33,35,39,41,44,56,58andstressful16,20,22,23,25,27,29-34,41,45,47,59and

hasbeenreferredtoasachaoticsituation1,32,34,41,44,46,60perceivedaswithanxiety1,14,16,23,27,32,36,44.

Inthisframework,theemergencyteamleadershouldrisetotheoccasionwhencalledupon,mark

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leadershipandidentifycompetenciesandresourcesoftheteamforthepurposeofensuringthe

besttreatmentofthepatient.

Theproblemhasbeentodefinetheseissuesandsubsequentlyfindawaytotraintheseobjectives

inhealthcare.

AIMS

Theoverallobjectiveofthisthesiswastoexploreadifferentapproachtotraintheleaderofthe

emergencyteamwithhelpfromanotherdomain.Furthermoretoinvestigateexistingaspectsof

trainingoftheteamleaderinemergenciesinhealthcareusingdifferentmethodsinthreestudies

withthefollowingaims:

Study1:Todescribehowliteratureaddressesworkableandoperationalleadershiptrainingforthe

emergencymedicalteam-leaderandtoenhanceunderstandingofleadershiptraininginthe

medicalenvironment.

Study2:Aninvestigationtodetermineanyconsensusinopinionsandviewsaboutchallengesor

barriersintrainingleadershipinemergencies.

Study3:Theoverallaimofthecourseistoinvestigatewhether,inanemergency,aclinicalteam

leadercouldapplyaconductor’sleadershipskills.Adescriptionofacourseheldforresidents,

medicalstudentsandemergencyroomnurses.

CONCEPTUALFRAMEWORK

DIFFERENTONTOLOGIES

Ontology:OntosisGreekforbeing,logosmeansstudyi.e.‘thestudyofbeing’.Whatcanbesaidto

reallybe,orexist?Epistemology:Epistememeansknowledgeandlogosstudyi.e.‘thestudyof

knowledge’.Evenifsomethingreallyexists,howcanIknow?

Theresearcher,whoisaconductor,isinfluencedbyaconstructivist’sontology,statingthatreality

isasocialconstructionandmustbeseeninthecontextofindividuals,andthereforemany

(interpretedandconstructed)realitiesarepresent.Hisepistemologyisinductiveandinterpretative.

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Qualitativeresearchmethodsare“usedintheexplorationofmeaningsofsocialphenomenaas

experiencedbyindividualsthemselves,intheirnaturalcontext”7.

Atypicalsurgeonisworkinginapositivisticresearchtradition,believingthattheworldisobjective

andcanbemeasured,thatthereareuniversalconcepts,andthatthesecanbeobjectivelyverified

bystatisticalmanoeuvres.Thereisonlyonereality.Hisepistemologyisasanempiricist,thatis,he

istesting.“Medicaldoctorsbelievethattheirfieldisfoundedonscientificknowledge;where

knowledgeisdefinedasfactsthatcanbeempiricallyverifiedbythebiomedicalmethod”,asstated

byMalterud6.

QUALITATIVEMETHODOLOGYCONSIDERATIONS

Thefollowingresearchapproacheshaveservedassourcesofinspirationinthisthesis:Grounded

theory(GT)61,62,qualitativecontentanalysis(QCA)8,63,andhermeneutics5.Centraltothese

approachesisthattheyallrelyonacontinuousmovementbetweenpre-understandingand

analysis,‘movingtoandfrom’64.

ThefollowingfeaturesarecommontoGTandQCA:Theresearcherlooksatphenomenawithfresh

eyesandfromnewperspectiveswithoutrestrictionwithinalreadyexistinghypotheses–andbased

onthefindings,ideasaredeveloped–andtheresearcherstakesanotherlookatthephenomena

8,63.Inhermeneuticsitisstatedthattounderstandapartofatext,onemustunderstandthe

whole.Atthesametime,however,onecanonlyunderstandthewholewhenunderstandingthe

individualparts5.Allthreeapproachestointerpretationbringtheimportanceoftheinterpreter

intofocus.Hans-GeorgGadamerarguedthatknowledgeisnotsomethingthatweacquireand

controlasapossession.Ratherknowledgeistobeunderstoodassomethinginwhichwearealways

alreadysituated.Thereasonweunderstandanythingatallisbecausewealreadystandinit65.It

hasbeenarguedinhermeneuticsthatpuredescriptionisimpossiblebecausedescriptionalways

involvesinterpretation5.Datacanbecollectedfrommultiplechannelsinallthreemethods,such

asinterviews,observations,documents,andvisualmaterials5.

OriginallyQCAwasdevelopedwithinthefieldofcommunicationandlinguisticsasameansto

understandthemeaningoftextandcontext8inordertochallenge/supplementatendencyto

focusonthequantitativecontent.GTmethodologyemergedfromthefieldofsociology66.GTisa

reactiontopositivisticperspectivesonscience8.Hermeneuticsisamethodologyworkingwith

semiotics,presumptions,andpre-understandings5.

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MajorCodingDifferencesAmongThreeApproachestoContentAnalysis

TypeofContentAnalysis

StudyStartsWith

TimingofDefiningCodesorKeywords

SourcesofCodesorKeywords

Conventionalcontentanalysis Observation Codesaredefinedduringdataanalysis

Codesarederivedfromdata

Directedcontentanalysis Theory Codesaredefinedbeforeandduringdataanalysis

Codesarederivedfromtheoryorrelevantresearchfindings

Summativecontentanalysis Keywords Keywordsareidentifiedbeforeandduringdataanalysis

KeywordsarederivedfrominterestofresearchersorreviewofLiterature

Table1.Hsieh:ThreeApproachestoQualitativeContentAnalysis63.

AspresentedinTable1,aninductiveapproach(conventional63)isappropriatewhenprior

knowledgeregardingthephenomenonunderinvestigationislimitedorfragmented8.Inan

inductiveapproach,codes,categories,orthemesaredirectlydrawnfromthedata8.Adeductive

approach(directed63)startswithpreconceivedcodesorcategoriesderivedfrompriorrelevant

theory,research,orliterature8.Asummativeapproachidentifiesandquantifiescertainwordsin

anattemptnottoinfermeaningbut,rather,toexploretheextenttowhichacertainwordisbeing

used,thusitisaquantitativeanalysis:theresearchercodesthevisibleandsurfacecontentoftext

(manifestcontent8)andcountwords.Butiftheresearchercodestheunderlyingmeaningofthe

text(latentcontentanalysis8)itisasummativeapproachtoQCA63.

Inqualitativestudiestheresearcherbringshimselfintotheinvestigation,andconsequently

attentionshouldbedrawntotheobjectivityandscientificqualityofthestudy.‘Subjectivity’arises

whentheeffectoftheresearcherisignored7.

However,theeffectoftheresearcherishighlyimplementedintheseapproaches.InGTandQCA

thefindingscaninfluencedatacollection,thatis,aninterpretationistakingplacebeforeexamining

thefindingssecondtime.Inhermeneuticsitisarguedthatunderstandingandpre-understanding

arefundamentalconditionstoeachother.

Theoriginoftheseapproachesisrelatedto’abduction’asdefinedbyCharlesSandersPeirce

(1839–1914).Anabductiveapproachtoresearchmakesitpossiblefortheresearchertopresenta

qualifiedpresumption(educatedguessorinference)67whencommencinghisinvestigation.Based

onhisfindings,heacquiresnewknowledge,hemightalter/adaptthisnewknowledgetothe

presumptionandtheprocessstartsover.

21

LEARNINGTHEORYCONSIDERATIONS

THEORIESSUPPORTINGCONCEPTUALCHANGEORTRANSFORMATION

Thissectionexplainshowthelearningenvironmentcansupportconceptualchangeand

transformation.

EMBODIEDCOGNITION

“Cognitionisembodiedwhenitisdeeplydependentuponfeaturesofthephysicalbodyofan

agent,thatis,whenaspectsoftheagent’sbodybeyondthebrainplayasignificantcausalor

physicallyconstitutiveroleincognitiveprocessing”68.Thetheorymightbeusedinthedesignof

effectivelearningenvironments,especiallythosetargetingconceptualchange69.Thecourse

describedinthisthesisassumesthatonehastoexperiencethepressureasaconductorbypractice

tounderstanditasdescribedinEmbodiedCognition.

TRANSFORMATIVELEARNINGTHEORY

InTransformativeLearningTheory70itisstatedthatoneprerequisiteforcreatingareal

transformationisbeingfacedwitha‘disorientingdilemma’definedasanacutepersonalorsocial

crisisandthrough10phases(Table2)of‘perspectivetransformation’leadingto‘areintegration

intoone’slifeonthebasisofconditionsdictatedbyone’snewperspective’71.

1 Adisorientingdilemma2 Self-examinationwithfeelingsofguiltorshame3 Acriticalassessmentofassumptions4 Recognitionthatone’sdiscontentandprocessoftransformationaresharedandthatothershavenegotiatedasimilar

change5 Explorationofoptionsfornewroles,relationships,andactions6 Planningofacourseofaction7 Acquisitionofknowledgeandskillsforimplementingone’splans8 Provisionallytryingoutnewroles9 Buildingofcompetenceandself-confidenceinnewrolesandrelationships10 Areintegrationintoone’slifeonthebasisofconditionsdictatedbyone’snewperspective

Table2.10phasesofperspectivetransformation,TransformativeLearningTheory70

Inthecoursementioned,participantswerepresentedfora‘DisorientingDilemma’atapersonal

levelasinthiscourse:theparticipantsweregivenassignmentsalmostimpossibletosolve.

APPRENTICESHIP

Apprenticeshipispractice,thestudentlearnsfromseniormasterwhoactsasrolemodel.The

masterfurthermoreallowshimselftobesubjectiveandbasesfeedbackonhisownexperiences

22

fromhisprofession.Inshort,thelearningmechanismsandprocessesaredefinedas:Imitation,

identificationwithrolemodels,feedbackonspecificworksolutions,indepthprofessionalfocusand

peer-to-peerlearning72(TL’stranslationfromDanish).

Inaddition,regardingapprenticeshipandleadership,itisstatedbyMintzbergthatleadership“isa

practice.Itisnotaprofession,notascience.Youcan’tlearnitthewayyoulearnsurgeryor

engineering”73.Thisisrelevanttothecoursedescribedinthisthesis,becausetheconductorhas

acquiredhisskillsmainlythroughpracticingleadership.

FLOWTHEORY–APEDAGOGICIDEAL

Thissectionexplainshowalearningenvironmentcansupporttheintensityinastudent’sfocusina

learningsituation.

“Flow”isdefinedbythepsychologistCsikszentmihályias:“thecreativemomentwhenapersonis

completelyinvolvedinanactivityforitsownsake.Theegofallsaway.Timeflies.Everyaction,

movement,andthoughtfollowsinevitablyfromthepreviousone…”74.“Theflowstatemustbea

generalpedagogicalidealbecauseitisoftenextremelygoodlearning,asyouareoptimally

challenged,fullyfocusedandemotionallyinvolvedsoyoutendtorememberverymuchofwhat

youaredealingwith”75(TL’stranslationfromDanish).Theconductorknowsthatwhen

collaborationworksoptimallywiththeorchestra,astatecanoccurwheretimeandplaceis

dissolvedasdescribedinFlow-Psychology76,andwantstogivetheparticipantsanopportunityto

experiencethefeelingofflowatthecoursedescribed.

ANXIETYCOUNTERACTSLEARNING

Anxietycausesthebodytoprepareitselfforfightorflight.ChrisWilliams,professorofpsychosocial

psychiatrystates“Ifyouareinasituationofimminentactualthreat,thentheincreasedalertness

andbodyresponsecanbelifesaving,[…]butifitoccurswhentryingtorevise,orpresentatalk,or

atsuchahighlevelthatitparalysesorcauseserrors,itcaninterferewithwhatwewanttodo.”[…]

ConsultantpsychiatristRajeevKrishnadasstates:“Undernormalcircumstancestheamygdalais

undertightcontrolfromtheprefrontalcortex,whichevaluatesthethreatassociatedwiththe

stimulus.[…]Ifitisthreatening,theamygdalafearresponseismaintained.” Thisisclearlynota

stateconducivetolearningorconcentratinginaseminar,saysclinicalpsychologistDrAngharad

Rudkin.“Evenifyoumanagetotakeinwhatisbeingsaid,theinformationislikelytobounce

around[inyourbrain],notbeingprocessedproperlyorstoredinyourlong-termmemory”77.

23

Itisimportanttoaddressfear;aconductorwhoisafraidinfrontofanorchestrahasbeendeprived

oftheopportunitytowork.However,anxietyisusedasafoundationforcreatingthedisorienting

dilemmadescribedabove.

THINKING,FASTANDSLOW

PsychologistDanielKahnemandiscussesthreetopicsrelevanttothisthesis:System1andsystem2,

theintuitiveexpert,andsubstitution.

System1andsystem2

Kahnemandescribestwowaysofthinking.System1isfastandintuitiveandautomatic:associative

memorycontinuallyconstructsacoherentinterpretationofwhatisgoingoninourworldatany

instant.System2isslower,deliberateandlogical:consistingofcontrolledoperationsrepresenting

aneffortfulmentalactivity.ThehighlydiverseoperationsofSystem2haveonefeatureincommon:

theyrequireattentionandaredisruptedwhenattentionisdrawnaway.Intensefocusingonatask

insystem2canmakepeopleeffectivelyblind,eventostimulithatnormallyattractattention.

System1runsautomaticallyandSystem2isnormallyinacomfortablelow-effortmode,inwhich

onlyafractionofitscapacityisengaged.System1continuouslygeneratessuggestionsforSystem2:

impressions,intuitions,intentions,andfeelings.IfendorsedbySystem2,impressionsandintuitions

turnintobeliefs,andimpulsesturnintovoluntaryactions78.

Theintuitiveexpert

TheintuitiveexpertisatermintroducedbyKahneman,andheexplains:“Thechessmasterwho

walkspastastreetgameandannounces“whitematesinthree”withoutstopping,orthephysician

whomakesacomplexdiagnosisafterasingleglanceatapatient.Expertintuitionstrikesusas

magical,butitisnot.”Italsooccursinourdailylives:“Mostofusarepitch-perfectindetecting

angerinthefirstwordofaphonecall,recognizingasweenteraroomthatwewerethesubjectof

theconversation,andquicklyrespondedtosubtlesignsthatthedriverofthecarinthenextlaneis

dangerous.Oureverydayintuitiveabilitiesarenolessmarvellousthanthestrikinginsightsofan

experiencedfirefighterorphysician–onlymorecommon”78.

Substitution

Themechanismofreplacingadifficultquestionwithasimpleroneisextensivelydescribedby

Kahneman:“whenfacedwithadifficultquestion,weoftenansweraneasieroneinstead,usually

withoutnoticingthesubstitution[…]Thetargetquestionistheassessmentyouintendtoproduce.

24

Theheuristicquestionisthesimplerquestionthatyouanswerinstead.Thetechnicaldefinitionof

heuristicisasimpleprocedurethathelpsfindadequate,thoughoftenimperfect,answersto

difficultquestions”78.

Kahnemansobjectiveshaveanimpactontheexistingtaxonomybasedtrainingaswellasthe

substitutionfoundintheliterature,but,furthermore,atthecoursedescribedinthethesis;the

master/apprenticeshiprelationshipandachievementoflearninggoalsfortheparticipants.

LEARNINGPYRAMID,NTL

TheNationalTrainingLaboratorieshasfoundthefollowingaverageretentionratesfordifferent

trainingandteachingmethods.Thisisincludedinthethesisinordertodiscussatwhichlevelthe

learninginthedescribedcourseis,accordingtoNTL.

Figure1.TheLearningPyramid

ANALYSISCONSIDERATIONSONEXTRALINGUISTICDATA

Whentwopeoplearepresent,communicationwillalwaystakeplace.Itisimpossiblenotto

communicate79.

Thisthesisaimsatinvestigatingandexploringtheconductor’snon-verbalskills.Therefore,the

followingtheoriesandmethodsofanalysisareincludedtoillustrateevidenceonnon-linguistic

communication,includingtheuseofvideoforresearchpurposes.

INCONGRUENCEBETWEENORALANDEXTRALINGUISTICCOMMUNICATION

Inthe1960s,Mehrabianbecameawarethattherewereotherfactorsthanlinguisticsthatwere

importantinfacetofacecommunication.Mehrabianperformedsimpleinterventionswherehe

25

demonstratedhisfindingsoninconsistentmessagesoffeelingsandattitudes(andtherelative

importanceofwordsvs.nonverbalcues).Whenthereisincongruencebetweenwords,voiceand

facialexpressionincommunication,ourattentionwillbedrawnfromthewordsandtheirmeaning

tonon-verbalcommunication.Thatis,wherethewordsdidnotmatchthefacialexpression

specificallyinMehrabian’sresearchpeopletendedtobelievetheexpressiontheysaw,notthe

wordsspoken80,81.

SEMIOTICS

ApioneerinsemioticswasCharlesSandersPeirce(1839-1914)andtodayhisthoughtsareamong

thefoundationsforMultimodalAnalysis.Atthecentreofhisphilosophywasamodeloftheway

humanbeingsthink,hechallengedtraditionalmodelsbydescribingthoughtsnotas’ideas’butas

’signs,’externaltotheselfandwithoutmeaningunlessinterpretedbyasubsequentthought.His

generaltheoryofsigns–orsemiotic–isespeciallypertinenttomethodologiescurrentlybeing

debated11.Hepioneeredapproachestostudyingvisualsemiotics,andwasinterestedintherange

ofdifferentkindsofsignsthatcanbefoundascomparedtolanguagethatcomprisesabstract

symbols10.

Pierce’sworkaboutsymbolizationandtotheconsciouscontrolandawarenessofsignsbecame

knowntoSusannKLanger(1895-1985).Langerisimportantforthisthesiswhenshestates:“The

limitsoflanguagearenotthelastlimitsofexperience,andthingsinaccessibletolanguagemay

havetheirownformsofconception,thatistosay,theirownsymbolicdevices”82.

MULTIMODALITY(EXTRALINGUISTICCOMMUNICATION)

GuntherKress(ProfessorofSemiotics)emphasisesthatinlinguisticsthereisalwayssomethingthat

isparalinguisticorextralinguisticexistingtogether9.Multimodalityisdescribingothermeanings

thanbasedonlanguageandlinguistics.Thereisvisuallanguage,gesturallanguage,andsoforth.It

issociallyproduced,culturalresourcesformakingmeaning.Situationsaregivenwheretextonly

givesapartialaccountofwhatisgoingon12.Thoughitisimportantweshouldnotthrow

knowledgeoverboard:linguisticshasshownushowlanguageworksandsociolinguisticsshowshow

itisused9.Multimodaldiscourseanalysisopensthepossibilityofmovingagainstthe

“reductivenessoftwentieth-centurygeneralizationsandabstractions[…]andtowardafullaccount

[…]oftheimpactofthefactthat,ashumans,wearephysical,materialbodiesandthatmeaning

cannotbeunderstoodoutsidetherecognitionofthismateriality”83.“Gaze,gestureandposture,

26

forinstance,tendtobeconsideredasupporttospeech;reinforcingorotherwisemodifyingspeech

butnotprovidingcommunicationinitsownright,andimageisoftenthoughttobeinasupportive

relationtowriting.Multimodalresearchacrossarangeofsocialsettingscastdoubtsonthis

assumption”84.

VIDEOANALYSIS

Itwasstatedin2000thatwhentranscribing‘visualphenomena’weareonlyatthebeginningofthis

process85.Anditwasconsideredachallengeassociatedwithenormousmethodologicaland

theoreticalproblems85.Furthermore,videoasdatacollectionwasextensivelydiscussedby

researchers86.

Xiaoetal.statedin2004thatvideorecordingsarearichsourceofdataforsuchresearchbecause,

incomparisontoobservationalnotesandaudiorecording,videorecordingscapturemuchofthe

richnessofhumaninteractionsandofthecontextinwhichactivitiesarestudied66.However,Xiao

doesnottaketheconsequencewhenhedecidestolimittheuseofvideostoverbalanalysisof

what’sgoingoninhisstudy.OnepossibleexplanationcouldbethatXiaodidnothavemethodsor

toolkitstodescribe/analysethis“richnessofhumaninteraction”whichheemphasizes.In2010

Raudaskoskistatedthatvisualdatamaterialhasnoestablishedtranscriptionstandards87.

Theavailabilityanduseofvideohasevolvedexponentiallyoverthelastdecade,andproductionof

HighDefinitionvideoisnowavailabletoeverybodyattheirdailylifeespeciallyviamobilephones

camcorder.Itistodayanaturalmeanofcommunicationandvideosaresharedonallsocialmedia.

Itmightbearguedthatvideohasevolvedintobeinganindependentformofcommunicationonits

own.AccordingtoStatisticBrainResearchInstituteitisinterestingtoascertainthatin2016300

hoursofvideowasuploadedtoYouTubeeveryminute,totalnumberofpeoplewhouseYoutube

1.325.000.000,andthenumberofvideosviewedeverydaywas4.950.000.000.

CONDUCTORSANDVIDEO

Inrecentyears,theuseofvideorecordingshasbeenanaturalandintegralpartofconductor

teachingattheconservatoriesaroundtheworld.Forexample,attheSibeliusAcademyinHelsinki,

Finland,acameraismountedintherehearsalroomforthepurposeofrecordingtheconductorin

close-upasheconductstheorchestra.Avideoroomhasbeenbuiltwherestudentsreceiveand

providefeedbackontheperformancetogetherwiththelectureraftertherehearsalwiththe

orchestra.

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VIDEOANDSIMULATIONINHEALTHCARE

Videoiswidelyusedinsimulationtraininginhealthcare,hencethestudentsarehighlyaccustomed

tothepresenceofacameraduringthetraining.Videorecordingsintheemergencydepartmentare

usedinUSAandareregardedasaneffectivetoolforimprovingtraumateamperformanceby

educatingclinicalstaffregardingrolesandresponsibilities88.Theuseofasurgicalblackbox

[integratingvideorecordings]hasbeenresearched89.Deliverysituations,thatrepresent

complications,arevideorecordedatAarhusUniversityHospitalinDenmarkinaPhDresearch

projectin2017managedbyLiseBrogaard,PhD-student.

PRE-UNDERSTANDING

Inaccordancewithqualitativeresearchtraditions,thePhDstudent’spreconceptionsareaccounted

for.Beinganorchestralconductor,Ifindthesocialmechanismsthattakeplaceintheinteraction

betweenconductorandmusiciansextremelyinteresting,bothtoobserveaswellastoinfluencein

mypositionasconductor.Furthermore,Ihavebeenaprofessionalmusicianandhavethusthe

otherperspectiveonthiscooperationseenfromtheteam’spointofview,andhavethus

experiencedthehugedistancebetweenthosehighlydifferentviewpoints.InadditionIama

composerandassuchIhavecreatedandhavedetailedorchestratedcomplexactionsandeventsat

alongtimedistance,asallcomposersdo.Thosearethepre-understandingsIbringintothisproject.

28

METHOD

SYSTEMATICREVIEW

Inthefirststudy,wesystematicallyreviewedtheliterature.Quantitativestudieswereclassed

accordingtoPRISMA3,Cochrane90,andGRADE91.PRISMAfocusesonthereportingofreviews

evaluatingrandomizedtrials,butcanalsobeusedasabasisforreportingsystematicreviewsof

othertypesofresearch,particularlyevaluationsofinterventions.GRADE’sapproachtoratingthe

qualityofevidenceisusedinthisstudy.WithGRADE,thequalityofevidencewasassessed,aswell

studydesign/methodasriskofbias,inconsistency,indirectness,imprecisionandpublicationbias.

InadditionCochrane’srecommendationsfortheriskofspecificbiashavebeenassessed:selection,

performance,attrition,detectionandreportingbias.Therehasbeenattentiontointernalvalidity

andexternalvalidityintheassessments.QualitativestudieswereclassedaccordingtoCASP(Critical

AppraisalSkillsProgramme)4.

Anumberofpresumptionswereincludedinthesearchinthesystematicreviewforthepurposeof

narrowingthenumberofarticlesinthissearch.Onepresumptionwasthatoperationalleadership

trainingisrelatedtonon-verbalcommunication.AnotherpresumptionwasthatNTSorNOTSS

mightturnouttoaddressthetopic.Athirdpresumptionwasthatspecificwordsaboutleadership

werenecessary(authority,respect,management,leader,lead,etc.).Theliteraturewassearched

forthewordsdescribingtheconductor’scompetencies(conductor,orchestra,symphon*).

Educationwasaddedinthesearch(teach,educa*,train*,learn*).Variousemergencies(CPR,

intensive,acuteetc.)wereadded.‘Meshterms’wassearchedinthePubmeddatabase:‘leadership’

and‘education,medical’.Combinationsoftheaboveweretestedtofindtheconnectionwiththe

clinicalteamleader.SupplementarysearchwasinspiredbyarticlesfoundinPubmed’s‘similar

articles’.Inspiredbythenewarticlesnewkeywordsemerged(trainingleaders,teamlearning,

urgency,situation,taskperformance,resuscitation,cardiacarrest,humanfactors,performance,

advancedlifesupport,etc.)combinationsofthesewereaddedtothesearch.

QUALITATIVECONTENTANALYSISASAMETHOD

Afterconductingtheconventionalsystematicreviewitwasdecidedtoexaminethearticlesin

anotherperspectiveabductive-inductiveQCA.

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Strategyforqualitativecontentanalysis

Inthesystematicreview,allarticlesincludedweregroupedtogetherinasinglePDFdocumentand

searchedseveraltimesforkeywords,theirsynonymsand,ifavailable,theirmeaningfulsimilar

positiveandnegativeanalogies,phrasesandsentences.Thequotesweregroupedintothemesin

aniterativeprocess,andsortedchronologically.Themostimportant/significantquoteschosenon

basisoftheauthors’interpretationarepresentedinthisthesis.

AtthebeginningoftheQCAthemethodwas‘conventional’,abductive–inductive.Whencodes

becameestablished,thesearchandanalysisbecamedirectedbythosefindings.Byusinga

directed,summativeapproachon‘quantitativemanifestcontentanalysis’63inordertoexplore

usageofthevisibleandsurfacecontentofthetextitwaspossibletoidentifyconsensusonselected

wordsfromaquantitativeapproach.Byusing‘qualitativelatentcontentanalysis’8itispossibleto

interprettheunderlyingmeaningofthewordsandthus,rather,interpretaqualitativeapproach.

Thepreconceivedcategoriesinthesearchconductedinthesecondpaperwereguidedbythe

contentofanarticle44.Directed(deductive)qualitativecontentanalysisstartswithpreconceived

codesorcategoriesderivedfrompriorrelevanttheory,research,orliterature63.Introducinga

differentperspectiveonthearticlesfoundinthesystematicreview,theinclusioncriteriawere

expandedtocoverexperience,perceptionsandemotionsrelatingtoleadershiptrainingin

emergencysituations,andthereforeprimaryaswellassecondaryarticlesbecamerelevant.

QCAwasfinallyusedtoanalyseacourseforresidents,3rdsemestermedicalstudentsandnurses,as

presentedinthethirdpaperaswell:Alltext-baseddataweregatheredintoonesinglePDF

documentandsearchedforkeywordsandsentencesdescribingthecontentofthecourse,andthe

wordswereinterpretedinameaningfulcontext.ThemethodwasQualitativeContentAnalysis,

conventional,andinductive:Themesemergedinandabductive–inductiveprocess,abductive

becausetheconductorhadhispresumptionsforthecourse–inductivebecausethefindings

adjustedthepresumptions.Whenthemesbasedonkeywordswereestablished,theprocess

becamedirectedbythethemes,thustheprocessbecamedeductive.Threekeywordswerepresent

atthecoursethoughrarelyverbalized,butshoweduponthevideofootage.Thewordswere

groupedintothreethemesaccordingtothepresumptionsaswellasthefindingsinthedataset.

30

VIDEO

Videofootagewasreviewedseveraltimes,andeditedwiththeaimofexemplifyingthethemes

describedabove.Integratedvideoandaudiorecordingsrepresenting22:12hoursofobservationof

allthecoursesfortheresidentsandstudentsweremade.Onecamerafocusedonthe‘leader’and

anotheronthe‘team’.ThefirstfourcoursedayswererecordedontheGoProSilveredition,and

thesecameraswerereplacedbytheGoProHERO4Blackedition,whichhashighdefinition

resolution(4K),allowingzoominginonthedetailsofthefootageintheeditingprocess.TheHD

footagewaseditedonaMacBookProwithtwoexternaltwoTBharddrives(oneforbackup).

Recordingsfromasinglecoursedaytookupbetween40and60GBofdiskspace:all22:12hoursof

recordingsfilledapproximatelyoneTBofharddrivespace.ThevideoswereeditedinAdobe

PremiereProCC,release2017.1.2.

TRANSCRIPTIONS

Writtenfieldnoteswerecompiledforallthecourses.Completedialoguesweretranscribedfromsix

courses(thefinalcoursedesign).TranscriptionmadepartlybyTLandpartlybytwomedical

studentswhowerenotattendingorinformedaboutthecourse(‘blinded’astothebackground,

methodandassumptionsforthecourse).Throughouttheproject,TLkeptaresearchdiary,where

observationsandthoughtsdeemedtoberelevantfortheprojectwererecorded(Onlinelog

availableinAppendix).

EVALUATIONS

Alltheparticipants(students,residentsandnurses)evaluatedthecourseimmediatelyafter.They

gavewrittenquantitativeevaluationsandrespondedtoashortsurveyoffourquantitative

questionsplusanoptionforafreeassessmentcomment(Appendix).Thestudentsandresidents

wereencouragedtoreflectonthecourseinwrittenevaluationsafterthecourse.Afterreceiving

editedvideoclipsshowingtheirpersonalperformanceduringthetwocoursedays,thestudents

andresidentsweresentasurveywith14questions.The‘blinded’studentswroteaqualitativenon-

guidedreflectionfromthevideostranscribed.

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ETHICALCONSIDERATIONS

TheCommitteesonHealthResearchEthicsfortheCapitalRegionofDenmarkwasaskedtogive

ethicalapprovalbutaformalreviewwaswaivedforthisstudy(H-4-2015-FSP).Allparticipantsgave

writtenconsentfortheirvideostobedisplayed/publishedhere.

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PRESENTATIONOFTHEINCLUDEDPAPERS

STUDY1

Trainingresidentstoleademergencyteams:ASystematicReview

Aim:Todescribehowliteratureaddressesworkableandoperationalleadershiptrainingforthe

emergencymedicalteam-leaderandtoenhanceunderstandingofleadershiptraininginthe

medicalenvironment

Results

Twenty-sevenarticleswereidentified.Onesinglestudyaddressingworkableandtargeted

leadershiptrainingwasidentified41.Mostofthearticlesdiscussedseveraldifferenttypesof

behaviouralmarkersandtaxonomies.Leadershiptrainingwasforthemostpartcombinedwiththe

trainingofalgorithmsincludingmedicalcompetencies.Ninestudieswerebasedoninterviewsor

questionnaires.

Atotalof20taxonomiesaddressingleadership,teamwork,andcommunicationwerementionedin

thearticles.Twentyfiveofthetwentysevenarticleswereinfluencedbyoneorbothoftwo

frequentlymentionedtaxonomies:1)TheLeadershipBehaviorDescriptionQuestionnaire,LBDQ

(adaptedfrommilitary)(ninearticles).2)TheNon-technicalskillstaxonomy,NOTECHS(adapted

fromaviation)(sevenarticles).Theabovementionedstudiesdidnotrefertoeachother.Nineother

articles,however,referredtobothtaxonomies.

Resultofcontentanalysis

Threekeythemeswereevolved:1)Leadership2)Taxonomies3)Trainingleadershipandmedical

competence.

Leadership

Eightdifferentdefinitionsofleadershipwereidentified.Fourarticlesstatedinthebackgroundto

theirstudythatleadershipislacking,andfivearticlesdiscussedorconcludedexplicitlythat

leadershipwaslacking.Threearticlesmentionedthatleadershiptrainingwasimportantand

appearedtoimprovebehaviour.Nineconcludedthatleadershiptrainingwouldhaveapositive

impact.Thatleadershiptraininghasbeenignoredwasstatedinthebackgroundforthreestudies.

Ninearticlesdiscussedorconcludedthatleadershiptraininghasbeenignored.18ofthe25authors

(20/27articles)identifiedarecurringneedforexplicittargetedteamleadershiptrainingin

33

healthcare,7articlesmentionedthisinthebackground/introductionand13articlesasafindingor

aconclusion.Ninearticlesproposeddifferentapproachesorfocusareastoimproveleadershipin

emergencies.(Aviation,NTS,Gender,Ethnicity,Non-Verbalcommunicationetc.)

Taxonomies

Fourarticlesagreedthattheideaofusingbehaviouralmarkersystemswastoidentifyexplicitlythe

neededskillswiththepurposeofteaching,observingandmeasuring.Twoarticlesfinda

comprehensivetaxonomyadvantageous;twostatedthattaxonomiesshouldbesimple.Fivearticles

statedthatmeasurementtoolswerelacking.Sevenarticlesannouncedthedevelopmentofanew

oradaptedtool.Threearticlesstatedinthebackgroundthatitcouldbedifficulttokeeptrackof

theactualcontentofthevarietyoftoolsandmethods.Onestatedexplicitly(in2015)thatthetime

hadcometostopdevelopingnewtoolsandbeginfocussingonworkableinterventionsinthisarea.

Trainingleadershipandmedicalcompetencesimultaneously

Onearticlestatedthatreducingthecognitiveworkloadbeforehandbyseparatingroleinstructions

wouldhaveapositiveimpactontheCPRperformanceandonthetrainees.Sixarticlesexplicitly

statedthatleadershiptrainingdifferedfrommedicalknowledgetraining.Onearticlestatedthatit

wasimportanttofocusonleadershipseparatedfrommedicalknowledge.

Conclusion

Notargetedtrainingprogrammeswerefound.Theliteraturehasfocusedondevelopingleadership

measurementtools.Aprevailingneedforexplicittargetedteamleadershiptraininginhealthcare

wasidentifiedinmostarticlesfound.

34

STUDY2

Trainingresidentstoleademergencyteams:Barriers,ChallengesandLearningGoalsconcerningtrainingresidentstoleademergencies:aQualitativeReview

Aim:Aninvestigationtodetermineanyconsensusinopinionsandviewsaboutchallenges,barriers

orlearninggoalsintrainingleadershipinemergencies

Results

Fortyarticleswereincluded.Ninethemesemerged1)Residentsfeelunsupervisedandunprepared

2)Acomplex,stressful,unpredictableandchaoticexperience3)Anunpleasant,disturbing,

frighteningandpanickedperception4)Loweredstress5)Confidence6)Howaleaderisperceived

7)Ashortcuttoperceptionofauthority8)AssumingLeadership9)Borntolead–orlearntolead

ResidentsfeelunsupervisedandunpreparedTenarticlesconcludedthatresidentsfeltunpreparedasleadersofcardiacarrestteams.

Acomplex,stressful,unpredictableandchaoticexperience

Abroadconsensuswereidentifiedthatleadershipinemergenciesisexperiencedasacomplex

issue,aswellintermsofstressfulsituationsdemandingimportantdecisionsforthebenefitofthe

patient,asofmanagingtheteamitself.Ninearticles,inthebackgroundforthestudies,mentioned

complexity,sevenstatedcomplexityinthediscussion/conclusionsection.Theterm:copingwith

pressurewasmentionedbysixarticles,andthreeusedasimilartermcopingwithstress.The

stressfulworkingconditionswereemphasizedinthebackgroundsectionofeightarticlesandten

articleshighlightedtheseconditionsinthediscussion/conclusionsection.Threearticlesdescribed

theperformanceinemergenciesasunpredictableorunanticipated.Thewordchaoswasusedby

sevenarticles,astheydescribedthesituation.

Anunpleasant,disturbing,frighteningandpanickedperception

Theemergencysituationswerecharacterizedbyvariousformsofdiscomfort:theconcerned

traineeswerementionedbysevenarticles,eightarticlesmentionedanxiety.Onearticlementioned

panic.

Loweredstress

Fourarticlesclaimedthatagoodleaderwasabletocreate“loweredstress”orto“calmother

peopledown”.Twoarticlesmentionednoiseandcrowdcontrol.32

35

Confidence

Threearticlesstatedthatconfidencewasimportantinthebackgroundsection.13articles

concludedthatadegreeofself-confidenceiscrucialforthequalityoftheleadership.

Howaleaderisperceived

Eightarticlesdiscussedtheteam’sperceptionoftheleader.Toestablishacomfortableandsafe

environmentfortheteam,teammembersmustbeabletoperceivetheirleaderastrustworthy16,47.

Jacobssonetal.emphasizesthatitwasimportancethattheleader“hadastrongethosand

expressedcompetence”30.

Ashortcuttoperceptionofauthority

Threearticlesstatethattheleadershouldtakecareofhis/herappearance“especiallyforfirst

meetings”andinthiscontextthat:“Theclinicianwillworkonwaystodevelophis/herown

charisma”46.Itisimportanttoadopt“apowerfulposture”32,and“Teammemberswhoareaware

ofhowtheyusetheirbodiestocommunicatewillbeabletofacilitateandimprovetheir

performance”35.Anotherissueemphasizedasimportantbyeightarticlesishowtheleaderuses

his/hervoice.

AssumingLeadership

Tobecomeagoodleaderitisimportanttoassumetheleadershipwithallitsimplicationsincluding

risksandfailure.Fivearticlesstatethisviewintheintroduction/backgroundsections.Sixarticles

elaboratethisviewintheirdiscussion/conclusionsections.Whenassumingleadershiponecan

benefitfrom‘introspection’46,‘psychologicalself-care’60,or‘self-management’47.

Borntolead–orlearntolead

Sevenarticlesmentionthatsomeareborntoleadwhileothershavetolearn.

Conclusion

Barriersforacquiringleadershipcompetenciesrequiredwhenmanagingemergencyteamswere

identified.Learninggoalswereidentified.Strongnegativeemotionssuchasstress,anxietyand

panicwerefoundwhenworkinginemergencies.

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STUDY3

Conductingtheemergencyteam:Anovelwaytotraintheteam-leaderforemergencies

Aim:Theoverallaimofthecourseistoinvestigatewhether,inanemergency,aclinicalteamleader

couldapplyaconductor’sleadershipskills.Adescriptionofacourseheldforresidents,medical

studentsandnurses.

Methods

Wedevelopedacourseforresidentsand3rdsemestermedicalstudents.Inordertosimulatean

emergencysituationandtooptimizeleadershiptrainingthecoursecreatesaframeworkwith

stress,anxiety,anddiscomfortinaharmless,non-clinical,andsafesetting.Theparticipantswere

challengedtoactasconductorsinmusicalexercises.Aconsultantandanorchestralconductor

werethefacultyforthecourse.Oneadditionalcoursedaywasheldforemergencyroomnurses.

Dataacquisitionandanalysis

Alltheparticipantsmadeevaluationsimmediatelyafterthecourses,n=61.Theygavewritten

quantitativeevaluationsandrespondedtoashortsurveyoffourquantitativequestionsplusan

optionforafreeassessmentcomment.Thestudentsandresidents,n=38,wereencouragedto

reflectonthecourseinwrittenevaluationsafterthecourse,thosequalitativeevaluationswere

receivedfrom20participants(53%).Thecourseswererecordedontwovideocameras.After

receivingeditedvideoclipsshowingtheirpersonalperformanceduringthetwocoursedays,the

studentsandresidentsweresentasurveywith14question,thosewerereceivedfrom10

participants(26%).Writtencommentsreceived24monthsafterthecoursefrom4participants

(10%).SelectedcoursesweretranscribedverbatimbyTLandbytwo‘blinded’students

respectively.The‘blinded’studentswroteaqualitativenon-guidedreflectionfromthevideos

transcribed.Participantsevaluatedandcommentedoneachother’sdevelopmentatthecourse.

Analysis

QualitativeContentanalysis

Alltext-baseddatawasgatheredintoonesinglepdf-documentandsearchedforkeywordsand

sentencesdescribingthecontentofthecourse,andthewordswereinterpretedinameaningful

context.ThemethodwasQualitativeContentAnalysis.Themesemergedinanabductive–

inductiveprocess.Whenthemeswereestablishedtheprocessbecamedirectedbythethemes,

thustheprocessbecamedeductive.Threekeywordswerepresentatthecoursethoughrarely

37

verbalized,butshoweduponthevideofootage.Videofootagewasreviewedseveraltimes,and

editedwiththeaimofexemplifyingthethemesdescribedabove.

Results

20three-hourcoursedayswerecompleted.

Threekeythemesemerged:1)Learningenvironment.2)Pedagogics.3)Learninggoals–the

conductor’sfocus.

Learningenvironment

Safe,enjoyablelaughterhadasignificantimpactonthecourseindicatingthattheparticipantsfelt

safeandenjoyedparticipating.15/38participantsstatedthattheyfeltthatthefacultyfully

understoodthechallengestheyfaced(‘gotundertheirskin’).17/38participantsstatedthatthey

greatlyappreciatedthispersonaland‘straighton’feedback.15/38participantsduringthecourse

and21/38participantsafterthecoursestatedthatthisfeedbackhascausedasignificant

developmentintheindividualparticipant’sbehaviour.Theparticipantsobserved,notedand

commentedfrequentlyoneachother’sperformanceanddevelopmentinthedialoguesrecordedat

thecourse.

Pedagogics

Itwasimportanttogivetheparticipantsafeelingoftheintensecommunicationwhenleadingan

orchestranon-verbally.Itwasobservedthatatrance-likestatefrequentlyoccurredbetweenthe

leaderandtheteamduringtheexercises.

Partofthelearningprocessthroughapprenticeshipistheverydirectpersonalfeed-back.As

presentedonthevideos,theparticipantswerechangingtheirbehaviourduringthecourse.

Learninggoals–theconductor’sfocus

Atotalof47/61(students,residentsandnurses)expressedthattheyhadbecomeawareofthe

importanceofbodylanguage.17/38(studentsandresidents)specificallystatedthattheyhad

achievedinteractionbetweenbodylanguage,appearanceandauthority–andunderstoodwhythis

leadstocalmnessandconfidence.Eighteenparticipantsstatedthattheyhadlearnedthateye-

contactisapowerfultoolforensuringthatdecisionsarecommunicated,receivedandunderstood.

Theparticipantslearnedthatinthiscoursecontextitwasvalidtotalkaboutandexpresssubjective

perceptions.15participantsstatedthattheywerepushedoutoftheircomfortzone,however19

38

participantsacknowledgedthattheenvironmentwasneverthelesssafe.Participantsweresurprised

andimpressedtoseehowmuchtheycouldcommunicateandhowexplicitandnuancedtheycould

maketheirdemandswithoutspeaking.

Additionalfindings

Oneblindedstudentandfourparticipantsstatedthattheyforgotthenewlylearnedlessonswhen

challengedonclinicalknowledge.Threeofthoseplusadditionalanotherfourstudentsand

residentsstatedthatitwasadvantageoustotrainleadershipseparatelyfrommedicalcompetence.

Theexperiencednursesrespondedmostpositivelytothecourse.Theaverageageinthisgroupwas

over50years,whichindicatesthatafteryearsofexperiencethisgroupwasawareofhowfatalit

couldbewhentheteamleaderfailed.35oftheparticipantsagreedthatthecoursewashighly

relevantfortheirclinicalpractice.Twoyearsafterthecourse,fourparticipantsstatedthatithad

changedtheirprofessionalbehaviour.11participantsstatedthatthecontentofthecoursehadan

importantobjective,whichwaslackinginteachingattheuniversity.13participantsstatedthatthe

subjectwasrelevanttoeducationalcontexts,totheclinic,whencollaboratingingeneral,daytoday

work,doctors’work,instructingcross-fit,swimminglessons,publicspeakingandattendingoral

exams.

Conclusion

Theparticipantsnotedandcommentedoneachother’sdevelopmentonthecourse.Accordingto

theirself-reportingafterthecoursethetransferofaconductor’sskillschangedtheparticipating

students’,nurses’andresidents’behaviour,andintroducedamethodtohandleanxietyandshow

calmnessandauthority.Thiscourseclearlyseemstoaccommodatetheneedforanoperationaland

targetedtrainingoftheteamleaderinemergencies,addressingawaytoachieveconfidenceina

stressful,butsafelearningenvironment.

39

DISCUSSION

Theoverallobjectiveofthisthesiswastoexploreadifferentapproachtotraintheemergencyteam

leaderwithhelpfromanotherprofession.Furthermore,toinvestigateexistingaspectsoftrainingof

theteamleaderinemergenciesinhealthcare.Thischapterwillsummarizethemainfindingsand

discussthestrengthandweaknessesofthestudies.

Nodefinedandworkableleadershiptrainingwasidentifiedinthesystematicreviewandnoclear

definitionofleadershiphasbeenfound.Inadditiontheliteratureonthissubjectaredominatedby

‘significantvariabilityinterminology,trainingmodalitiesandevaluation’inthisfield15,41,43.

Nevertheless,scientistsagreethatleadershiptraininghasanimpact,improvesbehaviourand

changesclinicaloutcome.Despitethis,theliteraturedemonstratedthatformalleadershiptraining

hasbeeninadequateorthateducationisinsufficient.Thisthesisdemonstratedagap–oratleast

lackofconsequence–inbetweenwhatmedicaleducatorsknowsandwhatactiontheydotake.

Anexplanationcouldbethatresearchinhealthcarehasatraditionforapplyingthepositivistic

clinicalresearchtradition,theneedtomeasure.Inaccordancewiththisexplanation:mostofthe

articlesfoundinthesystematicreviewinthisthesis(23of27)revealedapositivisticontology

aimingtomakequalitativefindingsquantitativeandmeasurable–andusedstatisticstoprovethe

result1,13-15,17,21-23,26,27,29,33-37,39-43,56,59.Theenthusiasmoftheresearchersisnoticeablewhenthey

considersolvingtheproblemasstatedbyProf.Yulein2006“thisstudyhastakentheadditional

stepofidentifyingexplicitlytheparticularnon-technicalskillswhichmightbebothtaughtand

observed–andthereforemeasured”38.Hereitseemstobecomeagoalinitselftobeableto

measure.

Butwhennodefinitionofleadershipisfound,asstatedabove,itwillsubsequentlynotbepossible

totrytomeasureanythingconcerningleadership.Anexplanationtothisdilemmacouldbethatthe

socialandcommunicativequalitiestheteamleaderneedsisnotmeasurable,butnevertheless

representsveryrealinterpretationsandconstructionsofrealityinbetweenhumans.Thisisin

accordancewiththeontologyofaconstructivistapproachandnottheontologyofapositivistic

approach.

Anotherexplanationtothischangeoffocuscouldalsobeexplainedby‘substitution’.The

mechanismofreplacingadifficultquestionwithasimpleroneisextensivelydescribedby

psychologistDanielKahneman:“whenfacedwithadifficultquestion,weoftenansweraneasier

40

oneinstead,usuallywithoutnoticingthesubstitution[…]Thetargetquestionistheassessmentyou

intendtoproduce.Theheuristicquestionisthesimplerquestionthatyouanswerinstead”78.

Thepredominanttrainingfoundinvolvestaxonomiesandalgorithmtrainingasdemonstratedinthe

SystematicReview.Thisisdominatedbytwoschoolsofmedicaleducationalresearch,oneinspired

bythemilitary,theLBDQ,andtheotheroneinspiredbyaviation,NOTECHS.Itisnotwithinthe

scopeofthisthesistodiscusswhythereisverysparsecommunicationbetweenthetworesearch

groups,butitisasurprisingfindingthatmaybeimportant.Theweaknessofusingmilitaryand

aviationmodelsisthattheyareaimedatpeoplewhohaveleadershipasafull-timeemployment,

whiledoctorsalsohavetocopewithseveralotherrolesintheirprofession,inaccordancewith

CanMEDSdefinitionofthesevenrolesofthedoctor92.

Asdescribedabove,literaturerevealedalargenumberoftaxonomiesaimingatmeasuringthe

abilityofresidentstoimplementvariousprofessionalalgorithmswithoutspecificfocusonthe

leadershiprole.Itcanbearguedthatthisrelationshipexpressesmoreaboutanactualclinicalskill

andbasicallynothingaboutthequalityofleadership.Again,inaccordancewithKahneman78,itis

possibletoarguethattraininginclinicalskillsandmemorizingalgorithmsaddressestheeffortful,

slowandrationaloperationsofsystem2whileinteractionbetweenpeople(leadership)takesplace

intheautomatic,fastandintuitivesystem1.Itisdifficulttooperateinbothsystemssimultaneously

anderrorscanoccurifthetwosystemsconflictwitheachother.

Thisthesisdescribesthatitisappropriatetotrainclinicalknowledgeandleadershipseparately.

Evidencefromevaluationsandvideosinthisstudydemonstratesthattheparticipantsarevery

excitedtohavetheopportunitytofocusexplicitlyontheirpersonalleadershipskillsaswellas

statedintheliterature14,17,23,27,33,36,41.

Instudy2,ithasbeendescribedthatthereisaneedtoaddresstheyoungphysician’sstrong

negativefeelingsassociatedwiththeleadershiprole.Anxietycanblocklearning(amygdalahijack)

andanxietycanblockperformance,‘paralysesorcauseserrors,itcaninterferewithwhatwewant

todo’asstatedbyProf.Williams77.Itisnotfoundintheexistingtrainingthattheresearchershave

considered–orevenmanaged–toaddressthefearthatyoungdoctorscanexperienceina

stressfulsituation.

41

Developmentandconductionofacourseaddressingleadership

Thisprojectdevelopedanunconventionalcoursefocusingontrainingleadershipfortheclinical

teamleaderinemergenciesinaneffectivewaythatseemstoaddresswhattheliteraturehas

soughtfor30years.

Inthisregard,itisimportantnottothreatentheyoungdoctorsprofessionally.Onthiscoursethey

arenotassessedonclinicalcompetencies,participantsdonotcompetewiththeirprofessional

knowledge.Thefocusissolelyontheleadershipaspectinthemusicalexercisesthataddressthe

intuitivesystem1,inaccordancewithKahneman,addressescreativityalsoand,infact,arefun

challengesasevidencedbythedata.Commontoallparticipants,however,isthetotallackof

knowledgeandprerequisitesforsolvingtheexercises.Allparticipants,inthisregardstartsona

sharedbaselineclosetozero.Thisisanimportantpointthatisinlinewiththephasesof

transformationallearningtheory70,71.Participantsaregivenanimpossibletasktobeperformedin

astressfulsituationwheretheyarehighlyvulnerableinfrontofeveryone.Thisisdescribedas‘a

disorientingdilemma’,whichprovidesanexcellentstartingpointforlatertransformationin

accordancewithtransformationallearningtheory.Asdescribedinthedata,aswellasclearlyvisible

onthevideos,cohesioniscreatedwhentheparticipantsdiscoverthatthisrecognitionof

inadequacyissharedbyall.Thisphaseisalsoexpressedasanimportantpartofthetransformative

learningprocess,whichdescribesaphasefour,whereitispronouncedasfollows:’Recognition

thatone’sdiscontentandprocessoftransformationaresharedandthatothershavenegotiateda

similarchange’70,71.Manyparticipantsexpressedthattheydiscoverednewcharacteristicsof

themselvesfromthecourse.

Previouslyithasbeenclaimedthatanxietycanblocklearning.Nevertheless,asdemonstrated,itis

possibletoprocesstheanxietycreatedonthiscoursebecausethechallengeisalmostimpossible

andthereforeridiculouslyunfair,creatingcohesionamongtheparticipantsandlotsoflaughter.

Furthermore,theexercisesarefunitselfwhendealingwithmusicandcreativity,notalgorithmsand

clinicalknowledge.

Itwasanimportantobjectivetogivetheparticipantsafeelingoftheintensecommunicationwhen

leadinganorchestranon-verbally.Thiswasasmuch‘learningbyfeeling’as‘learningbydoing’.

Withtheintentionofgivingtheparticipantsthisdeepunderstandingandexperienceofbeingin

control,creatingconfidenceintheleadership,focusontheworkathandandcreatingcalmnessin

theteam,itwasconsidereddesirablethattheparticipantsintheirownbodyexperiencedthatit

42

waspossibleinpractice.Thefeedbackwasdependentuponfeaturesofthephysicalbodyofthe

participant,thatis,aspectsofthebodybeyondthebrainandthereforethecognitionofthe

participantisembodied,asdescribedinembodiedcognition68.Thisphenomenaisdescribedas

importantforeffectivelearningespeciallypromotinglearningtargetingconceptualchange,in

accordancewithembodiedcognition69.

Itisdescribedintheliteraturethatthereisaneedtoaddressthestrongnegativefeelingsofyoung

doctorsassociatedwiththerole.Therefore,consciousworkistointegratethefearintothedesign

ofthecourse.Itmayseemparadoxicalthatitshouldbepossibletocreateasafelearning

environmentwhileintroducinganxiety-inducingexercises,butitisneverthelesswhathappensand

thisparadoxisemphasizedbytheparticipants’evaluations.Everybodylaughsveryoftenand

everyoneisspeakingfreely,asisevidentfromtranscriptionsofthecourseandofthevideos.

Discussionsamongthestudentspromoteahighleveloflearning,witharetentionrateof50%,

accordingtoNTL’saverageretentionratesfordifferenttrainingandteachingmethods.

Forashortwhile,theparticipantgetstheopportunitytoworkasaconductorandactuallyinfluence

otherstoactandrespondtotheirintuition–noquestionsareasked–andespeciallywhen

conductingtheGhettoBlastersessionastatecanoccurwheretimeandplaceisdissolved,the

participantsareoptimallychallenged,fullyfocusedandemotionallyinvolved–describedas

learningbyfeeling–ascanbeobservedatthevideos(youtu.be/KcyZf3_QfMk).Thisconditionis

describedinFlow-Psychologyasageneralpedagogicideal74-76.Furthermore,thisisalso‘learning

bydoing’(bypractice),whichpromotesahigherleveloflearning,witharetentionrateat75%,

accordingtoNTL.

Theteachingmethodatthecourseisapprenticeship.Theconductoractsasarolemodeland

providesfeedback.Theparticipantsimitatetheconductorandreceivefeedbackontheirown

performance,whichguaranteesindepthprofessionalfocusaccordingtothequalitiesof

apprenticeship72.Participantschosetocallthisfeedback‘straighton’,andthisgavethemthe

opportunitytogaindirectinsightintotheirownweaknessesasexperiencedbytheconductor.

Onefactorthatisunusualinrelationtomedicaleducationisthattheconductorallowshimselfto

haveanopinionandbesubjectivewhengivingfeedback.Inaccordancewiththeprinciplesof

hermeneutics,itispossibletorecognizeandobserverealitywhenpresentinitandbeingableto

interpretonthebasisofpresumptions5,65.Theconductoriscapablebecauseheisan‘intuitive

expert’,accordingtoKahneman78.

43

Abenefitofthismethodisthattheparticipantsrealisethatitisacceptabletotrustanintuitionand

besubjectiveintheirinterpretationastheconductordoes.Thisisemphasizedonthejoint

discussionsandreflectionswhereparticipantsdiscoverthatthisabilityisnotatalentora

competencereservedtotheconductor.Thesepersonalsubjectiveinterpretationsaresharedby

everyoneandthusgenerallyapplicable.Itshouldbeemphasisedthattheparticipantsdonotlearn

tointerpretatthiscourse,theyalreadyknow;webelieveitisdeepwithinustoseektounderstand

andfindexplanations,thatis,tointerpret.Thecourseteachestheparticipantstotrusttheirown

intuitive,subjectiveinterpretationandconsequently;thatitispossibletobeinterpretedor‘read’

asdesired.Therefore,realityisanon-measurableconstruction,butneverthelessrealconstruction

ofwhattakesplaceinpeople’smindswhentheyaretogether.Realitybecomesasocial

constructionof(intuitive)interpretationsandmustbeseeninthecontextofindividualsinteracting,

asalsodescribedinconstructivism.

Thestudyistobeseeninacontextofallowingexperiencesandperceptionstoexistbeyondthe

limitsoflanguage,accordingtosemioticsandmultimodality9-12,83,84,86,93.Thecoursedealswith

non-verbalcommunicationonmultiplelevels.1)Oneleveldealswithbodilyexpressionand

gesture.2)Anothermoreintangible,butstillshared,recognisedleveldealingwith’presencetothe

moment’,’credibility’,’responsiveness’and’authority’.3)Finallythere’smusic,which,accordingto

Langer,dealswithexperiencesinaccessibletolanguage82.EspeciallyintheGhetto-Blaster

exercises,theparticipantgetsacquaintedwithanexerciseinwhichtheyareplayingcreativelywith

amusic-aesthetictheyhavenotexperiencedbefore.The(spoken)focusattheabovementioned

level1and2,butthelanguageintheexercisesisthemusic–level3.Themusicandthe

interpretationofthemusicisatopicthatisrarelymentionedinthetextmaterialrepresentingdata

fromthecourse,butitmaybeimportantforanon-verbalcoursetoworkwiththiscreativeand

wordlesscommunicativemediawheretheoutcomeonlyexistsinthemomentitiscreated–and

onlyinthecognitionandinterpretationinthemindsoftheparticipants.

Feedback

Asdocumentedintheevaluationsandinthevideofootage,theparticipantsaremostexcitedabout

thepersonalandclearfeedback.Thisisconsidered–bytheparticipants–asaveryusefuland

completelyuniquestrengthofthecourseasdescribedintheevaluationsafterthecourses.

Obviously,thisisnotasurprisingreaction,it’shighlyunusualforadultstocommentoneachother’s

appearanceandnon-verbalcommunication,butthisishighlyappreciatedinthiscontext.

44

Itisadelicatebalanceforthefacultywhenfeedbackisgiventotheparticipant;itisimportantto

‘getundertheskin’oftheparticipant,butcrucialthatthefeedbackissafe;thisisthedecisive

challengeforthecourse.Participantsstatedthattheyfeltthatthefacultyfullyunderstoodthe

challengestheyfaced.

Animportantfactoristhatfeedbackisgivenimmediatelythemomentaproblemarises.Common

practiceinsimulationtrainingistoprovidefeedbackafterthesimulationiscompleted;i.e.witha

certaindistanceoftime.Asdemonstratedonthevideos,theconductorimmediatelypinpointsan

inappropriatebehaviour,isabletoimitateitandtherebydemonstratethedisadvantageofthis

behaviourandheisabletodemonstratewhatamoreappropriatebehaviourwouldlooklikeinthe

situation,inaccordancewithapprenticeship72.

Initially,itistheconductorwhogivesfeedback,thenitistheclinicalteacherforclinicalrelevance

butsoonduringthecoursethefeedbackishandedtothecourseparticipants.Thereareon-going

discussionsandreflectionsonthelessonslearnedandabouttheinterpretationofthenon-verbal

expressionsthatarethesubjectsofthecourse,andequippedwiththisnewawarenessand

vocabulary,theparticipantsgraduallygiveeachotherfeedbackoneachother’sbehaviourand

appearanceasleaders.Whentheparticipantscommentoneachother’sdevelopment,itis

consideredasthemostoptimallearningsetting,witharetentionrateat90%,accordingtoNTL.

Anotherimportantlearningtakesplacewhenparticipantsobservehowandwhypersonalfeedback

isgiven,andexperiencehowthisfeedbackimmediatelyinfluences,transformsandstrengthensthe

‘leader’s’credibilityinfrontoftheteam.

Faculty

Theparticipantslearnfromtheconductor,whoisamasterinnon-verbalcommunicationand

leadershipoftheorchestra.Hehimselfhasacquiredhisleadershipcompetenciesthrough

apprenticeship,andtheseskillshaveevolvednotthroughtheoreticallearning,but,inaccordance

withMintzbergthroughmanyyearsofpractise73.Thisgiveshimahighlevelofcredibilityamong

theparticipants.

Asdemonstratedinthedata,thecourseworksexplicitlyandishighlytargetedwithintangible

topicssuchasnon-verbalcommunication,appearance,presenceandauthority.Itispossibleto

workwiththesesubjectsbecausethecoursedrawsontheexperienceofaconductorwhoworks

45

consciously(deliberately)withthesesubjectsinhisprofessionwhenhestandsinfrontofthe

orchestra.

Onecansaythattheentireargumentforthisthesisabouttheconductor’scommunicationisthat

theconductorcanworktobeinterpretedunambiguously–withoutusingwords,andthisskillis

valuableknowledgefortheclinicalteamleader.

Participantsacknowledgehisexpertiseandexperiencehowmuchhecan‘speak’withoutwordsand

acquireaclearunderstandingofthispossibilityofcommunication,which,accordingtoMehrabian’s

research,isaverystrongelementin‘facetoface’communication;peopletendstobelievethe

expressiontheysee80,81.

Thisconductorseemstoclaimthatthereisonlyonewayofconductinganorchestra:keepcalm,

raisedsternum,incontrolofarmsandbody.Butthereareevidentlymany,differentandoften

extremelypassionateandexpressiveconductors,andfurthermoretheirleadershipstyleisvery

differentaswell.RiccardoMuti=commandingstylecentredaround‘I,theconductor’.Richard

Strauss=onlyexecutionofthewrittenmusic–nointerpretation.HerbertvonKarajan=closedeyes

andnoclearinstructions,allaboutinterpretationandlistening.CarlosKleiber=createsconditions,

motivationandpartnership–butauthoritativeleadership.LeonardBernstein=demonstratingthe

feelingsofthemusic57.Whatisthesameforallconductorsisthatthebasicknowledgeandability

areshared.Onlywhenthisisacquireditispossibletoaddpersonalitytotheleadershipstyle.

However,itwasimportantthattheotherteacheronthecourseisclinicallecturerandconsultant

andsettheframeworkforthecourse.Byconsultantspresence,theclinicalrelevanceisvisualized

andguaranteedinthedialoguesanddiscussionsonthecourse.Thelecturerdrawsparallelsfrom

thelearnedtotheclinicandtheclinicalteamleader.

Itisinterestingtoascertainthattheskillsandcompetencesaddressedinthecoursearesituatedon

ameta-levelandareaprerequisitefortheteaching:thefacultyhastobeabletoassumethe

leadershiproleaseducatorswhoareabletoimprovisewhenteaching,whichisaskillrequiringa

highlevelofexperienceandknowledgeaccordingtoKoivunenandBarrett94,95.Itisveryimportant

forthefacultytobeabletodemonstrate‘presenceatthemoment’and‘responsiveness’inorderto

appearcredibleasteachersandrolemodels.Iftheteachinginleadershipwasbasedontheories

andtheteacherwasunabletodemonstrateleadership,theteachingwouldnothavetheimpactit

had.Itwouldnotbeexperiencedasauthenticbutratherasanassertionoranabstraction.

46

Assessmentoftheimpactofthecourse

Accordingtotheresultsofthecourse,participantsreportedtogainself-confidence,calmnessand

overviewwhencalledupontoactasconductors.Videorecordingsfromthecoursehaveshown

thatthecoursestrengthenedtheparticipant’scredibility,andtheparticipantsreceivedtoolsfor

dealingwithpersonalanxietyasdemonstratedinthequalitativecontentanalysisofthe

transcriptionsfromthecourse,theevaluationsaswellasshowninthevideofootage.

TheKirkpatrickModelisahighlyrecognizedwayofassessinglearning96.Onaquestionnaire

designedaccordingtothismodel,theparticipantsthemselvesassessedhowthelearningwill

changetheirbehaviorandhowtheywillimplementthelearnedintheirprofessionalwork.The

qualityofthisassessmentmaybechallenged.Itwouldhavebeenbetterifathirdparthad

evaluatedthechangeinbehaviour.Thisisnotanoptioninthisthesis.However,manyevaluations,

afterthecourse,describedthatthecoursehadanimpactontheirprofessionalactivitiesaswellas

intheirdailylives.

Onevideosequencesummarizesinaveryconvincingwayoneofthecoreobjectivesofthecourse

anddocumentsthetransformationofaparticipant.Thisvideodemonstrateshowthetrainers‘gets

undertheskin’oftheparticipants,showsthereflectiononthelearningandthesupportfromthe

otherparticipants.Theparticipantinfocusgoesfromsaying“Mypalmsaretotallysweaty”and“I

thinkit’shorrible”tosay:“Iwisheveryonecouldtrythis”and“Itismostimpressive”.

youtu.be/GW7XPdnf-EU.

Weallowourselvestointerpretthatwechangetheparticipants’behaviorasteamleaders,

measuredbytheirownexperienceontheirownbodyaswellasbyobservingtheotherparticipants

inthesituation.However,wethinkitisnecessarytointerpretbecausewearediscussingthingsthat

havenodefinitedefinition.Thereisnofixeddefinitionofthequalityofleadershipanditisnot

possibletoassess‘charisma’orassessthequalityofnon-verbalcommunicationandleadership,

onlyqualitativeandinterpretativeapproachesexist.

STRENGTHSANDLIMITATIONS

Thesearchinthesystematicreviewhasbeensystematic,objectiveandreproducible.Butthe

searchstringproducedcanbecriticizedforinvolvingnon-verbalcommunicationinthesearch.Itis

theresearchers’convictionthatitisnecessarytoaddressthistopicinthetraining.Thesearchcan

47

becriticizedfornotincorporatingthetheoreticalaspectofleadership,butithasnotbeenthe

purposeofthestudy,whichhasexplicitlyfocusedonfindinganoperationalandworkabletraining.

Itcouldbealimitationthatthesearchstringusedfocusedonleadershiptraininginavarietyof

emergencies.Itcouldbearguedthatotherleaderdevelopmentprogrammesmighthavebeen

ignored,bydoingso.

Itcanbediscussedwhetheritisreasonabletoexaminetextsinarticleswritteninpositivist

ontologywithaninterpretativeepistemology.Itcouldbearguedthatitisirrelevanttoemphasize

andinterpretwhatthearticlestatesbasedonexperienceinascientificstudy.Thescientificpremise

fortheirstudymustbediscussedonthebasisoftheirscientificapproach,design,method,and

analysis.Itcanbeconsideredinappropriatetomakethearticlesaccountableforstatementsasitis

expressedinthearticles.However,thisinterpretativemethodtellswherethefocushasbeen.The

methodrevealswhetherleadershipisneededandthatleadershipisimportant.Theinterpretative

methodmakesuslookthroughtheliterature,intermsofconsensusonopinionsaswellasbehind

theaimsofthearticles.

Astrengthofthisthesisisthelatentcontentanalysisbywhichitispossibletoincludethe

underlyingmeaningofatext,andthestudyaswellsearchedsynonymsand,ifavailable,meaningful

similarpositiveandnegativeanalogies,phrasesandsentences.Thisanalysisisbroaderthan

Isersonswords,whichwasusedastheobjectivesintheQCA.

Itcanbediscussedifthepopulationwhoattendedthecoursewasrepresentative,iftherewasany

selectionbias.Theresidentsandthemedicalstudentswereofferedacourseinleadershiptraining,

andmaybethosewhoenrolledinthecoursewereparticipantswhohaddifficultytakingthe

authorityinthisrole.Iftherehadbeenmoreattendeeswhoalreadyhadhighself-confidenceas

leaders,therewouldnotbesomuchimprovementoftheparticipants,andeventually,the

evaluationswouldhavebeenmoremoderate.Nursesparticipatedinotherterms,theywerenot

offeredacoursebutweretoldtoattend.Theyfoundthecoursemostvaluable.

Ithasbeeninaccordancewiththisgeneralpracticeinconductorteachingtointegratevideoatthe

course.Onebasicideafortheprojectistoplaceaparticipantinastressfulandvulnerablesituation

infrontoftheotherparticipants,givinghimdifficulttaskstosolveinthesituationforthepurpose

ofprovokingdiscomfortandanxiety.Ifthecameraisexperiencedasanadditionalstressfactor,it

willonlyaddbeneficialchallengestotheideaoftheinterventionitself.

48

Ithasbeenrepeatedlyshownthattherearecommunicativetermswhicharenotverbalin

accordancewithMehrabian,Peirce,MultimodalAnalysisandLanger11,67,80,82,83,97.Ithasbeen

demonstratedthatvideohasevolvedtoanindependentcommunicationtoolsuitableforshowing

thediversityofsocialinteractioninaccordancewithXiao66.Ithasbeendemonstratedseveral

timesinthisstudythatinterpretationandintuitioncanbeshared,andthusgeneral.Insome

situations,werecognisethatthereisonlyonereality,themeasurablereality.Inothersituations,

andespeciallyinthecontextofhumaninteraction,wemustacknowledgethatthereareseveral

realities,andtheseareconstructedandinterpretedamongpeoplewhointeract.Inaccordance

withthis,weallowourselvestopresenttheeditedvideosthatarenotinterpretedwithwordsas

evidence.Itshouldbementionedthatallthevideospresentedintheappendixareinfactmore

explanatorywhendocumentingthediversityandnuancesinthecontentofthecourse.

Inordertounderlinewhichobjectiveswereaddressedduringthecourse,thisisdemonstrated

primarilybywordsintheformofquotes.Itisstatedthatthemoreparticipantswhosaythesame

independentlyofeachother,thegreaterthepossibilitythatthestatementisgenerallyapplicable.

Thiscanbecriticizedforusingpositiviststatisticsinastudybasedonaninterpretativeapproach.

Thechallengeinherentinthisthesisistodocumenttheconductor’shighlyqualitativeapproach

whenintroducingnon-verbalcommunicationinaclinicalresearchtradition.Moreover,itisnot

consideredthatoneontologyexcludetheother.

Whatcanbedocumentedcanbeseenfromtheavailabledata:Itisestimatedthat1)the

participants’reflectionsatthecoursereflecttheirimmediateexperience.2)Theirevaluationsafter

thecoursereflectwhattheytookhomefromthecourse.Theseanswersareavailableoneweek

after,tenmonthsafteranduptotwoyearsafterthecoursewasconducted.3)Thetwo‘blinded’

studentscommentedthecourseimpactoncourseparticipantsindependently,basedontheirown

interpretationofthevideos.4)Videosareeditedandcategorizedaccordingtotheencoded

themes.Thecontentofthisdatapresentsatriangulationofthecourse’simpact.

Astrengthforthecoursewasthediverseontologiesrepresentedbytheresearchersinthestudy.

ThePhDstudent,theconductor,andthemainsupervisor,theconsultant,constitutedaunique

researchteamintheconstellationbetweentwoverydifferentontologiesacquiredthroughtheir

verydifferentprofessions.Thisrepresentedadifferentapproachinrelationtotheconventional

approachinmedical-pedagogicalresearchinthisfield.Theylookedatthephenomenawithfresh

eyesandfromnewperspectiveswithoutrestrictionwithinalreadyexistinghypotheses,buthadan

49

ideabasedonintuition.Fromthefindings,newknowledgewasacquired,thisnewknowledgewas

adaptedtotheoriginalideaandtheprocesswasrestarted,accordingtotheabductive-inductive

methodologyintroducedbyPierce67,andfoundinthehermeneutics5,GT62,63,andQCA8,63.

Throughthosevariousontologiesandthusthefollowingdiscussionsonepistemology,thesubject

hasbeenstudiedandelucidatedfromseveralangles.Consequentlythisledtonewfindingson

leadershipintheclinicthroughunderstandingofwhataconductordoesinfrontoftheorchestra.

50

CONCLUSION

Noconsistentandtargetedleadershiptrainingfortheemergencymedicalteamleaderwas

identified.Formanyyearsmultipletaxonomiesandassessmenttoolshavebeendevelopedbut

failedtocometoaddressleadershiptraining.Aneedforexplicittargetedteamleadershiptraining

inhealthcarewasidentified.Theauthorsrecommendtrainingofleadershiptakeanotherturnto

investigateifitispossibletofindotherandmoreefficientwaystotraintheteamleaderin

emergencies.

Barriersforacquiringleadershipcompetenciesrequiredwhenmanagingemergencyteamswere

identified.Learninggoalswereidentified.Strongnegativeemotionssuchasstress,anxietyand

panicwerefoundwhenworkinginemergencies.Wedevelopedacoursethataddressedthose

barriers.

Theparticipantsnotedandcommentedoneachother’sdevelopmentonthecourse.Accordingto

theirself-reportingafterthecoursethetransferofaconductor’sskillschangedtheparticipating

students’,nurses’andresidents’behaviour,andintroducedamethodtohandleanxietyandshow

calmnessandauthority.Thiscourseclearlyseemstoaccommodatetheneedforanoperationaland

targetedtrainingoftheteamleaderinemergencies,addressingawaytoachieveconfidenceina

stressful,butsafelearningenvironment.Inadditiontheoutcometurnedouttobeaprofound

transformationofparticipants’self-understanding.

Thethesisillustratedthatitwasbeneficialtoinvolveanotherprofessiontohealthcare.Thisthesis

demonstratedagap–oratleastlackofconsequence–inbetweenwhatisknownandwhataction

istaken.

51

PERSPECTIVES

Implicationsforfuturepractice

Thethesisdescribeshowitispossibletoachieveleadershipskillsbyusingmusicalexercises.Itis

thereforerecommendedtocontinuethedevelopmentofcoursesinmedicalunchallenging,

harmlessenvironmentsthatalloweachresident/studenttogaininsightintotheirownpersonal

challengesandguidanceinhowtoworkwiththese.Thisthesishasshownacontextwherethisis

possible.

Educationalimplications

Werecommend:Ifthiscourseistobeintroducedasacompulsorypartoftheeducatingofdoctors,

theidealtimewouldbeafterclinicalskillshavebeenacquired,experiencegainedandroutines

understoodintheclinic.Thecoursewillbeanimportantsupplementtoexistingeducational

programsforresidents.

Furtherresearch

Itisrecommendedtoevaluatewhetherthelearningcanbetransferredtoclinicalpracticeand

whethertheyhaveapositiveimpactonthetreatmentofpatients.

Researchisneededtoexamineifitispossibletotraintheseskillsinmixedclinicalteams.

Researchisneededtodevelopandvalidateascoretoassessthequalityofnon-verbal

communicationandleadership.Thiscouldbemeasuredatconductorstudentsataconservatory.

Inthisconnection,anotherstudycouldbeconductedtoinvestigatetheemotionalresponseof

conductorstudentswhenconducting.Measuredonpulse,orhormonalchangesinnorepinephrine

orcortisollevelifpossible.

Itisrecommendedtodevelopa‘trainthetrainer’programmeaimingtoeducatemoretrainersand

involvetheminthefurtherdevelopmentofthecourse.Inthiscontext,itisrecommendedto

developacertificationmethodfora‘trainthetrainer’educationprogramme.

53

TRAININGRESIDENTSTOLEADEMERGENCYTEAMS[PARTONE]:ASYSTEMATIC

REVIEW

TureLarsen,RandiBeier-Holgersen,JetteMeelby,PeterDieckmann,DorisØstergaard

TureLarsen,PhDStudent,SimulationUnit(SimNord),DepartmentofAdministration,Nordsjællands

Hospital,Denmark

RandiBeier-Holgersen,MD,MHPE,DepartmentofGastrointestinalSurgery,Nordsjællands

Hospital,Denmark

JetteMeelby,MLS,DepartmentofClinicalResearch,NordsjællandsHospital,Denmark

PeterDieckmann,PhD,Dipl.-Psych.CopenhagenAcademyforMedicalEducationandSimulation

(CAMES),CapitalRegionofDenmarkandUniversityofCopenhagen,Copenhagen,Denmark

DorisØstergaard,MD,DMSc,Professor,DiplomaHPE,CopenhagenAcademyforMedicalEducation

andSimulation(CAMES),CapitalRegionofDenmarkandUniversityofCopenhagen,Copenhagen,

Denmark

Correspondingauthor:TureLarsen,SimNord,Kvalitetsafdelingen,NordsjællandsHospital,

Dyrehavevej29,3400Hillerød,Denmark.Phone:+4531127281,Mail:[email protected]

RandiBeier-Holgersen,DorisØstergaard,andPeterDieckmann:reprintswillnotbeavailablefrom

theauthors

Funding:TrygFoundation,LaerdalFoundationandNordsjællandsHospital,Denmark.

Disclosure:T.L.receivedgrantsfromTrygFoundation,LaerdalFoundationandNordsjællands

Hospital,Denmark.R.B.H,D.Ø.andP.D.havenoconflictsofinteresttodeclare.Thesponsorsofthe

studyhadnoroleinthestudydesign,datacollection,dataanalysis,datainterpretation,orinthe

writingofthereport.

54

Abstract

Objective:Todescribehowliteratureaddressesworkableandoperationalleadershiptrainingfor

theemergencymedicalteam-leaderandtoenhanceunderstandingofleadershiptraininginthe

medicalenvironment

SummaryBackgroundData:Worldwide,medicalsupervisorsfinditdifficulttogetstudentstorise

totheoccasionasleadersofemergencyteams:manyresidents/rescuersfeelunpreparedtoadopt

theleadershiproleinemergencies.Itappearsthatmanyresidents/rescuersfeelunpreparedto

adopttheroleasleaderinemergencies.Inspiteoftheknowledgeacquiredin30yearsofresearch,

scientistsarestillseekingasolutionastohowtoteachworkableleadershipinhealthcare.

Method:Asystematicreviewwasconducted(May-December2016inaccordancewiththePRISMA

2009Checklist).Aqualitativecontentanalysiswasadded.

Results:27articles,by25singlecorrespondingauthors,wereconsideredprimaryandcoveredthe

period1986-2016.Notargetedleadershiptrainingfordoctorswasfound.Themajorityofthe

researchprojectsdescribeddifferenttypesofbehaviouralmarkers,taxonomiesandchecklists.A

needforexplicittargetedteamleadershiptraininginhealthcarewasidentifiedin20/27articles.

Conclusions:Noconsistentandtargetedleadershiptrainingfortheemergencymedicalteamleader

wasidentified.Overtheyears,multipletaxonomiesandassessmenttoolshavebeendevelopedbut

failedtoaddressleadershiptraining.Theauthorsrecommendtrainingofleadershiptakeanother

turntoinvestigateifitispossibletofindotherandmoreefficientwaystotraintheteamleaderin

emergencies.

Introduction

Worldwidemedicalsupervisorsfinditdifficulttogetstudentstorisetotheoccasionwhencalled

upontoactasleadersofemergencyteams:manyresidents/rescuersfeelunpreparedtoadoptthe

leadershiproleinemergencies.16,17,23,26,27,32,37,39

Theaimofthissystematicreviewistoinvestigatehowliteraturedescribesworkableand

operationalleadershiptrainingfortheemergencymedicalteam-leader.Thescholarlyfieldof

leadershipandgeneralhealthcare-leadershipisrich,butthisstudyisnotaimedatdiscussing

differentiatedleadershipbehaviouratatheoreticallevel.

55

Thecorrespondingauthorinthissystematicreviewrepresentsanotherprofession.But,

nevertheless,hasaclearsenseofpracticalandoperationalleadershipacquiredfromaprofession

ofbeinganorchestralconductor.Thestudycouldbeconsideredasafreshlookathowthe

literatureandteachersapproachleadershiptraininginemergencies.

Thisstudywilldescribeissuesrelatedtotheeducationandtrainingoftheclinicalteamleaderin

emergencies.

Background

In1986Isersonstated:“Mostpeoplearenotbornleaders;theymustbetaughtleadership

techniques”44.In2016Robinsonandcolleaguesasserted:“Inthefieldofcardiacarrestleadership,

anincreasingweightofevidencesupportsthenotionthatindividualscanbetrainedtolead”23.

Forthelastthreedecades,leadershiphasbeendescribedasanimportantissueinhealthcare.But

inspiteoftheknowledgeacquiredin30yearsofresearch,scientistsarestilllookingforasolution

astohowtoteachworkableleadershipinhealthcare1,16,17,21-23,25-29,34,36-39,41,42,44,46,47,58-60.This

studyindicatesthatitisseemsnecessarytoacknowledgethat‘practicalguidanceneededforthe

deliberatepracticeofleadershipskills’22insteadoffocusingondevelopingneworadapting

existingleadershipmeasuringinstruments.

Thereappearstobealackofclarityontheperceptionof“goodteamleadership”intheliterature.

In2010Yukl98cited:“therearealmostasmanydefinitionsofleadershipastherearepersonswho

haveattemptedtodefinetheconcept”(Stogdill(1974,p.259).AndYuklcontinues:“Thestreamof

newdefinitionshascontinuedunabatedsinceStogdillmadehisobservation,Leadershiphasbeen

definedintermsoftraits,behaviors,influence,interactionpatterns,rolerelationships,and

occupationofanadministrativeposition”.

Method

ThesystematicreviewwasconductedinaccordancewiththePreferredReportingItemsfor

SystematicreviewandMeta-Analysis2009(PRISMA)Checklist.Asearchofthedatabasesof

Pubmed,Psycinfo(viaOvid),andERICwascarriedoutinJune-December2016withtheaidofa

researchlibrarian.AppendixIshowsthesearchtermsandstrategy,towhichnotimelimitor

languagerestrictionswereapplied.Thesearchstrategywasnotlimitedbydesignormethodology.

Alltypesofpapersconcerningleadershiptrainingandeducationinemergencymedicalscenarios

wereincluded.Technicalskillstraining,organizationalleadershipandteamworktrainingwithout

56

explicitfocusonleadershipwereexcluded.Duringtheearlystagesofthesearch,systematic

reviewsidentifyingrelevantoriginalarticleswereusedassources.


ethicalapprovalbutaformalreviewwaswaivedforthisstudy(H-4-2015-FSP).

Screeningarticles

Oneauthor(TL)searchedPubMedandscreenedtitlesincluding820eligiblearticles.Pubmed´s

feature‘similararticles’wasusedandafurther226articleswereidentified.Afurthersearchwas

conductedinspiredbythenewkeywordsfoundinthearticles,andanother131articleswerefound.

ThesearchstrategywasappliedtoasearchinthedatabasesofPsycinfo(viaOVID)andEric

resultingin1.177articlesfromPubmed,82fromPsycinfo,and242fromERIC.Afterremoving

duplicates,twoauthors(TLandRBH)screened1.405titlesandabstractsapplyingtheabove

mentionedinclusionandexclusioncriteria.Onearticlewasaddedonthebasisofthereferences

(Yule,2006)38.Thetwoauthorsthenreadthefulltextofthe53potentialarticlesapplying

inclusionandexclusioncriteria.39articleswereselected.Therewasahighdegreeofoverall

agreementbetweenthetworaters(94.45%).Interraterreliabilitywasverygood(Cohen’sκ

coefficient=0,852).Differencesofopinionaboutinclusionorexclusionwereresolvedbydiscussion

betweenTLandRBH.13articleswereexcludedbecausetheircontentdidnotmeettheinclusion

criteriaandonearticlewasincompletebecauseofmissingreferences.Towardstheendofthe

reviewprocessonefurtherarticle,foundinanadditionalmanualsearchinGoogle(Ford2016)was

added24.40articlesandreportswereidentified.Ofthese27wereconsideredprimaryasthey

wereoriginalarticleswithinterventionsandnewfindings/evidence.13articleswereconsidered

secondary:10reviewsand3opinions.Fig.1(Flowchart)

Qualityofbodyofevidence

Areviewofqualitativeaswellasquantitativeresearchpaperswasconducted.Quantitativearticles

wereclassedaccordingtoPRISMA,CochraneandGRADE.Qualitativearticleswereclassed

accordingtoCASP(CriticalAppraisalSkillsProgramme).Theywereconsideredprimaryifthey

reportedempiricaldataaboutleadershiptrainingorbehaviour(i.e.,specificreportsabout

leadershiptaxonomiesandfindingsinquestionnaires).Onlyprimarystudiesareincludedinthis

SystematicReview.(Table1)

57

Abductionasamethod

Anabductiveapproachtoresearchmakesitpossiblefortheresearchertopresentaqualified

presumption(educatedguessorinference)67whencommencinghisinvestigation.Basedonhis

findings,heacquiresnewknowledge,hemightalter/adaptthisnewknowledgetothe

presumptionandtheprocessstartsover.Thisprincipleisthefoundationofmorecontemporary

methodse.g.GroundedTheoryorQualitativeContentAnalysis.

QualitativeContentAnalysis

Aninductiveapproach(conventional,inductive63)toQualitativeContentAnalysis(QCA)is

appropriatewhenpriorknowledgeregardingthephenomenonunderinvestigationislimitedor

fragmented.8Inaninductiveapproach,codes,categories,orthemesaredirectlydrawnfromthe

data8withoutimposingpreconceivedcategoriesortheoreticalperspectives.63Byadding‘latent

contentanalysis’8itispossibletointerprettheunderlyingmeaningofthewords.

QualitativeContentAnalysisinthisstudy

Afterconductingtheconventionalsystematicreviewnofocusedtrainingofteamleadershipwas

revealedandinsteadmanyleadershipmeasurementtoolswerefound.Itwasdecidedtoexamine

the27primaryarticlesinanabductive-inductiveQCA.Thisinvestigationwasconductedwiththe

purposetoidentifyopinionsaboutleadershipinemergenciesandviewsontheidentified

leadershipmeasurementtools.

Strategyforqualitativecontentanalysis

AllarticlesweregroupedtogetherinasinglePDFdocumentandsearchedseveraltimesfor

keywords,theirsynonymsand,ifavailable,theirmeaningfulsimilarpositiveandnegativeanalogies,

phrasesandsentences.Thequotesweregroupedintothemesinaniterativeprocess,andsorted

chronologicallyinappendixII.Whenthoughttopossiblyinfluencetheinterpretation,theywere

sortedaccordingtowheretheyappearedinthearticles:beforeorafterthemethodologysection,

i.e.expressingeitherapre-conditioninthebackgroundforthestudyorafindingoraconclusionas

aresultofthestudy.Apre-conditionforaninterventionmaychangewhentheinvestigationis

completedandaconclusionmaycontradictthepre-condition.Therefore,itisassumedthata

conclusioncanbestrongerthanapre-condition.Themostimportant/significantquoteschosenon

basisoftheauthors’interpretationarepresentedinthisarticle.AllquotesareavailableinAppendix

II.

58

Results

27originalarticles,coveringtheperiodfrom1986to2016wereincludedinthereview.Two

authorswereresponsibleformorethanonearticle:Yule34,38andCooper1,42.Ofthe27articles

fivewereRandomizedControlledTrials,sixCaseControls,tenCaseStudies,andsixQualitative

Studies.

Onesolestudyaddressingworkableandtargetedleadershiptrainingwasfound41.Thisstudy

focusesonleadershiptrainingseparatefrommedicalcompetence.Onearticlecoveringnon-verbal

communicationandpositioningaroundthepatientsimulatorwasidentified35.Onearticle

investigatedwhetherexternaldistractorsinfluencedperformanceduringaCPRscenario59.Eleven

studiesonresuscitation,eightontrauma,fouronsurgeons,twoonALSwerefound(acutedyspnea

43andburns56)andfinallyoneonleadershipstyleinhealthcareteams“asperceivedbynurses”

36.Themajorityofthearticlesdescribedanddiscusseddifferenttypesofbehaviouralmarkersand

taxonomies.Leadershiptrainingwasmostlycombinedwiththetrainingofmedicalcompetencies

includingalgorithms.Fourstudiesusedaquestionnaireaftertraining.Onestudyconductedafocus

groupinterviewaftertraining.Ninestudieswerebasedonquestionnairesorinterviews.Asummary

ofthearticlesisdisplayedinTable1.

LBDQorNOTECHSmeasurementtools:25ofthe27articlesweretosomeextentinfluencedbyone

orbothofthemostfrequentlymentionedtaxonomies,onedevelopedoriginallyforthemilitary

andtheotherfortheaviationindustry.1)TheLeadershipBehaviorDescriptionQuestionnaire,LBDQ

(military,1945)(Fig.2)(ninearticles,eightauthors1,14,17,23,27,32,33,42,59mainlysituatedin

Switzerland).2)TheNon-technicalskillstaxonomy,NOTECHS(aviation,thenineties)Adaptedto

healthcarein2003:Anaesthetist’snontechnicalSkills(ANTS)andadaptedtosurgeonsin2006:Non-

TechnicalSkillsforSurgeons(NOTSS)(Fig.3)(sevenarticles,sixauthors15,21,34,38,39,43,56mainly

situatedinScotland).Theabovementionedresearchers(LBDQorNOTECHS)didnotrefertoeach

other.However,nineauthors13,16,22,26,29,30,35,40,41referredtobothtaxonomies.Researchinto

leadershipisstronglydominatedbythetwodifferentconceptsandtheirprerequisiteswhichhave

influenced93%ofthearticlesinthisstudy.Twoarticlesfoundinthisreviewdonotreferto

NOTECHSorLBDQbuthaveuniquereferences.36,37

14articlescoveredtrainingtosomeextent(trainingalgorithmsanddebriefing).13articlesfocused

onotheraspects(surveys,questionnairesetc.).(Table2)

59

Resultofcontentanalysis

Threekeythemesemerged:Leadership,taxonomies,andtrainingleadershipandmedical

competencesimultaneously.Thequotesarecollectedinthethemesandtheirsubgroups,andare

representativeforsubgroups(pre-conditionorconclusion).

Leadership

Definitions:LeadershipisimplicitlydefinedintheLeadershipBehaviorDescriptionQuestionnaire

(LBDQ)taxonomy(Fig.2)aswellasintheNon-TechnicalSkillsforSurgeons(NOTSS)taxonomy(Fig.

3).Inaddition,sixotherdefinitionswerefound1,16,36,37,41,56.Manthaandcolleaguesrefersto

Heifetz(2009)in2016:

“…leadershipinvolvesanalyzingcomplexsituations,identifyingavailableresourcesandrequiredexpertise,

formulatingastrategyinreal-time,andcoordinatingmultiplestakeholders”41.

Leadershipislacking:Fourarticles16,23,38,40statedinthebackgroundtotheirstudythatleadership

islacking.

Fivearticles14,16,17,21,23discussedorconcludedexplicitlythatleadershipwaslacking.

“Ourstudysuggeststhatparticipantsdidnothaveagenerallackofleadershipskills,buttheymaynothave

linkedthenecessityofleadingandstructuringateamtotheresuscitationsituation”17.

Hunzikerandcolleagues,2010

Leadershiptrainingisimportant–leadershipchangesbehaviour

Gilfoyleandcolleaguesstatedinthebackgroundtotheirarticlein2007:

“Teamleadershiphasbeenrecognizedasveryimportantformanyyears,inareassuchasbusiness,the

military,andaviation”26.

Three1,26,39articlesdiscussedthatleadershiptrainingwasimportantandappearedtoimprove

behaviour.Nine13,15,17,23,27,33-35,42studiesconcludedthatleadershiptrainingwouldhaveapositive

impact.

“OuraimwastofocusontheleadershipaspectofCPR,asithasbeenwidelyrecognizedasbeinglinkedtothe

adherencetoestablishprotocols,fewererrors,andmorefavorablepatientoutcome”33.

Castelaoandcolleagues,2015

60

Leadershiptraininghasbeenignored:Despiterecognitionthatleadershiptrainingappearsto

changeandimprovebehaviour,itseemsthatleadershiptraininghasbeenignored,asstatedinthe

backgroundforthreestudies37-39.

“Traditionally,developmentofphysicianleadershiphasoccurredatrandominsurgicaltraining.Onepossible

reasonisthatsurgicaleducatorshavefocusedondetailedinstructiononcriticalpatientsituations,

resuscitation,andtechnicalskills,buttheyhaveprovidedlittleformaltrainingintheessentialleadershipskills”

37.

Itaniandcolleagues,2004

Ninearticles1,16,17,22,23,27,29,36,39discussedorconcludedthatleadershiptraininghasbeenignored.

“Traditionally,surgicaleducationhasnotformallytaughtleadershipskills…”39.

Nicksaandcolleagues,2015

Leadershiptrainingisrequired:18ofthe25authors(20/27articles)identifiedarecurringneedfor

explicittargetedteamleadershiptraininginhealthcare,7articles17,22,34,36,38,39,43mentionedthisin

thebackground/introductionand13articles1,14-16,23,26,27,29,34,37,39,41,42asafindingoraconclusion.

Amongthelatter,Marschandcolleagues,2004:

“Absenceofleadershipbehavior[…]wereassociatedwithpoorteamperformance…thisfindingcouldhave

importantimplicationsfortheteachingofmedicalemergencies”14.

“Werecommendthattraininginandassessmentofleadershipskillsinemergencyscenariosshouldbean

integralcomponentofpostgraduatemedicaltraining”23.

Robinsonandcolleagues,2016

Ninearticles13,21,30,32,33,35,40,56,59proposeddifferentapproachesorfocusareastoimprove

leadershipinemergencies.(Aviation,NTS,Gender,Ethnicity,Non-Verbalcommunicationetc.)

Taxonomies

Atotalof20taxonomiesaddressingleadership,teamwork,andcommunicationwerementionedin

thearticles.(Table3)

Thepurposeoftaxonomies:TheideaofusingbehaviouralmarkersystemswasexplainedbyYule

andcolleaguesin2006:

“TheprototypeNOTSSbehaviouralmarkersystemwasdesignedtoallowstructuredobservationandfeedback

totraineeandconsultantsurgeonsonobservablenon-technicalskills[…]thisstudyhastakentheadditional

61

stepofidentifyingexplicitlytheparticularnon-technicalskillswhichmightbebothtaughtandobserved–and

thereforemeasured”38.

Thisviewissharedbythreearticles15,22,33.

Comprehensiveorsimple:Somearticles22,36findacomprehensivetaxonomyadvantageous:

Leenstraandcolleagues,2016:

“TheTTLSdetails5skillcategories[…]and37skillelements.Theskillelementsarecapturedby67behavioral

markers”22.

Somepreferasimpletool43,59:Carlsonandcolleagues,2009:

“Onebarriermaybethatmanyreportedinstrumentsmaybetoocomplex”43.

Measurementtoolslacking:Fourarticles15,21,29,43pointedoutintheintroduction/backgroundthat

measurementtoolswerelacking.

“AlthoughtheimportanceofteamNTSscontinuestobeatopicofinvestigation,theroleoftheteamleader

hasnotbeenevaluatedinpreviousstudies”21.

Briggsandcolleagues,2015

AndKrageandcolleaguesconcludedin2014:

“However,toourknowledgenostandardscoringprotocolsareavailabletoassessoverallindividualhuman

performanceoftheresuscitationteamleaderduringCPR”59.

Newtooldeveloped:Twoarticles22,38statedintheaim/backgroundthatnewtoolshadbeen

developed:Leenstraandcolleagues,2016:

“Toaddresstheneedforataxonomyofleadershipskillsthatspecifiestheskillcomponentstobelearnedand

thebehaviorsbywhichtheycanbeassessedacrossthefivephasesoftraumacare,theauthorsdevelopedthe

TaxonomyofTraumaLeadershipSkills”22.

Fivearticles26,33,36,39,43announcedthedevelopmentofaneworadaptedtoolinthe

discussion/conclusionsectionoftheirarticles:Nicksaandcolleaguesusedapreviouslyadapted

NOTECHStaxonomy,2015:

“AmodifiedOxfordNon-TechnicalSkills(NOTECHS)scale[…]wasusedtoassesssurgicalresidentnontechnical

performance”39.

62

Threearticles15,41,43statedinthebackgroundtotheirstudythatitcouldbedifficulttokeeptrack

oftheactualcontentofthevarietyoftoolsandmethodsdeveloped.

“WhileNTShavebeenshowntocorrelatewithtechnicalproficiency,thereissignificantvariabilityin

terminology,trainingmodalities,andevaluationofNTS”41.

Manthaandcolleagues,2016

Yuleandcolleaguesindicatedin2015thatthefocusmightadvantageouslybechangedawayfrom

thedevelopmentofnewmeasuringtools:

“Therateofdevelopingassessmenttoolsinthisareahasoutpaceddevelopmentofworkableinterventionsto

improvenon-technicalskillsinsurgicaltrainingandbeyond”34.

Trainingleadershipandmedicalcompetencesimultaneously

Itmaybeadvantageoustoseparateleadershiptrainingfromtraininginmedicalcompetencies,

Castelaoandcolleaguesstatesinthebackground:

“…thecomplexityofsuchamultifactorialstructureincreases,creatingthepotentialforanincomplete

understandingofthewholeprocess.[…]Thus,reducingthecognitiveworkloadbeforehandbyseparatingrole

instructionscanhaveapositiveimpactontheCPRperformanceandonthetrainees’individuallearning

process”33.

Sixarticles14,17,23,27,36,41concludedthatleadershiptrainingdifferedfrommedicalknowledge

training.

“…thetrainingprovidedthroughtheALSqualificationisnotsufficienttodevelopthenecessarylevelof

leadershipskillsforacardiacarrestteamleader”23.

Robinsonandcolleagues,2016

AndManthaandcolleaguesconcludedin2016inthestudyfocusingexplicitlyonleadershiptraining

separatefrommedicalknowledge:

“Short-termoutcomesofthisleadershipcurriculumdemonstrateasignificantincreaseinparamedictrainees’

self-perceivedconfidence,communication,andleadershipskills”41.

Discussion

Oneoftheobjectivesofthissystematicreviewwastosearchforaworkablemethodtotrain

physiciansforleadershipinemergencies.Forthelastthreedecades,leadershiphasbeendescribed

asanimportantissueinhealthcare.Wefoundsixdefinitionsofleadership,whichcentredmostly

onachievingcommonaimsthroughcollaborationbetweenleaderandteam.Somearticles

63

describedleadershipasamorecomplexprocessinwhichtheleaderhadtoanalysethesituation

andhandlemultiplestakeholders.Wedidnotfindacleardefinitionandmustconclude,likeStogdill

in1974,that“therearealmostasmanydefinitionsofleadershipastherearepersonswhohave

attemptedtodefinetheconcept”.

Despitetherebeingnocleardefinition,theliteraturedescribeslackofleadershipashighly

prejudicialtoperformanceduringacritical,clinicalsituationandperformanceasveryvariable.The

literaturesoughthelpoutsidethemedicalworldfromthemilitary(LBDQ)andfromaviation

(NOTECHS),adaptedtaxonomiestothebehaviouroftheleaderandteamandcustomizedthemto

medicalemergencies.TheLBDQandNOTECHStaxonomieswereoriginallydevelopedtoassess

officersandpilotsincommandofaircrafts–leadersintheirprofessions.Peopleselectedand

educatedtobeleadersinprofessionalemergencies.Itcouldbesaidthatthisstartingpointis

essentiallydifferentforthatofnewlyqualifiedyoungdoctorswhohavenotyetbeenintroducedto

leadership.Inmedicinethetaxonomies(i.e.LBDQformXII,NOTSS)seemtohavebeendeveloped

andadaptedtoassessmedicalalgorithms(i.e.ALS)orprocedures(i.e.surgery)inordertooptimize

patientoutcomebychanging/improvingthebehaviouroftheteam-leaderandhisteam.Butmany

articlesconcludedthatleadershipisstilllacking.

Overtheyearstheresearchhastriedtodefineanappropriatetaxonomytomeasureandimprove

doctors’abilitytoactasleaders.Itisveryinterestingthat2/3oftheresearchintotaxonomieshas

beenconductedbytwocompletelyseparateresearchgroupsinspiredbyeitherthemilitaryorthe

aviationindustryalmostwithoutreferringtoeachother.Theother1/3ofresearcherswasinspired

bybothtaxonomies.Thetaxonomiesmostlyassessedhowwellthealgorithmhadbeencompleted,

nottheactualqualityofleadership.Onecouldassertthattheythereforemeasuredhowwellthe

doctorsknewhowtotreatthepatient.Onecouldconcludethatleadershiptrainingactuallytakes

placeinaclinicalcontextwhichiscomplexitself–focusingsimultaneouslyon‘taskdistribution’,

‘humanfactors’or‘initiatingstructure’(LBDQ)or‘taskmanagement’,‘non-technicalskills’or

‘situationawareness’(NOTECHS)aswellasonmedicalknowledgeandcreatingstructureswhile

implementingalgorithmsandmaintainingstandards.Butthissettingcoulddiminishtheactual

focusontargetedleadershiptraining.

Theuseoftaxonomiesandassessmenttoolsinmedicinecouldbeexplainedbythewishtoproduce

evidencefortheactionsandchangesintreatment/behaviour.Wediscoveredseveraltaxonomies

andassessmenttoolsintheliterature;somecomprehensive,someverysimple.Howeverthe

64

literaturestillaffirmsthatstandardperformancemeasurementtoolsarelackingandthereforea

constantlyincreasingnumberofnewtoolshavebeendeveloped.Inaddition,itshouldbe

mentionedthatsignificantdiversitywasrevealedintermsofterminology,trainingmethods,

evaluationsandconclusionsintheinterventionsfound.Itcouldbeconcludedthatthedefinitionof

leadershipisunclearandthereforeconsensusisimpossible.Theliteraturebeginstoquestionthe

numberoftools–andmethodsused–inthetaxonomies.

Asdemonstratedintheresultssection,scientistsagreethatleadershiptraininghasanimpact,

improvesbehaviourandchangesclinicaloutcome.Despitethis,theliteraturedemonstratedthat

formalleadershiptraininghasbeenneglectedorthateducationisinsufficient.Itstillappearstobe

askillthatistraditionallyacquiredby‘learningbydoing’.Neverthelesstheliteratureaffirmedthat

targetedleadershiptrainingisveryimportant.Morethanhalfofthe27articlesexamined

concludedthattherewasanurgentneedtodevelopaworkablemethodtoprovideresidentswith

specificandtargetedleadershiptraining.

Severalarticlesstateditmaybeanadvantagetoseparateleadershiptrainingfrommedical

competenciestraining.Medicalandbehaviouraltrainingareverydifferenttopics,andtraining

simultaneouslycouldevenworkbecounter-productivebecauseofthehugecognitiveworkload.To

ourknowledgenobodyhasaddressedworkabletargetedteamleadertrainingfordoctorsin

emergencies.Taxonomiesmightdetail‘whattodo’,butapparentlydonotaddresstheactualneeds

oftheteam-leaderinemergenciesinordertoassumeleadershipinasatisfactorymanner.

Itispossibletoarguethatthis–asthisstudyalsoreveals–obviouslyisnotnewknowledge,the

importanceofthishasbeenemphasizedandsoughtafterfor30years.Theresultofthissystematic

reviewisthusnegativeandconsequently,itispossibletoarguethatthestudyisunsuccessful.One

canalso,astheauthorsofthestudy,arguethattheresultisalarmingandrevealsthedeficiencyof

researchinthisareainthelast30years.Thiscanbeconsideredasasubstantialcontributionadding

constructiveandimportantknowledge.

Conclusion:Noconsistentandtargetedleadershiptrainingfortheemergencymedicalteamleader

wasidentified.Formanyyearsmultipletaxonomiesandassessmenttoolshavebeendevelopedbut

failedtocometotermswithleadershiptraining.Yuleandcolleaguesbacktrackedin2015:


improvenon-technicalskillsinsurgicaltrainingandbeyond”34.

65

Aneedforexplicittargetedteamleadershiptraininginhealthcarewasidentifiedin20/27articles.

Theauthorsrecommendtrainingofleadershiptakeanotherturntoinvestigateifitispossibleto

findotherandmoreefficientwaystotraintheteamleaderinemergencies.

Furtherresearchrecommendations

Doestheliteratureidentifyareastobeaddressedinthetrainingofleadershipforresidentswhen

actingasteamleadersinemergencies?

Contributors

TLarsenhadfullaccesstoallthedatainthestudyandhadfinalresponsibilityforthedecisionto

submitforpublication.TLundertookthesearchformaterial,extractedandcollecteddata,

developedtheanalysisstrategy,andwroteuptheresults.TL&RBeier-Holgersen,conceivedand

designedtheproject,reviewedthescientificreports,madequalityassessmentsandinterpretation

oftheresults.JMeelbyassistedintheliteraturesearchandprovidedadvice.PDieckmannandD

Østergaardprovidedadviceandcriticallyrevisedthemanuscript.

66

AppendixI,AsearchforLeadershipTraininginHealthcare–SearchstrategySearchinPubmed

#1((((gestureORmimicOReye-contactOReyecontactOReyebrowORsmile))OR(((NTSSkillsOR"non-technicalskills"ORnotss))OR((communicat*)AND("nonverbal"OR"nonverbal"OR"non-verbal"ORvisual)))))=99.119entries

#1b((gestureOR"bodylanguage"ORmimicOR"eye-contact"OR"eyecontact"OReyebrowORsmile))OR(((NTSSkillsOR"non-technicalskills"OR"nontechnicalskills"ORnotss))OR((communicat*)AND("nonverbal"OR"nonverbal"OR"non-verbal"ORvisual)))NOT(autismORpregnancyORpainORAlzheimer*ORvertebralORdrawing*ORchildren)=69.150entries

#2(taskmanagementORauthorityORdisciplineORrespect)OR(leadsORleadingORleadORteamleaderOR"teamleader"ORteamleader)=1.465.692entries

#2c((taskmanagementORauthorityORdisciplineORrespect))OR(leadsORleadingORleadORteamleaderOR"teamleader"ORteamleader)NOT(“leadto”or“leadsto”or“leadingto”)=824.514entries

#1AND#2limitedtoSystematicrev.=138entries

#3:(conductor*ORorchestra*ORsymphon*)=22.335

#1AND#2AND#3=29entries

#4:(teach*OReducat*ORtrain*ORlearn*)=1.684.125

#1bAND#2cAND#4=432entries

#5(((("advancedlifesupport")OR("cardiopulmonaryresuscitation"[MeSHTerms]OR("cardiopulmonary"[AllFields]AND"resuscitation"[AllFields])OR"cardiopulmonaryresuscitation"[AllFields]))OR((Acute*ORintensiveORemergencyORtraumaORtraumaticORresuscitat*OR"cardiacarrestsimulation"))))=2.501.517

#8(("leadership"[Mesh])AND"Education,Medical"[Mesh])=1.262

#5AND#8=114entries

#9“bodylanguage”=354

#10communicat*ORleadershipORleadingorleadsorleadORteamleaderOR"teamleader"ORteam-leader=1.476.894entries

67

#9AND#10(NOT(autismORpregnancyORpainORAlzheimer*ORvertebralORdrawing*ORchildrenorconsultationorhypno*))=107entries

Total=820

SupplementarysearchinspiredbyarticlesfoundinPubmed’s‘similararticles’=226entries

Total=1046

Newkeywordsemergedinspiredbythenewarticles:

“trainingleaders”OR(“teamlearning”AND“interprofessionalteams”)OR(urgencyANDsituationandleadersandgoal)OR(leadershipand“resuscitationteams”andtaskandperformance)OR(Leadershipandmanagementandeducationandtrain*andhealthcareanddoctors)OR(leadershipand“cardiacarrest”andtask)OR(Leadershipandcardiopulmonaryresuscitationandskills)OR(leadershipand(“cardiacarrest”ORcardiopulmonary)andresuscitationandhumanfactors)OR((“cardiacarrest”ORcardiopulmonary)and"resuscitationperformance"andtraining)OR(leadershipandteamand(“cardiacarrest”ORcardiopulmonary)andperformanceandcommunication)OR(leadand"advancedlifesupport"andperformanceandtraining)OR(leadsand"advancedlifesupport"andperformanceandtraining)OR(leadingand"advancedlifesupport"andperformanceandtraining)OR(leadershipand"advancedlifesupport"andperformanceandtraining)

134entries

68

Fig.1

69

Studytype Objective Contentofintervention Outcome/Conclusions RiskofbiasValidityofevidence

RCT

YULE,S.etal.2015

Demonstratetheeffectofnon-technicalskillscoachingonintraoperativebehaviorsandclinicallysignificantdecisionsduringsimulatedoperations.

16surgeons,twogroups.Fiveoperationseachsurgeon.CasegroupreceivedcoachingonNTSaftereachoperation-controlnot.Operationoneandfivewasvideorecorded.Blindedassesors

Coachingimprovedresidents’non-technicalskillsinthesimulatedORcomparedwiththoseinthecontrolgroup

Performancebias:participantsnotblinded.Smallsamplesize.Nobaselineforparticipantswererecorded.Externvalidityunclear.

LowbodyofevidenceaccordingtoGRADE.++

FERNANDEZCASTELAOetal.2015

ThisstudyassessedtheimpactoftheCRMteamleadertrainingonCPRperformanceandteamleaderverbalization

Forty-fiveteamsoffourmembersreceivedALStraining.OneineachteamassignedtoteamleaderinaCPRsimulation.Teamleadersingrouponeattended90min.CRMtraining.Allothers90min.ALStraining.Videorecorded.Check-listbasedtooldevelopedbyexperts.Authorsassesorsblindedtotheexperimentalallocation

TrainingonlythedesignatedteamleadersinCRMimprovesperformanceoftheentireteam,inparticularguidelineadherenceandteamleaderbehavior.(Emphasisontrainingofteamleaderbehaviorappearstobebeneficialinresuscitationandemergencymedicalcourseperformance.)

Selectionbias:Randomization1alphabetically.Randomization2unclear.Randomization3unclear.Performancebias:participantsnotblinded.Statisticalmethodquestionable(studycalledformediannotmean).Nobaselineforparticipantswererecorded.

LowbodyofevidenceaccordingtoGRADE.++

KRAGE,R.etal.2014

ToinvestwhetherexternaldistractorsinfluenceperformanceduringastandardizedsimulatedCPRscenarioingeneralandwhetherlevelofexperiencehasanimpact

30physisicians,twosimulatedCPR.Cross-overstudy:1:distractors(radionoise70dB,scriptedfamilymember,talkingatcrucialmoments)2:not.Videorecorded.Scoringprotocoldeveloped.Twoassesorsratedindependently

Nointeractionwasobservedbetweenadditionaldistractorsandexperiencelevel.Externaldistractorsmarkedlyreducethequalityofcardiopulmonaryresuscitation.

Performancebias:participantsnotblinded.Smallsamplesize(N=10ineachgroup).

ModeratebodyofevidenceaccordingtoGRADE.+++

HUNZIKER,S.etal.2010

TheaimofthisstudywastocompareleadershipinstructionwithageneraltechnicalinstructioninsimulatedCPRscenario

237(280)medicalstud.inteamsofthree.CPRsimulation,pre-video.Basicinstruction20min.Twogroups.Case:Leadershiptraining.Control:Technicaltraining.CPRsimulation,2post-video,n=96andn=93.Followupafter4Mo.Videotapescodedbytwoindependentblindedresearchers

Causalrelationshipbetweenleadershipandperformancewasproven:Leadershipinstructionsweresuperiortotechnicalinstructions,withmoreleadershiputterancesandbetteroverallcardiopulmonaryresuscitationperformance.

Performancebias:participantsnotblinded.

HighbodyofevidenceaccordingtoGRADE.++++

COOPER,S.etal.2001

Developacoursetrainingleaderswiththeaimofchangingbehaviorandperformance

ThreedayALScourse.N=68.Threecourses.DayoneALStraining.DaytwoandthreeallactedasteamleaderinaCPRsimulation.Afterdaytwocasegroupattendedaleadershipseminar.Controlnot.Fiveindependentassesors,blinded

Theleadershiptrainingprogrammesignificantlyimprovedcandidatesleadershipperformanceinthetrainingsituation

Performancebias:participantsnotblinded.Unclearassessmentprocedure.

ModeratebodyofevidenceaccordingtoGRADE.+++

Case-Control

MANTHA,A.etal.2016

NTScurriculumforIndianparamedictraineesfocusedonstrengtheningon-sceneleadership,teamwork,andpublicspeakingskills

40paramedictrainees.Six-daycourse.Traineescompletedself-assessmentsanddeliveredtwobriefvideo-recordedpresentationsbeforeandaftercompletionofthecurriculum.Independentblindedobserversscored10randomlyselectedtrainees.

Outcomesofthisleadershipcurriculumdemonstrateasignificantincreaseinparamedictrainees’self-perceivedconfidence,communication,andleadershipskills

Performancebias.

LowbodyofevidenceaccordingtoGRADE

NICKSA,G.A.etal.2015

Toeducatesurgicalresidentsinleadership,teamwork,effectivecommunication,andinfrequentlyperformedemergencysurgicalprocedureswiththeuseofinterprofessionalsimulations.

43surgicalresidentsPGYs1and2.Interdisciplinaryhigh-riskclinicalscenarios.Pre(control)and6MoafterPost(case)37respondedtoasurvey.Authorassesor

ThePGY2residentsimprovedtheirskills,butthePGY1residentsdidnot.Atotalof89%oftheresidentsfeltthesessionswereofgreatbenefit.

Educationallevelcouldbeaconfounder

VerylowbodyofevidenceaccordingtoGRADE

ROBERTS, Toinvestigateifbrief 57medicalstaffmembers.Pretest Participantschangedteamwork Moderate

70

N.K.etal.2014

trainingwouldhaveasustainedeffectonindividualacquisitionandretentionofknowledgeandteampracticebehaviorsandonteambehaviorsofhealthcareprofessionalsinmedicalemergencysituations…

simulatedCPRsessions.Thentrainingconcludingwithapostsimulation.Debriefing.Threeweekslaterthirdsimulation.Videorecordings.Twoblindedraters.Questionnaire

andcommunicationbehaviorontheposttest,andchangesweresustainedaftera3-weekinterval,thoughtherewassomelossofretention.Brieftrainingexercisescanchangeteamworkandcommunicationbehaviorsonadhoctraumateams.

bodyofevidenceaccordingtoGRADE

MAKINEN,M.etal.2007

Thepurposeofthisstudywastoassesstheresuscitationskillsofnursestofacilitateconstructionofaneducationalprogramme

FromFinland:110,Sweden:40nurses.Case,leadershiptraining(S),controlnot(F).Subjectstestedinpairs.Achecklistusedtograde.5assesorsindependently,notblinded

Definingandteachingleadershipseemstoimproveresuscitationperformance.

Notblindedassesors


GILFOYLE,E.etal.2007

Educationalintervention.evaluateimmediateandlongtermlearningoutcomesinordertodeterminewhetherresidentscouldacquireandretainteamleadershipskillsinpediatricadvancedresuscitation.

Case15paediatricresidents2leaderskillstraining,simulatedresuscitationscenarios.Evaluatedagain6monthslater.ControlN=7notraining.Ratingbychecklistandself-reportedquestionnaire

Residentsacquiredresuscitationteamleadershipskillsfollowinganeducationalintervention.Six-monthfollow-updemonstratedskillretentionbeyondtheinitialintervention.Controlgroupsuggestedthatthiswasbecauseparticipantshadattendedthefirstworkshop.

Verysmallsamplesize.Inkonsistencyingroups.DoubtfuluseofstudentsT-test


MCCUE,J.D.etal.1986

Toassesstheresidents'leadershipstyleandthenurses'perceptionsoftheeffectivenessofthosestyles.

17residents.Aself-administered,self-ratingleadershipstyleindicator,LSI.SelfReportsandNursesReports.Questionnaire.Computerizedscale.Notblindedassesors

Thepresentstudysuggeststhatfemaleresidentsmaybemorelikelytousehighrelationshipleadershipstylesintheirinteractionwithnurses…analysisofleadershipstyleisapotentiallyusefulwayofhelpingresidentsassumeleadershipmoreeffectively.

Onlywomennurses.Sexbias.Onlyresidentsknowntonurseswasallowed=notblindedassessors


CaseStudy

ROBINSON,P.S.etal.2016

Toassesstheperceptionsofleadershipandteamworkingamongmembersofacardiacarrestteamandtoevaluatefuturetrainingneeds

102membersofacardiacarrestteam.Survey.Responsessoughtfromdoctors,nursesandhealthcareassistants

Werecommendthattraininginandassessmentofleadershipskillsinemergencyscenariosshouldbeanintegralcomponentofpostgraduatemedicaltraining

Notrelevant

HARGESTAM,M.etal.2016

Investigatehowtraumateammembersarepositionedintheemergencyroom.Howleaderscommunicateintermsofgazedirection,vocalnuances,andgesturesduringtraumateamtraining.

108participants.Eighteentraumateamswereaudioandvideorecordedduringtraumateamtraining.Focusisonteamleaders’communication,analysisisperformedinrelationtobothverbalandnon-verbalcommunication.

Non-verbalcommunicationreinforcedtheteam-leaders’communication.Team-memberswhoareawareoftheirnon-verbalcommunicationcanimprovetheirperformance.Vaguenon-verbalcommunicationreinforcesambiguityandcanleadtoerrors

Notrelevant

BRIGGS,A.etal.2015

Doesteam’sandteamleader’sNTSscorrelatewithtechnicalperformanceofclinicaltasks?

20teams.Twoseparate,high-fidelity,simulatedtraumascenarios.Video,dividedinto4consecutivesections.TeamleaderassessmentusingNOTSS.Entireteam2additionalratersusedT-NOTECHS

TheNTSsoftraumateamsandteamleadersdeteriorateasclinicalscenariosprogress,andtheperformanceofteamleadersandteamsishighlycorrelated.CognitiveNTSscorescorrelatewithcriticaltaskperformance.

Notrelevant

RINGEN,A.H.etal.2011

ToassesstheexperienceandeducationofNorwegiantraumateamleaders,andallowthemtodescribetheirperceivededucationalneeds

Writtenquestionnaires.All45hospitalsinNorwayreceivingseverelyinjuredtraumavictimswerecontacted,randomlyselectedweeknight.Teamleadersaskedtospecifywhattraumarelatedtrainingprogramstheyhadparticipatedin,howmuchexperiencetheyhad,andwhatfurthertrainingtheywished,ifany.

Levelofexperienceamongteamleaderswashighlyvariableandtheireducationalbackgroundinsufficientaccordingtointernationalandproposednationalstandards.Teamleadersstatedthatmoreexperienceandbettertrainingareimportanttotheminordertobecomebetterleaders

Notrelevant

71

CARLSON,J.etal.2009

Todevelopameasurementtoolreliableatcapturingteambehaviorduringahigh-fidelitysimulationwhenusedbymultipleraters.Usethetooltoexploretherelationshipbetweentheteambehaviorsmeasuredandthestandardoftechnicalmedicalcaredeliveredspecifictotheneedsofthecase.

Studyparticipants(n=113),44teams(2or3teammembers)Duringtheworkshop,everyteamparticipatedinthesamescriptedcasescenariofacilitatedbythesametraininginstructor.Ratersusingtheteambehaviormeasurementtoolwereunawareoftheteams’globalassessmentoftechnicalstandardofmedicalcaredelivered

Themethodsusedprovideapossiblemethodfortrainingandassessingteamperformanceduringsimulation.Theinstrumentpresentedinthisstudyoffersapossibletemplateforfuturework

Notrelevant

HAYES,C.W.etal.2007

Determineinternalmedicineresidents’perceptionsoftheadequacyoftheirtrainingtoserveasinhospitalcardiacarrestteamleaders

654residentsweresentasurvey,289residents(44.2%)responded.Subjects:adequacyoftraining,perceptionofpreparedness,adequacyofsupervisionandfeedback,andeffectivenessofadditionaltrainingtools

Asignificantnumberofinternalmedicineresidentsfeelinadequatelytrained,unprepared,andunsupervisedtoleadcardiacarrestteamsinteachinghospitals.

Notrelevant

ITANI,K.M.etal.2004

Assesstheperceptionofsurgicalresidentsinleadershipskills.

Questionnairewasadministeredto43residents.1)theresidentsranked18leadershipskillsonascaleof1to4inimportanceforcareerdevelopment.2)asimilarscalewithregardtotheirpersonalconfidenceandcompetenceinthesesameareas.3)toevaluatethemselveswithregardtofiveleadershiptraits.

Traditionally,developmentofphysicianleadershiphasoccurredatrandominsurgicaltraining.Itisourjobassurgicaleducatorstoprovidethisopportunitytoourresidents.Ethicswastheonlyareainwhich75%oftheresidentsbelievedthemselvestobemorethanminimallycompetent

Notrelevant

MARSCH,S.C.etal.2004

Howhumanfactorsaffecttheteamperformanceduringasimulatedcardiacarrest.Andshowcorrelationbetweenleadershipbehaviourandoutcome

16teams,eachthreehealth-careworkers.Simulator.Video.Dataanalysiswasperformedindependentlybytwooftheauthorsusingachecklist.

Twothirdsofteamscomposedofqualifiedhealth-careworkersfailedtoprovidebasiclifesupportand/ordefibrillationwithinanappropriatetimewindow.

Notrelevant

WISBORG,T.etal.2003

Doesthetrainingofmultiprofessionaltraumateamsandresusciationteamsfornewbornsvary?

Atelephonesurveyoftrainingpractices.Theheadnurseateachemergencydepartment(n=50)andneonatalward(n=16)wasinterviewedinastructuredfashion.Theywereaskediftheiremergencyteampersonnelhadparticipatedinpracticalmultiprofessionaltrainingduringtheprevious6or12months.

Regularteamtrainingrepresentsanunderusedpotentialtoimprovehandlingoflow-frequencyemergencies.

Notrelevant

COOPER,S.etal.1999

Determinetherelationshipbetweenleadershipbehaviour,teamdynamicsandtaskperformance

20resuscitationattemptswereobserved(19onvideo).Allteamsmorethanfivemembers.Atotalof18leaders.LBDQ:measurelevelofstructure.Interpersonalbehaviourandtasksofresuscitationwithateamdynamicsandataskperformancescale.Observers:anALSinstructorandavideorater

Leaderswhoinitiatedastructure,distributedtasks,andremained“handsoff”improvedteamperformance.Anemergencyleadershiptrainingprogrammeisessentialtoenhancetheperformanceofleadersandtheirteams.

Notrelevant

QualitativeStudies

SADIDEEN,H.etal.2016

VideoanalysisofleadershipbehaviorswithinTheBurnsSuite(asimulationtooltodeliverinterprofessionalandteamworktraining).ExplorewhetherSimulation-basedteamtrainingwithinTBScanelaborateonkeyleadershiptheories.WhichleadershipmodelsappearedpredominantwithinTBS.

N=12,3simulations,eachteam4members.Video.Focusgroupinterviewsafterdebriefing.Objectivetoidentifyleadershipskillsmappingthemontoleadershiptheory.2authorsand2otherauthorsindependentlyassesors

Effectiveleadershipisessentialforsuccessfulfunctioningofworkteamsandaccomplishmentoftaskgoals.Leadershipinateam-basedresuscitationscenariocanbeconsideredasdistributed,ratherthancontinuouslybeingassociatedwithaspecificleader.

“Therewasadifficultyinblindingauthorsduringcodingofparticipantleadershipbehaviors,whichmayhaveintroducedanelementofdetectionbias,althoughcarewasexercisedtoavoidthis”

AccordingtoCASPthereisaclearstatementsoffindingsandtheresearchisvaluable

72

LEENSTRA,N.F.etal.2016

Toaddresstheneedforataxonomyofleadershipskillsthatspecifiestheskillcomponentstobelearnedandthebehaviorsbywhichtheycanbeassessedacrossthefivephasesoftraumacare,theauthorsdevelopedtheTaxonomyofTraumaLeadershipSkills,TTLS

28interviewsw.traumaleadersand14raters.Skillelementscapturedby67behavioralmarkers.Categorizedusingmultipleraters

TheTTLSprovidesaframeworkforteaching,learning,andassessingteamleadershipskillsintraumacareandothercomplex,acutecaresituations


KOLEH-MAINEN,C.etal.2014

Investigatingcodeleadershipasperceivedbyresidentsinfourareas:(1)learningtobeacodeleader(2)leadershipdefinescodesuccess(3)idealcodeleadershipbehaviors(4)leadershipandgender

25residents,semi-structuredtelephoneorin-personinterviews.Recordedandtransscribed.Threeauthorsanalyzedthreeinterviewsfocusingoncontentareas.Fourauthorsreadalltranscripstinfull

Leadershipdefinescodesuccess.Poorleadershipwascitedasthemajorfactortoachaoticcode.Participantsreportedthatitwasimportanttobe“authoritative”;tohavea“strongpresence”bybeingbothseenandheard.Femaleparticipantsdescribedfeelingstressfromhavingtoviolategenderbehavioralnormsintheroleofcodeleader.


JACOBSSON,M.etal.2012

Analyzehowformalleaderscommunicateknowledge,createconsensus,andpositionthemselvesinrelationtoothersintheteam

Sixteentraumateams,sixmembersoneachteam.Highfidelitytraininginanemergencydepartment.Video.

Thisstudyindicatesthatcommunicationintraumateamsiscomplexandconsistsofmorethanjusttransferringmessagesquickly.Italsoconcernswhattheleadersexpress,andevenmoreimportantly,howtheyspeaktoandinvolveotherteammembers


HJORTDAHL,M.etal.2009

Toobtainadeeperunderstandingofwhichnon-technicalskillsareimportanttomembersofthetraumateamduringinitialexaminationandtreatmentoftraumapatients.

Twelvesemi-structuredinterviews.2authorsparticipatedinall12.

Leadershipwasperceivedasanessentialcomponentintraumamanagement.Theidealleadershouldbeanexperiencedsurgeon,haveextensiveknowledgeoftraumacare,communicateclearlyandradiateconfidence.Lackofleadershipwasoftengivenasareasonfordysfunctionalteamwork.


YuleSetal.2006aDeveloping

Describethemethodusedtoidentifysurgeons’non-technicalskills,andthedevelopmentofaskillstaxonomyandbehaviouralratingsystemtostructureobservationandfeedbackinsurgicaltraining

27consultantsurgeons.Interview.Identifykeynon-technicalskillsandinterpersonalskills.Multidisciplinarygroupdevelopedtheinterviewscedule(psycologists,surgeonsandananaesthetist).Interviewsrecorded,transscribedandanalysedbytheepairsofpsycologistsindependently.

TheNOTSSskillstaxonomyandmarkersystempresentedherehasbeengroundedempiricallyinsurgery,andwasdevelopedwithdomainexperts(consultantsurgeons)ateverystagetoensurethatthesystemisexplicit,transparentandhasanacceptabledegreeofconstructvalidity.


Table1:Primarystudies

73

Studytype Leadershipisimportantfortheoutcome

Educationalneeds/recommendations Measure/Aim Teaching?

RCT

YULE,S.etal.2015 "…Non-technicalskillsmatteratcriticalstagesofsurgicalcare"

"Importantnextstepsaretoimplementnon-technicalskillscoachingintherealOR"

Measure,NOTSS Non-technicalskillscoaching +

FERNANDEZCASTELAOetal.2015

"InCPR,effectiveleadershipispositivelyassociatedwithpatientoutcome"

"…leaderstrainedinaseparateexplicitstepappearstobeanefficientwaytofosterteamprocessesandoutcomesasawhole"

Measure(LBDQinspired)

CRMteamleadertrainingandadditionalALS-training.TeamleadersoftheCRM-TLgroupsattendeda90-minCRM-TLtraining

+

KRAGE,R.etal.2014"...stresscaninterferewiththeperformanceoftechnicalskillsincriticalsituations"

"…moreeffortintotrainingthenon-technicalskillsofindividualsandteamswhoareworkinginahighstressenvironment"

Measure,protocolERCguidelines Notteaching -

HUNZIKER,S.etal.2010Briefleadershipinstructions

"…strongleadershipmaypositivelyinfluenceteamperformance"

"However,becauseinexperiencedrescuersareofteninvolvedearlyinsituationsofcardiacarrest,theirtrainingisofoutmostimportance"

Measure,prespecifiedchecklist(LBDQinspired)

Leadershipinstructionwithprespecifiedchecklists-LBDQinspired +

COOPER,2001

"…aleadershipdevelopmentprogrammesignificantlychangesbehaviourandincreasesperformance"

Itisrecommendedthata"formalleadershipdevelopmentprogrammeshouldbeintroducedintoadvancedlifesupportcourses".

Measure(LBDQinspired)

Theexperimentalgroupthenattendeda75-minleadershipdevelopmentseminar

+Case-Control MANTHA,A.etal.2016

"...wedesignedanNTScurriculumforIndianparamedictraineesfocusedonstrengtheningon-sceneleadership,teamwork,andpublicspeakingskills"

"focusedNTSdevelopmentcurriculumintoIndianparamediceducationandfurtherevaluationofthelongtermimpactsofthisadaptiveleadershiptraining".

PersonaltrainingANDmeasuringposture,gesture,eye-contactemotions,confidence-etc.

6-dayseminar.Presentationofanonprofessionaltopictoclassmates.

+

NICKSA,G.A.etal.2015

"Simulation-basededucationhasbeenshowntodirectlyimpactphysicians’clinicalbehaviorandchangeoutcomes"

"Traditionally,surgicaleducationhasnotformallytaughtleadershipskills,effectivecommunication,professionalism,orteammanagement"

Measure,NOTECHS

Teaching:"feedback,facilitateddiscussion,instructedonareasofknowledgeasneeded,providedinsight,andencouragedparticipantself-reflection"

+

ROBERTS,N.K.etal.2014

"...themajorityofparticipantsstronglyagreedthatthetraininghadthepotentialtoimprovepatientsafety"

"…thereisagreatdealoftalkaboutthedesirabilityofmultiprofessionalteamtraining,butthenumberofexamplesofsuchtraininginhospitalsettingsislimited".

Measure(LBDQ-inspired,TeamSTEPPSinspired,Kilpatrick)

Simulation-videoanalysis-simulation-debriefing.3weekslater:simulationandquestionnaire

*

MAKINEN,M.etal.2007

"Definingandteachingleadershipseemstoimproveresuscitationperformance"

"InpreviousanalysesmadethemajorityofphysiciansandnursesfeltthattraininginCPRwasinsufficientatvariouslevelsofcare"

Measure-compareSwedenandFinland

Notteaching -

GILFOYLE,E.etal.2007

"Teamswhofunctionwithaneffectiveteamleader[…]haveamorefavourableoutcomefortheirpatients,bothsimulatedandreal"

"...itisourhopethatlearningleadershipskillsspecifictoresuscitationwillcarryovertootherareasofprofessionalpracticeofpaediatricmedicine"

Measure,checklistandquestionnaire.CRM

Half-dayworkshop:Basedontheneedsassessmentlearningobjectivesweredeveloped.2simulations-debfiefing

*

74

MCCUE,J.D.etal.1986

"…increasedemphasisontheimportanceofdoctors'noncognitiveskillsinmedicalpractice…"

"Althoughphysiciansarerequiredtoactasleadersinavarietyofsituations,leadershipabilityandleadershiptraininghavebeenlargelyignoredbymedicaleducators…"

Nurses'perceptions.Measuring.Tool:LSI

Two-hourdiscussionaboutleadership. *

CaseStudy ROBINSON,P.S.etal.2016

"LeadershipskillsdirectlycorrelatewiththequalityoftechnicalperformanceofCPRandclinicaloutcomes"

"…traininginandassessmentofleadershipskillsinemergencyscenariosshouldbeanintegralcomponentofpostgraduatemedicaltraining"

Measure.Survey,12ratedstatementsand4dichotomousquestions-LikertScale

Notteaching -

HARGESTAM,M.etal.2016

"...understanding…non-verbalcommunicationcouldnotonlyimproveteamworkbutalsoincreasepatientsafety..."

"Communicationcannotbetakenforgranted;itneedstobepracticedregularlyjustastechnicalskillsneedtobetrained".

Measure.Non-verbalfocus.

Teamtraining,CRM +

BRIGGS,A.etal.2015

…theperformanceofteamleadersandteamsishighlycorrelated...teamworkandNTSperformancedocorrelatewithclinicaloutcomesintraumaresuscitation

"IncreasedattentiontoNTSsduringtraumateamtrainingmayleadtosustainedperformancethroughouttraumascenarios"

Measure.NOTSS,T-NOTECHS

Simulations-briefCRMtraining.FocusonMeasuring *

RINGEN,A.H.etal.2011

"Thismightleadtonegativeconsequencesnotonlyfortheteamleaderandmembers,butmayalsoaffectpatientoutcomes"

"Proposednationalstandardsshouldbeurgentlyimplementedtoensureequalaccesstohighqualitytraumacare"

Measure.Questionnaire.NTS

Notteaching -

CARLSON,J.etal.2009

"…cognitiveorsocialskillsthatplayanimportantroleinpromotingsafetyandsuccessfulproblemmanagement"

"Theoveralltoolshouldcontainasfewitemsaspossibletoeffectivelyyetreliablycaptureleadershipstyleandkeyteambehaviors".

Measure.Developmentofatool

Simulation-facilitator-debriefing *

HAYES,C.W.etal.2007

"…thequalityofcardiopulmonaryresuscitationprovidedinteachinghospitalsissuboptimalsuggestthatinadequateresidenttrainingmaycontributetopoorpatientoutcomes".

"Theperceivedlackofadequatetrainingseemedtoberesponsible,atleastinpart,tofeelingsofbeingunprepared,overwhelmed,andofworryingaboutcommittingerrorsduringcardiacarrests"

Measure.Survey.Likert-Scale.

Notteaching -

ITANI,K.M.etal.2004 NA

"…developmentofphysicianleadershiphasoccurredatrandominsurgicaltraining...theyhaveprovidedlittleformaltrainingintheessentialleadershipskills"

Measure.Questionnaire,measuring18leadershipskills

Notteaching -

MARSCH,S.C.etal.2004

"Inthepresentstudy,theabsenceofstructuredleadershipbehaviourwasassociatedwithunfavourableoutcome"

Absenceofleadershipbehaviourwas"associatedwithpoorteamperformance…thisfindingcouldhaveimportantimplicationsfortheteachingofmedicalemergencies"

Measure.StrongLBDQinspired

Simulation-video-debriefing *

WISBORG,T.etal.2003

"…trainingofmultiprofessionalteamswillimprovepatienttreatment...asubstantialproportionofdeathsoccurringaftertraumaareavoidable"

"Leadershiptrainingalsoseemstoimproveleadershipperformanceduringcardiacarrest"

Measure.Survey.Prevalence Notteaching -

75

COOPER,S.etal.1999

…astudywhichdemonstratedthat"leaderswhoinitiatedastructure,distributedtasks,andremained“handsoff”improvedteamperformance"

"…withoutperformancefeedback,leaderswillnothaveamodeltopositivelyinfluencetheirbehaviourandperformancewillbedependentonpersonality"

Measure.StrongLBDQinspired Notteaching -

QualitativeStudies SADIDEEN,H.etal.2016

"Effectiveleadershipisessentialforsuccessfulfunctioningofworkteamsandaccomplishmentoftaskgoals"

"Understandingleadershipbehaviors[…]canidentifyimportantbehaviorsrequiredtooptimizenontechnicalskillsinamajorresuscitation"

Measure Simulation-video-debriefing. *

LEENSTRA,N.F.etal.2016

"poorleadershiphasbeenidentifiedasapotentialthreattopatientsafety"

"Goodleadershipisessentialforoptimaltraumateamperformance,andtargetedtrainingofleadershipskillsisnecessarytoachievesuchleadershipproficiency"

Measure.Needforataxonomy.TTLS.67behaviouralMarkers

Notteaching -

KOLEHMAINEN,C.etal.2014

Effectiveleadershipiscritical....Poorleadershipwasconsistentlycitedasthemajorcontributingfactortoachaoticcode:“ifyou’requietandwishy-washy,itjustgoeshorrifically"

"practicalguidanceneededforthedeliberatepracticeofleadershipskills…targetedtrainingofleadershipskillsisnecessarytoachievesuchleadershipproficiency"

Measure.Survey.Gender.

Notteaching -

JACOBSSON,M.etal.2012

"itisachallengefortheformalleadertocoordinateteammembers’tasksinordertooptimizeteamworktoobtainasuccessfuloutcome"

NA MeasuringLeadershipStyles Notteaching -

HJORTDAHL,M.etal.2009

"Betterteamfunctioncouldimprovepatientoutcome.[…]Lackofleadershipwasoftengivenasareasonfordysfunctionalteamwork"

"Theneedforbettertrainingoftraumateamsandespeciallyteamleadersrequiresfurtherinvestigationandaction"

Measure.Survey.Gender. Notteaching -

YuleSetal.2006a(Development)

"Futureresearchwillestablishthecriterionvalidityofnon-technicalskillsratingsonperformanceintheoperatingtheatreandonpatientsafetyoutcomes"

"Todate,theformaltrainingofsurgeonshasfocusedondevelopingtechnicalskills...leadershiphavebeendevelopedinaninformalandtacitmanner"

Measure.Developmentofataxonomy

Notteaching -

Table2.Symbols:+=actualteaching.*=debriefing,discussion.-=noteaching/training

76

AdaptedLBDQ(FormXII):LBDQ(initiatingstructure)

1 Lettheteamknowwhatwasexpectedofthem2 Useofuniformguidelines3 Positiveattitude4 Whatshouldbedone5 Howthingsshouldbedone6 Allocatetasks7 Makesurethathispartintheteamwasunderstood8 Plantheworktobedone9 Maintaindefinitestandards10 Remain‘handsoff’

Fig.2.Abridgedbytheauthor(TL)(Cooper,2001)

NOTSSskillstaxonomy(V1.1)2006

Category Element

Situationawareness GatheringinformationUnderstandinginformationProjectingandanticipatingfuturestate

Decisionmaking ConsideringoptionsSelectingandcommunicatingoptionImplementingandreviewingdecisions

Taskmanagement PlanningandpreparationFlexibility⁄respondingtochange

Leadership SettingandmaintainingstandardsSupportingothersCopingwithpressure

Communicationandteamwork

ExchanginginformationEstablishingasharedunderstandingCoordinatingteamactivities

Fig.3.AspresentedbySYule38

77

Taxonomiesdiscoveredinthisreview:leadership,teamwork,andcommunication

Type1945:LDBQ LeadershipBehaviourDescriptionQuestionnaire-military

1978:CRM Crewresourcemanagement-aviation.Lateradaptedtohealthcare

1980:LSI LeadershipStyleIndicator(48adjectives)1998:CRM CRMcurriculumvalidatedbyGaba

1999:LDBQ(FormXII) Adaptedfrom1790originalstatementstotendimensionsofbehaviour2000:Jartel(JARTEL) JointAviationRequirements:TranslationandElaborationofLegislation

2002:NOTECHS(NTS) Non-TechnicalSkillsforAirlinePilots

2003:ANTS Anaesthetists’Non-TechnicalSkills2005:ACGME AccreditationCouncilforGraduateMedicalEducationhasestablished6

competenciesforresidentandfellowdevelopment

2006:NOTSS Non-TechnicalSkillsforSurgeons

2007:MayoHighPerformanceTeamworkScale

Ratesteamperformanceontheconsistencyof16differentcriteria

2007:GILFOYLE Checklist(adaptedfromGaba1998)

2009:JimCarlson Areliableteambehaviourmeasurementtool

2009:OxfordNOTECHS Measuringteamworkbehaviourintheoperatingtheatre2010:SMARTT Algorithm:SituationManagementActivityRapidityTroubleshootTalktome

2011:OttawaGlobalRatingScale

OttawaCrisisResourceManagementGlobalRatingScale.Evaluatestheperformanceoftheteamleader

2012:T-NOTECHS TheModifiedNon-TechnicalSkillsScaleforTraumasystem

2013:SLI Surgeons’LeadershipInventory,Taxonomy2015:OxfordNOTECHS AmodifiedOxfordNOTECHSScale(Nicksa)

2016:TTLS TaxonomyofTraumaLeadershipSkills.5skillcategories,and37skillelements.Theskillelementsarecoveredby67behaviouralmarkers

Table3

79

TRAININGRESIDENTSTOLEADEMERGENCYTEAMS[PARTTWO]

Barriers,ChallengesandLearningGoals:aQualitativeReview

TureLarsen,RandiBeier-Holgersen,DorisØstergaard,PeterDieckmann

TureLarsen,PhDStudent,SimulationUnit(SimNord),DepartmentofAdministration,NordsjællandsHospital,Denmark

RandiBeier-Holgersen,MD,MHPE,DepartmentofGastrointestinalSurgery,NordsjællandsHospital,Denmark

DorisØstergaard,MD,DMSc,Professor,DiplomaHPE,CopenhagenAcademyforMedicalEducationandSimulation(CAMES),CapitalRegionofDenmarkandUniversityofCopenhagen,Copenhagen,Denmark

PeterDieckmann,PhD,Dipl.-Psych.CopenhagenAcademyforMedicalEducationandSimulation(CAMES),CapitalRegionofDenmarkandUniversityofCopenhagen,Copenhagen,Denmark

Correspondingauthor:TureLarsen,SimNord,Kvalitetsafdelingen,NordsjællandsHospital,Dyrehavevej29,3400Hillerød,Denmark.Phone:+4531127281,Mail:[email protected]

RandiBeier-Holgersen,DorisØstergaard,andPeterDieckmann:reprintswillnotbeavailablefromtheauthors





writingofthereport.

80

Abstract:

Objective:Aninvestigationtodetermineanyconsensusinopinionsandviewsaboutchallengesor

barriersintrainingleadershipinemergencies.

SummaryofBackgroundData:Leadershipinemergenciesisreportedasbeingveryimportantfor

thepatientoutcome.Asystematicreviewfailedin2016tofindanyfocusedtrainingofthis

function.Theresearchhasfocusedondevelopingtaxonomiesandtoolstomeasuringleadership.

Anexplicitneedforworkableleadershiptrainingofteamleadersinemergencieswasidentified.

Method:Articlesfoundinthesystematicreview,otherreviewsandopinionswereincludedto

incorporateexperiences,perceptionsandemotionsconnectedwithleadershiptrainingin

emergencysituations.Onthebasisofanarticlewrittenin1986,statementsaboutchallenges

regardingleadershiptrainingwereidentifiedandallarticlesweresearchedforthese.Themethod

wasdirectedsummarizedqualitativecontentanalysis.

Findings:Intotal40articlescoveringtheyears1986-2016wereanalysed.Mainfindings:23articles

describedthesituationasstressful,18describedtheimportanceofself-confidenceand16

describedthesituationascomplexorcomplicated,12describedthesituationwasperceivedwith

concern,anxietyorpanic.

Conclusions:Theliteraturerecommendsfindingasolutiontoteachresidentstogainconfidencein

stressfulsurroundings.Theliteraturerecommendsfindingawaytoworkwithbodylanguage,non-

verbalcommunication,attitudeandappearanceinordertoradiatecredibilityinasettingseparated

frommedicalknowledge.

Background

Teamleadershipinemergenciesisreportedasbeingimportantforthequalityofthetechnical

performanceofteams,13-24forpatientoutcome,patientsafetyandpatientcare.22,23,25-35The

qualityofteamleadershipmayeveninfluencepatientmortalityandsurvivalrates.19,23,27,32

However,manystudiesrecognisethatleadershiptraininghasbeenneglected,1,16,17,23,27,29,36-39and

arecurrentcallforaworkableleadershiptrainingprogrammehasbeenexpressedexplicitly.

1,14,16,17,21-23,26,27,29,34,36-43Thisneedhasprevailedthroughoutthe31-yearperiodaddressedinour

investigation.

81

Asystematicreviewoftheliteratureonleadershiptrainingforresidentsrevealednofocused

trainingofthisfunctionin27eitherqualitativeorquantitativeinterventionstudies(describedin

PartOneofthisarticle:Larsen,Tetal:Trainingresidentstoleademergencyteams:ASystematic

Review(underreview)).

Manyinitiativeshavesoughttoaddresstheproblems:inparticularitcanbeemphasizedthat

leadershipispartoftheScottishinitiativeAnaesthetists’NontechnicalSkills(ANTS)49,adaptedto

‘Non-TechnicalSkillsforSurgeons’(NOTSS)38andto‘ScrubPractitioners’ListofIntra-operative

Non-TechnicalSkills’(SPLINTS).50ThelatterreplacedNOTECHSfornurses51–whichwasalso

modifiedto:OxfordNOTECHS52andamongotherthings:T-NOTECHS53,aswellastheSwiss

leadershiptrainingprogrammebasedontheLeadershipBehaviourDescriptionQuestionnaire

(LBDQ)1.Theseprogrammesfocusondeveloping‘formativeassessmenttools’,54behavioural

markers55andtaxonomiesinordertomeasure15,22,33,38leadershipskills.Thecontent,qualityand

complexity22,36,43,59ofthesetoolshavebeendiscussedextensively;existingtoolshavebeen

adapted/modifiedornewtoolshavebeendeveloped22,26,33,36,38,39,43andthoseinvolvedhavespent

yearsdiscussing,inpapers,the‘significantvariabilityinterminology,trainingmodalitiesand

evaluation’41inthisfield.15,43

However,‘something’isapparentlystillmissing,andthereasonwhy‘residentsfeelunpreparedand

unsupervisedasleaders’27shouldbeexplored.Oneexplanationcouldbethatthereisalackof

clarityabouttheperceptionanddefinitionofgoodleadership,asdescribedbyStogdill(1974),who

wrote:“[Thereare]almostasmanydefinitionsofleadershipastherearepersonswhohave

attemptedtodefinetheconcept”.99Anotherexplanationcouldbethattheexistingprogrammes

havefailedtolocatetheactualchallengesintheefforttodevelopassessmenttools.

Theaimofthisarticleisdeterminewhethertheliteraturerevealsanyopinions,attitudes,

experiencesorviewstoidentifyanyactual,butperhapsoverlookedchallengesorbarrierswhich

leadershiptrainingforresidentsinemergenciesneedstoaddress.Similarly,thestudywill

investigatewhetheritispossibletoidentifyconsensusonwhatcharacterizesagoodclinicalteam

leader,thusidentifyingspecificlearninggoals.Finally,thearticlewillexaminetheliteratureto

determinewhetherthereisconsensusaboutthosechallenges,barriers,andgoals.Inaddition,this

resultwouldrevealwhethertherehavebeenanydevelopmentsoverthelast31yearsinrelationto

thesefindingsregardingleadershiptraining.Dowefindthesameneedstodaythathaveidentified

overthepastthreedecadesorhasasolutionbeenfound?

82

Method

Duringthesystematicsearchincludingtheearliermentionedsystematicreview,40articleswere

foundrelevant,coveringtheperiod1986-2016.Adetailedreviewofsearchstrategyandquality

assessmentisdescribedindetailinthearticle:Larsen,Tetal:Trainingresidentstoleademergency

teams:ASystematicReview(underreview).Thereviewsandopinionpieceswereincludedinour

review,astheycontainedconceptsthatwererelevantforsystematizingthecurrentdiscussion.


ethicalapprovalbutaformalreviewwaswaivedforthisstudy(H-4-2015-FSP).

Byusingadirected,summativeapproachon‘quantitativemanifestcontentanalysis’63inorderto

exploreusageofthevisibleandsurfacecontentofthetextitispossibletoidentifyconsensuson

selectedwordsfromaquantitativeapproach.Byusing‘qualitativelatentcontentanalysis’8itis

possibletointerprettheunderlyingmeaningofthewordsandthus,rather,interpretaqualitative

approach.Directed(deductive)qualitativecontentanalysisstartswithpreconceivedcodesor

categoriesderivedfrompriorrelevanttheory,research,orliterature.63Introducingadifferent

perspectiveonthearticlesfoundintheabove-mentionedsystematicreview,theinclusioncriteria

wereexpandedtocoverexperience,perceptionsandemotionsrelatingtoleadershiptrainingin

emergencysituations,andthereforeprimaryaswellassecondaryarticlesbecamerelevant.

Thepreconceivedcategoriesinthesearchwasguidedbythecontentofanarticlepublishedin

1986,31yearsagoandwrittenbyKennethIserson.44Thearticlewasidentifiedasveryrelevantin

thatitfocusedontheactualexperienceofphysicianswhenperformingasteamleaderinan

emergency.Modernsafetyconceptsemphasizetheneedtotaketheactualworkingconditionsinto

accountandnot(only)howworkshouldbeperformed.Isersonstatesinthisarticle:“Incritical

clinicalsituationsleadershipisoftenlacking”.Thisisbecause“physiciansarenevertaughtclinical

leadership”.Isersonemphasizestheneedwhenhestates:“Especiallyinemergencycare,

developmentofclinicalleadershipisvitalandmustbeintegratedintooureducationsystematall

levels.”Finallytheauthorconcludes:“Thisisaseriousdeficiencyinmedicaltraining.”Thearticle

providedkeyconceptsthatarestilltobefoundincontemporarypapers,22,23,31,39,41,46formulated

theissuesveryclearlyandthusservedtoguideourfurthersearch.

KeywordswereselectedinIserson’sarticle.Hestronglyemphasizesthatphysiciansare1)

unsupervisedandunpreparedtorisetotheoccasionasteamleadersinemergencies.Hedescribes

2)thesituationitself,whichmaybe“stressful”,“chaotic”and“confusing”,andthereforeteam

83

leadersoftenexperiencethesituationwith3)negativefeelings,suchasbeing“uncomfortable”,as

an“overwhelmingburden”,andperceiveitwith“fear”and“anxiety”.Inorderto“restoreorder”in

achaoticsituationitisnecessarythattheleadercreates4)calmnessfortheteamandtherefore5)

self-confidenceisprerequisiteforgoodleadership.AccordingtoIerson,agoodleaderis6)

perceivedthroughhis“forceofpersonality”and“dominance”,andtheleaderdemonstrates7)

capacityasleader/appearsasauthoritativeifheisabletoshow“responsibility”,“knowledge”,

“powerandauthority”.Heemphasizesthenecessityof8)assumingleadership,whichinvolvesthe

mentaldecisiontoassume“themantleofthegroup’spossiblefailure”.Hefinallystatesthatitis

possibleto9)“learntolead”.Thoseninekeyissuesconstitutethethemestobeexaminedinthis

article.

All40articleswerecollectedinasinglePDFdocumentandsearchedforwordstoinvestigatein

ordertoestablishwhethertheabovekeyissuesidentifiedbyIsersonarestillrelevanttodayinthe

abovethemes.Acomprehensiveexaminationofthedocumentwasconductedsearchingforkey

words,theirsynonymsand,ifavailable,meaningfulpositiveandnegativeanalogies,associations,

metaphors,andsentencesusingthesearchfunctioninAdobeAcrobatReaderDC,version

2017.012.20093.Wordsweresearchedinthedocument,andsentencesbasedonthesewords

werescreenedinrelationtotheirrelevanceforthecontentofthisstudy.Sentenceswereincluded

iftheycontainedanythingaboutteamleadership,teamwork,orpersonalchallengesandfeelings

relatedtothis.ThewordswereselectedbyTL,andrelevancetoinclusionandexclusionwas

discusseduntilTLandRBHreachedagreementonthedecision.

Thekeywordsweregroupedintheabove-mentionedninethemes,andthethemesandquotes

containingthewordsweresortedchronologicallyandpresentedinAppendixI.

Themostimportant/significantquoteschosenonthebasisofthearticlesexaminedarepresented

inthisarticle.Whenconsideredtohaveapossibleinfluenceoninterpretation,quotesweresorted

accordingtowheretheyappearedinthearticles:beforeorafterthemethodologysection,i.e.,

whethertheyformedapre-conditioninthebackgroundforthearticleorafindingorconclusion.

Weassumedthataconclusioncanbestrongerthanapre-condition;apre-conditionforan

interventionorareviewmaybechangedwhentheinvestigationiscompletedandaconclusionmay

contradictthepre-condition.

Referencesmentionedinthebackgroundsectionplusallquotesmentionedintheresultsectionare

availableinappendixI.

84

Results

Thekeywordsweregroupedintoninekeythemes(Table1).Thestudyrevealedsentencesthat

arguedorexpressedattitudesdescribingwhatsubjectswererelevantchallengesinteamleadership

training.Therewasanemphasisonshowingdiversityinthestatementspresented.Originalquotes

arepresentedaswellasotherarticles’referencestothem.

Residentsfeelunsupervisedandunprepared:Tenarticles16,17,23,26,27,31,37,39,44,46concludedthat

residentsfeltunpreparedasleadersofcardiacarrestteams.

“Nevertheless,ourdatasupportpublishedfindingsthattraineeswouldlikefurtherleadershiptraining.”

Robinsonetal.,201623

Acomplex,stressful,unpredictableandchaoticexperience:Therewasbroadconsensusthat

leadershipinemergenciesisperceivedasacomplexissue,bothintermsofstressfulsituations

demandingmanydecisionsforthebenefitofthepatient,aswellasofmanagingrelationswithin

theteamitself.

Ninearticles16,24,25,29,30,33,44,56,58mentionedcomplexityintheirintroduction/backgroundsections.

”Leadershipisacomplexconcept,andthetoolsusedtoassessthequalityofleadershiparepoorlydescribed,

inadequatelyvalidated,andinfrequentlyused.”

Fordetal.,201624

Inthediscussion/conclusionsections,sevenarticles19-22,35,39,41stressedcomplexity.

“Sincemanysituationscannotberesolvedbytechnicalmasteryalone,adaptiveleadershipinvolvesanalyzing

complexsituations,identifyingavailableresourcesandrequiredexpertise,formulatingastrategyinreal-time,

andcoordinatingmultiplestakeholders.”

Manthaetal.,2016.41

Sixarticles16,25,28,34,38,56usedthephrase“Copingwithpressure”asapre-definedterminthe

originalNOTSS-taxonomy(Non-TechnicalSkillsforSurgeons)asdevelopedbyYuleetal.in200625,38

andpresentedbyFlinetal.in2007.28Threeotherarticles21,24,40usedasimilarphrase:“Coping

withstress”.

Eightarticles16,23,27,29,30,33,47,59emphasizedthestressfulworkingconditionsintheir

introduction/backgroundsections.

“Cardiopulmonaryresuscitation(CPR)isperceivedasastressfultaskbymedicalteams.”

85

Krageetal.,201459

Tenarticles20,22,25,27,31,32,34,41,44,45highlightedtheseconditionsinthediscussion/conclusionsection.

“Cardiopulmonaryresuscitationcanproduceconsiderablestress,andtheexperienceofstressandoverload

mayimpairPerformance.”

Hunzikeretal.,201331

Performanceinanemergencywasdescribedas“unpredictable”23,30or“unanticipated”.25

Jacobssonetal.,2012:“Thetaskscarriedoutbyemergencyinterdisciplinaryteamsarecomplex,

unpredictable,andurgent.”30

“Inhospitalcardiacarrestsarechallenging,stressfulandunpredictable.Theycancomewithoutwarning,often

inunfamiliarclinicalenvironments,withlimitedordifficultaccesstoequipment.Furthermore,theirsuccess

dependsonthecoordinatedperformanceofanoftenad-hoccardiacarrest(‘crash’)team.”

Robinsonetal.,201623

Sevenarticles1,32,34,41,44,46,60usedtheword‘chaos’whendescribingthesituation.Chaoswhenno

leaderrisestotheoccasion.44Chaoswhenleadershipisnotclear46intheenvironmentforIndian

ParamedicswasdescribedbyManthaetal.,2016:

“…facecomplexandchaoticclinicalenvironmentsthatdemandeffectiveleadership,communication,and

teamwork.”41

Anunpleasant,disturbing,frighteningandpanickedperception:Theemergencysituationwas

characterizedbyvariousformsofdiscomfort.

“Theleaderneedstodisplayapositiveattitude,motivateandencouragetheteam,inasituationthatisoften

unpleasantanddisturbing.”

Cooperetal.,19991

Notsurprisinglythisledtoconcernedtrainees.1,16,23,27,32,37,39

“Theperceivedlackofadequatetrainingseemedtoberesponsible,atleastinpart,tofeelingsofbeing

unprepared,overwhelmed,andofworryingaboutcommittingerrorsduringcardiacarrestsinasignificant

numberofresidents.”

Hayeset.al,2007.27

Eightarticles1,14,16,23,27,32,36,44mentionedanxiety.

“Severaloftheinexperiencedteamleadersmentionedthattheyfeltanxiouswhentheywerethesolesurgeon

intheemergencyroom”

86

Hjortdahletal.,2009.16

Asinglearticlementionedpanic.

“Theyalsodescribedoftenbeing“panicked”buttryingtoappearasthe“calmestpersonintheroom”.“One

likenedhisbehaviortoaduck,saying:“Ifyou’veeverwatchedaduckonapond,itlooksasthoughit’sfloating

effortlesslyacrossthelake.Butifyou’veeverlookedunderneathataduck’sfeet,they’repaddlingfeverishly.”

Kolehmainenetal.,201432

Loweredstress:Fourarticles16,30,32,44claimedthatagoodleaderwasabletocreate“lowered

stress”44andto“calmotherpeopledown”32

Twoarticles32,58mentionednoiseandcrowdcontrol.

“…theteamleaderhasanimportantroleinnoiseandcrowdcontrol.”

Merceretal.,201458

Confidence:Threearticles1,29,39usedthewordconfidenceintheirbackgroundsection:theteam

should“demonstrateconfidenceintheirleader”,1theleadershould“radiateconfidence”,29and

theleadershouldhave“confidenceinperformingemergencyprocedures.”39

13articles1,16,23,27,32,36,37,39,41,42,44,46,47concludedthatthedegreeofself-confidenceiscrucialforthe

qualityoftheleadership.Thiswillproduce“moreeffectiveleaders”,36“savethesituation”,44

make“trainingforleadershipmucheasier”,1and“improvepatientcareandcardiacarrest

outcomes”23.

“…residentsoftentakeyearstogaintheconfidenceandexpertisetomasterthenon-technicalandtechnical

skillsneededtoaddresshigh-riskclinicalemergencies.”

Nicksaetal.,201539

Howaleaderisperceived:Eightarticles13,16,29-31,44,47discussedtheteam’sperceptionoftheleader.

Toestablishacomfortableandsafeenvironmentfortheteam,teammembersmustbeableto

perceivetheirleaderastrustworthy.16,47Stolleretal.,2013:“Theteammembershadtobeableto

trusttheirleader.”47Hjortdahletal.,2009:“Onenursesaidthatiftheleaderseemsconfidentshe

feelsconfidenttoo.”16Jacobssonetal.emphasizesthatitwasimportancethattheleader“hada

strongethosandexpressedcompetence.”30

87

Ashortcuttoperceptionofauthority:Threearticles32,35,46statethattheleadershouldtakecareof

his/herappearance“especiallyforfirstmeetings”andinthiscontextthat:“Theclinicianwillwork

onwaystodevelophis/herowncharisma.”46Itisimportanttoadopt“apowerfulposture”32and

“Teammemberswhoareawareofhowtheyusetheirbodiestocommunicatewillbeableto

facilitateandimprovetheirperformance.”35

“…participantswhoassumedapowerfulversusanon-powerfulposturefeltmoreconfidentandweremore

likelytotakeaction.”

Kolehmainenetal.,2014.32

Anotherissueemphasizedasimportantbyeightarticles16,26,29,30,32,35,41,44ishowtheleaderuses

his/hervoice.

“Anyonewhotellsyouthatbeingawhitemalewithadeepvoiceandwho’salittlebittallerisnotan

advantagetobeingperceivedpositively,orperceivedasincontrol,wouldbelying,inreallyanysituationnot

justacode.”

Kolehmainenetal.,2014.32

AssumingLeadership:Tobecomeagoodleaderitisimportanttoassumetheleadershipwithallits

implicationsincludingrisksandfailure.Fivearticles1,18,24,26,32statethisviewinthe

introduction/backgroundsections.

Sixarticles16,20,32,36,44,46elaboratethisviewintheirdiscussion/conclusionsections.

“…recentAdvancedTraumaLifeSupport(ATLS)guidelineshavecodifiedleadership’simportanceby

emphasizingthatforateamto“performeffectivelyoneteammembershouldassumetheroleoftheteam

leader.”

Fordetal.,2016.24

Whenassumingleadershiponecanbenefitfrom‘introspection’46,‘psychologicalself-care’,60or

‘self-management.’47

”…theabilitytounderstandandmanageoneselfandtounderstandothersandmanagerelationships–has

beenshowntodifferentiatebetweengreatandaverageleaders.”

Stolleretal.,2013.47

Borntolead–orlearntolead:Sevenarticles1,16,23,26,32,42,44mentionthatsomeareborntolead

whileothershavetolearn.

88

“Inthefieldofcardiacarrestleadership,anincreasingweightofevidencesupportsthenotionthatindividuals

canbetrainedtolead.”

Robinsonetal.,2016.23

Discussion

Theliteraturestatesthatthechallengeandbarriertheteamleadermustaddressisstrongnegative

emotionscausedbyanextremecontext.Theliteratureontaxonomiesstatesthatifwefindaway

torefineandimprovemeasurementtools,thenwewilleventuallybeabletotrainleadership.

ItisinterestingtonotethattheliteraturelargelyagreesonIserson’sviews.Itissimilarlyinteresting

tonotethattheliteraturethusagreesthatthereareactuallyverystrongemotionstobeaddressed

whentrainingleadershipforemergencies.ItisdisturbingtolearnthatallIserson’sstatements

written31yearsagoarestillvalidtoday.Despitemanyinitiatives,researchprojectsandmanhours

distributedovertheseyearsofintensework,theliteraturehasfailedtoaddresswhattheliterature

itselfhaspointedoutduringthisperiod.However,theliteratureseemsrepeatedlytoprovidean

answerdifferentfromthetargetquestion,finding“something‘thatworks’intermsofleadership

traininginemergencies”toaseeminglysimilar–butessentiallydifferent–question:“Istherea

methodtomeasureleadershipbyphysiciansinemergencysituations?”Thechangeoffocuscould

beexplainedby‘substitution’.Themechanismofreplacingadifficultquestionwithasimpleroneis

extensivelydescribedbypsychologistDanielKahneman:“whenfacedwithadifficultquestion,we

oftenansweraneasieroneinstead,usuallywithoutnoticingthesubstitution[…]Thetarget

questionistheassessmentyouintendtoproduce.Theheuristicquestionisthesimplerquestion

thatyouanswerinstead”.78EvenYule,whoin2006emphasizedtheimportanceofassessment

toolsandbehaviouralmarkersinordertomeasure,38hadchangedhismindin2015:


improvenon-technicalskillsinsurgicaltrainingandbeyond.”

Yuleetal.,201534

InPartOneofthisstudyitwasdiscussedthatitwaspossibletostatethatleadershiptraining

actuallytakesplaceinaclinicalcontextwhichiscomplexitself–focusingsimultaneouslyon‘task

distribution’,‘humanfactors’or‘initiatingstructure’(LBDQ)or‘taskmanagement’,‘non-technical

skills’or‘situationawareness’(NOTECHS)aswellasonmedicalknowledgeandcreatingstructures

whileimplementingalgorithmsandmaintainingstandards.Butthissettingwoulddiminishthe

actualfocusontargetedleadershiptrainingbecausethecognitiveworkloadistoodemanding.

Kahnemandescribestwowaysofthinking.System1isfastandintuitiveandautomatic:associative

89

memorycontinuallyconstructsacoherentinterpretationofwhatisgoingon.System2isslower,

deliberateandlogical:consistingofcontrolledoperationsrepresentinganeffortfulmentalactivity.

78Accordingtothis:whentrainingsituationawarenessandleadershipincombinationwithmedical

knowledgeandalgorithmswechallengetheresidenttoworkbothinsystem1and2

simultaneously.Thisisaverydifficulttrainingsetting.

Themostimportantsubjecttotheauthorsofthispaperisthefoundationfortheleadershiprole:

theprimarydeliberatedecisiontoassumeleadershipasdescribedintenoffortyarticles.To

‘assumeleadership’isamental,deliberatedecision,andimportantchoicetobemadebeforehand.

Thisshouldbepartoftheeducation.Thebasicfoundationforbeingabletotaketheleadership.

Intheliteraturewefoundaconsensusontheactualchallengethatneedstobetakeninto

consideration.Overthepast31yearstheliteraturehasstatedthatthesenegativeemotions,

feelingsandperceptionsarehighlyinvolvedwhenateamleaderneedstorisetotheoccasionin

frontofanemergencyteam,buttheliteraturehasnotasyetdescribedamethodtoaccommodate

this.Thishasbeenthecasewhetherthereasonhasbeenlackofknowledge,lackofleadership

definition,lackoffocusorlackofabilitytohandlethesimplebutdifficultquestion:tofind

“something‘thatworks’intermsofleadershiptraininginemergencies”inordertoprepare

residentsforthis.

Asstatedbysixarticlesagoodleadershouldcreatecalmnessintheextremesituation.13articles

concludedthattheteamleader’sdegreeofself-confidenceiscrucialforthequalityofthe

leadership.Twospecificlearninggoalstobeaddressedintheteachingofteamleadershiptraining

wereexpressed.

Anotherfindingis,thatitisimportantthattheleaderhascharisma,istrustworthyandexpress

competence.Elevenarticlesrecognisethatnon-verbalcommunicationisimportant;threearticles

mentionbodypostureandeightarticlesstresstheimportanceofhowtospeakanduseofthe

voice.Obviously,itshouldbeinvestigatedhowtooptimisetheleaderscharismaaswellasradiating

credibilityandcompetenceincludingnon-verbalcommunication.

“Inacceptingtheleadershiprole,theindividualassumesthemantleofthegroup’spossiblefailure.Any

individual’sfalteringcanbelaidattheleader’sfeet.Thisisthelawoftotalresponsibility.”

Iserson,198644

90

Limitations

Whenconsideredtohaveapossiblerelevancetotheaimofthisarticle,quotesweresorted

accordingtowheretheyappearedinthearticles:beforeorafterthemethodologysection,i.e.

whethertheyexpressedapre-conditioninthebackgroundforthearticleorafinding/conclusion

asaresultofaninvestigation.Itisassumedthataconclusionmaybestrongerthanapre-condition;

apre-conditionforaninterventionorareviewmaychangewhentheinvestigationhasbeen

completedandaconclusionmaycontradictthepre-condition.Itturnedoutthatwhetherthewords

werementionedasapre-conditionoraconclusionhadnoeffectontheoutcome.Areasonforthis

couldbethatthewordshadbeninheritedandrecycledthroughouttheliterature.Ontheother

hand,itmaybearguedthatitisnotcrucialwhetherthewordsappearasaconclusionontheaimof

aninterventioninaresearchproject.Whatisimportanttoourstudyisthefactthatthearticles

consideritnecessarytoemphasizethewordsintheirarticlesatanystagewhatsoever.

Conclusions

Assumingleadershipisanindividualandpersonalmatterandanimportantanddeliberatechoice.

Theliteraturerecommendsthatamethodshouldbefoundwhichteachesresidentshowtoachieve

calmnessandconfidenceinastressfulandthreateningcontext.Tothisenditisrecommendedto

findawaytoworkwithbodylanguage,non-verbalcommunication,attitudeandappearancein

ordertoaddressemotionsandradiateauthorityandcredibilityinasettingseparatedfrommedical

knowledge.

Contributors

T.Larsenhadfullaccesstoallthedatainthestudyandhadfinalresponsibilityforthedecisionto

submitforpublication.TLundertookthesearchformaterial,extractedandcollecteddata,

developedtheanalysisstrategy,andwroteuptheresults.TL&RBeier-Holgersenconceivedand

designedtheproject,reviewedthescientificreportsandperformedqualityassessmentsand

interpretationoftheresults.P.DieckmannandD.Østergaardprovidedadviceandcriticallyrevised

themanuscript.

91

Themesdescribingwhatproblemstheliteraturerefertoasissuesateamleadercanexperienceinfrontofanemergencyteam

Whenanarticlemakesastatementbothinthebackgroundandconclusionsectionsonlyoneref.islisted.

No.ofstatements

Physiciansfeelunsupervisedandunprepared

Residentsfeelunprepared/lackofcompetence/needfurthertraining16,17,23,26,27,31,37,39,46

10

Theexperienceoftheemergencysituation

Acomplex/complicatedsituation16,19-22,24,25,29,30,33,35,39,41,44,56,58 16

Astressfulsituation/pressure16,20,22,23,25,27,29-34,41,45,47,59Inadditionstress/pressureisimplicitlypartofNOTECHS21,24,28,40,56

185

Anunpredictable/unanticipatedsituation23,25,30 3

Achaoticsituation1,32,34,41,44,46,60 7

Anoverwhelmingexperience

Anunpleasant/disturbingsituation1,32 2

Perceivedwithanxiety/asathreat/‘alosingbattle’/fail1,14,16,23,27,32,36,44 8

Perceivedwithpanic32 1

Perceivedwithconcern/doubt/isoverwhelming/isworrying/isstressed1,14,27 3

Theleaderisablecreatecalmness

Goodleadershipcreatescalmnessandloweredstress16,30,32,44,58 5

Self-confidenceisimportant

Self-confidenceisanimportantelementinleadership1,16,23,27,29,32,36,37,39,41,42,44,46,47 18

Theteam’sperceptionoftheleader

Individualleadershipbehaviourwillhaveanimpactontheteam’sperception(radiateconfidence,overallorganization,clearlydefined,trustworthy,mostimportanthumanfactor,communicatesclearly,strongethosetc.)13,16,29-31,44,47

8

Theleader’sappearance:short-cuttoauthority

Bodyposture,appearance,non-verbalcommunication32,35,46 3

Voice(calm,clear,distinct,deep,fluentetc.)16,26,29,30,32,35,41,44 8

Assumingleadership–adeliberatedecision

Assumingleadership/risks/responsibility1,16,18,20,24,26,32,36,44,46 11

Managingoneself/introspection/psychologicalself-care46,47,60 3

Mentallyprepare/rehearse/mentalstrain/mentalmodels25,32,56,58 4

Itispossibletolearntolead

Leadershipcomesnaturallytosome/isaproblemforothers1,16,23,26,32,42,44 7

Table1

93

CONDUCTINGTHEEMERGENCYTEAM:ANOVELWAYTOTRAINTHETEAM-LEADERFOR

EMERGENCIES

TureLarsen,RandiBeier-Holgersen,PeterDieckmann,DorisØstergaard

TureLarsen,PhDStudent,SimulationUnit(SimNord),DepartmentofAdministration,Nordsjællands

Hospital,Denmark

RandiBeier-Holgersen,MD,MHPE,DepartmentofGastrointestinalSurgery,Nordsjællands

Hospital,Denmark

DorisØstergaard,MD,DMSc,Professor,DiplomaHPE,CopenhagenAcademyforMedicalEducation

andSimulation(CAMES),CapitalRegionofDenmarkandUniversityofCopenhagen,Copenhagen,

Denmark

PeterDieckmann,PhD,Dipl.-Psych.CopenhagenAcademyforMedicalEducationandSimulation

(CAMES),CapitalRegionofDenmarkandUniversityofCopenhagen,Copenhagen,Denmark

Correspondingauthor:TureLarsen,SimNord,Kvalitetsafdelingen,NordsjællandsHospital,

Dyrehavevej29,3400Hillerød,Denmark.Phone:+4531127281,Mail:[email protected]

RandiBeier-Holgersen,DorisØstergaard,andPeterDieckmann:reprintswillnotbeavailablefrom

theauthors





writingofthereport.

94

Abstract

Introduction:Worldwide,medicalsupervisorsfinditdifficulttogetstudentstorisetotheoccasion

whencalledupontoactasleadersofemergencyteams:manyresidents/rescuersfeelunprepared

toadopttheleadershiprole.Thechallengeistoaddresstheresidentsverystrongemotionscaused

bytheextremelystressfulcontext.Nosystematicleadershiptrainingtakesthisaspectintoaccount.

Aim:Theoverallaimofthecourseistoinvestigatewhether,inanemergency,aclinicalteamleader

couldapplyaconductor’sleadershipskills.

Background:Anorchestralconductorisaspecialistinpracticingleadershipfocusingonnon-verbal

communication.Theconductorworkswithhighlytrainedspecialistsandmustleadthemto

cooperateandputhisinterpretationintoeffect.Theconductorworkspurposefullyinorderto

appearcalm,genuineandgainauthority.

Method:Aconductorandaconsultantpreparedacourseforresidents,medicalstudentsand

nurses,n=61.Tenxtwocoursedayswerecompleted.Theexercisesweremusicalandthussafefor

thestudentsastherewerenoclinicalskillsatstake.Theprogrammeaimedtocreatestressand

anxietyinasafelearningenvironment.

Conclusion:Thetransferofaconductor’sskillsimprovedandprofoundlychangedtheparticipating

students’,nurses’andresidents’behaviourandintroducedamethodtohandleanxietyandshow

calmnessandauthority.

Perspectives:Ifthiscourseinleadershipistobeintroducedasacompulsorypartoftheeducating

ofdoctors,theidealtimewouldbeafterclinicalskillshavebeenacquired,experiencegainedand

routinesunderstoodintheclinic.


Introduction

Worldwide,medicalsupervisorsfinditdifficulttogetstudentstorisetotheoccasionwhencalled

upontoactasleadersofemergencyteams100:manyresidentsfeelunpreparedfortheleadership

roleinemergencies16,17,23,26,27,32,37,39.However,leadershipinemergenciesisconsideredvery

importantforpatientsafety1,13,14,16,17,19-23,26,27,29-33andcanaffectmortality.19,23,27,32

95

Itisnecessaryforresidentstoaddressandhandleanxiety16,23,27,32,44andpanic32instressful

20,22,25,27,31,32,34,41,45andcomplex19-22,35,39,41situations.100Therefore,inordertoprovidegoodand

convincingleadership,residentsmustlearntobeconfident1,16,23,27,32,36,37,39,41,42,44,46,47andcalm

16,30,32,44whenassumingtheroleofteamleader.100

Thereisnosystematicleadershiptrainingthattakesthisaspectintoaccount.Handlingnegative

feelingsisnotpartofexistingprogrammes.101Leadershipduringanemergencysituationinvolves

knowledgeandskills,butalsoimpliesdealingwiththepressure16,25,28,34,38,56ofbeingthedecision-

makerandthepressureofbearingtheultimateresponsibilityforwhathappens(ordoesnot).101

Thisarticledescribesacoursethatsupplementsexistingprogrammesbyaddressingtheemotional

challengesforthoseleaders.

Background

Leadershipanditsrelationtohealthcare

Itisimportanttofullyunderstandthatleadershipandassumingleadershipisanindividualand

personalmatterandadeliberatechoice.101Itisnecessarythatthepersonwhostepsforwardas

teamleaderfullyunderstandstherisksandresponsibilitiesoftheleadershiprole1,20,32,44,47–also

referredtoastheleaders’introspection,46psycologicalself-care,60mentalreadiness20,25or

havingtheabilitytounderstandandmanageoneself.47“Inacceptingtheleadershiprole,the

individualassumesthemantleofthegroup’spossiblefailure.Anyindividual’sfalteringcanbelaid

attheleader’sfeet.Thisisthelawoftotalresponsibility”,44statedbyIsersonin1986.

Theconductor’sroleanditsrelationtoleadershipinhealthcare

Anorchestralconductorisaspecialistinpracticingleadershipfocusingonnon-verbal

communication.Theconductor’sgoalistointerpretandrealizethecomposer’sintentionsandto

conveythisinterpretationtotheorchestratoensurethemusiccomesaliveinanartistically

satisfactoryway.Theconductorworkswithhighlytrainedspecialistsandmustleadthemto

cooperateandputhisinterpretationintoeffect.

Inordertoachievetherespectandauthoritytoleadanorchestra,itisimportanttoappearcalm,

balanced,competent,authentic,andcredible.Theleaderworkspurposefullywithhispostureand

appearanceinordertoeliminateanythingthatcouldpossiblypreventthemessagefrombeing

interpretedasintended.

96

Itisnecessaryfortheconductortolisten,sense,andobservewhatactuallytakesplaceintheroom

anddemonstratea‘presencetothemoment’,whichwillgivehimtheabilitytoconstantlyadapt

andadjusttochangesandembracetheunexpected.Thispresenceshouldalsoreflecthis

‘responsiveness’,definedbytheabilitytosense,notice,recognize,feel,andexperiencethe

emotionsofanotherpersonorgroupofpersonssubjectively.

Thisabilitytogainanoverviewofthesituationinallitscomplexityandfindsolutionsbasedon

technicalaswellashumanresourceswillbeperceivedbytheteamassignsofcompetence.When

theleaderaddsthecourageto‘improvise’onthebasisofagivensituation,hewillnotonly

demonstratecompetence,butmakehispresencefelt.Insodoing,hewillbeperceivedaseven

moregenuinebytheteams.

“Improvisationrequiresalotofexperienceanddisciplineandcannotbeexecutedbybeginners,

neitherisitsomethingtobepulledoutwheneverythingelsefails”.94Theimportanceofskilled

professionalsbeingabletoimproviseintheirleadershiprolesisalsodiscussedandemphasizedby

jazz-pianistandProfessorofManagement,FrankJ.Barrett.95

Byworkingwiththeseobjectives,theconductorortheteamleader’scredibilitywillbeenhanced.

Conductorsknowthatonlywhenthiscredibilityisestablishedistheconductorabletoleadthe

orchestra,andtoprovidetheappropriatelevelofencouragementorcriticismconsidered

appropriatewithoutupsettinganyone.

Table2showstherelationbetweenthefunctionsofaconductorandateamleader.Basedonthese

similarities,weconsiderthattraininginthenon-clinicalcontextofconductingmusicmighthelp

residentstotakeintoaccount,face,anddealwiththeemotionalchallengesofbeingaleader.The

conductor’sfocusandobjectivesduringthecoursearepresentedintable3.

Theoverallaimofthecourseistoinvestigatewhether,inanemergency,aclinicalteamleader

couldapplyaconductor’sleadershipskills.

Method

Thissectioncoversseveralaspects.Firstly,pedagogicconsiderationsandassumptions,thenthe

developmentofthecourseandhowitwasconducted,andfinallytheevaluation.

Pedagogicconsiderations

Anxietyandsafety

97

Inordertosimulateanemergencysituationandtooptimizeleadershiptrainingthecoursecreates

aframeworkwithstress,anxiety,anddiscomfortinaharmless,non-clinical,andsafesetting.Itis

importanttoprovidepsychologicalsafety102wheretheparticipantsfeelabletoacceptbeing

uncomfortableandfeelthattheywillbeviewedpositivelyeveniftheymakemistakes.103

Transformativelearningperspective

Thecourseassumesthatparticipantshavetoexperienceandobtaina‘bodilyfeel’ofthepressure

ofbeingaconductorinordertoreallyunderstandit,asdescribedinEmbodiedCognition.68This

theoryisusedinthedesignofeffectivelearningenvironments,especiallythosetargeting

conceptualchange.69AccordingtoTransformativeLearningTheory70oneprerequisitefor

ensuringarealtransformationistobefacedwitha‘disorientingdilemma’71.A‘Disorienting

Dilemma’isdefinedasanacutepersonalorsocialcrisisor,atanotherlevellikeonthiscourse:the

participantsweregivenassignmentswhichwerealmostimpossibletosolve.

Changeofsetting

Thecoursebuildsonachangeofteachingstrategytoimplementanelementofsurprise,whichis

alsoneededtocreatethedilemmathatisusedastriggerfortransformativelearningprocess.There

isaradicalchangeofsettingwiththeshiftfromatraditionalclass-roomset-uptoamusicalset-up

inanotherroom;thischangeofsettingemphasizesthegreatimportancethattheinstructorsattach

tothissurprisingexercise.

Apprenticeship

Traditionally,aconductorhimselfistrainedviaanapprenticeshipandthismethodwouldbe

appliedtothecourse.Individual‘straighton’feedback,offeredwiththeutmostcareand

sensitivity,isacornerstonewhendoingtheexercises:theparticipantsmustnotfeelconcernedat

thispoint.Theconductorhasexperiencedthatlearningispromotedbygettingclosetothislimit

whengivingthisverypersonalfeedback.

Developmentofthecourse

Asdescribedintheliterature,theconsultanthadexperiencedthelackofleadershipandanxietyin

simulationtrainingofresidentsandthemissingfocusonleadership.Asanamateurtrombone

playersherealizedtheparallelbetweentheteamleaderandtheconductorwhenherconcertband

receivedanewskilledconductor.Thedevelopmentofthecoursewasbasedonaconductor’sskills

98

inordertogivemedicalstudents,nurses,andresidentsthetoolsrequiredtoappearcalmand

credibleintotheemergencyteam.

Theconductofthecourse

Aconsultantandanorchestralconductorwerethefacultyforthecourse.

Theconsultantwasfamiliarwiththestudentsandresidentsassheisresponsiblefortheir

educationatthehospital.Inaddition,herpresenceguaranteedtheclinicalrelevanceofthecourse.

Thepresenceoftheconductorwasanewelementintheclinicalcontextandthereforethe

participantsweremoreattentive.

Classrooms:Teachingtookplaceinthreedifferentrooms.Roomonewasanordinaryclassroom

setup.Thefacultystoodinfrontoftheboard.Thissituationwasaknownandsafeframeworkfora

courseformedicalstudentsanddoctors.Inroomtwo,amusicstandwasplacedinfrontofasemi-

circlewithchairsfortheparticipants.Behindthesemi-circlewasapiano.Thismusicalsetupwasa

‘changeasetting’fortheparticipants.Roomthreecontainedafullyequippedsimulationroomwith

aSimMan2Gpatientsimulator,againfamiliartoeverybody.

Primarily,theconsultantexplainedthebackgroundofthecourse,andbasedonherownexperience

describedacasewheretheteamleaderfailedwithunfortunateconsequences.Thesimilarity

betweenateamleaderinanemergencyandaconductorataconcertwasdescribed:twohighly

tensesituationsdemandingfirmleadershipinwhichdecisionsmustbeobeyedandthereisn’t

muchroomfordiscussion.Then,theConductorbrieflydescribedhisthoughtsonleadershipas

describedinthebackgroundsectionandintable3.Theconductorpromotedachangeofsettingby

explainingthatteachingwouldcontinueintheadjoiningroom,andthecourseparticipants

themselveswouldhavetheopportunitytoactasconductorsandsingersinachoir.

AchronologicalreviewofthecontentofthecoursedaysispresentedinTable4.

Participants

AllparticipantswererecruitedfromNordsjællandsHospital,Denmark:Residentsstartingworkin

spring2015werecontactedbymailandofferedacourseonteamleadershipandnon-verbal

communication.Theresidentswereappointedandparticipatedinthecourseonemonthpriorto

thebeginningoftheirfirstclinicalperiodasadoctor.Inautumn2014,3rdsemestergraduate

99

studentswereofferedcoursesstartinginJanuary2015.Thestudentsenrolled.Asanexperiment,

anadditionaltrainingdaywasaddedfortwodifferentteams.Toinvestigatewhetherthecourse

wasapplicabletootherages,groupsandhealth-careprofessionalsorwasrelevantinteamwork

withnurses,acoursedaywasheldforemergencyroomnurses.


ethicalapprovalbutaformalreviewwaswaivedforthisstudy(H-4-2015-FSP).Allparticipantsgave

writtenconsentfortheirvideostobedisplayed/publishedhere.

Evaluationmethods

Dataacquisitionandanalysis

Integratedvideoandaudiorecordingsrepresenting22:12hoursofobservationofallthecourses

fortheresidentsandstudentsweremade.Onecamerafocusedonthe‘leader’andanotheronthe

‘team’.ThefirstfourcoursedayswererecordedontheGoProSilveredition,andthesecameras

werereplacedbytheGoProHERO4Blackedition,whichhashighdefinitionresolution(4K),

allowingzoominginonthedetailsofthefootageintheeditingprocess.TheHDfootagewasedited

onaMacBookProwithtwoexternaltwoTBharddrives(oneforbackup).Recordingsfromasingle

coursedaytookupbetween40and60GBofdiskspace:all22:12hoursofrecordingsfilled

approximatelyoneTBofharddrivespace.ThevideoswereeditedinAdobePremiereProCC,

release2017.1.2.

Dialoguesfromselectedcoursesweretranscribedverbatim(includingshortdescriptionsof

importantevents,e.g.‘laughter’).Writtenfieldnoteswerecompiledforallthecourses.Complete

dialoguesweretranscribedfromsixcourses(thefinalcoursedesign)–atotalof160pages.

TranscriptionmadepartlybyTLandpartlybytwomedicalstudentswhowerenotattendingor

informedaboutthecourse(‘blinded’astothebackground,methodandassumptionsforthe

course).Throughouttheproject,TLkeptaresearchdiary,whereobservationsandthoughts

deemedtoberelevantfortheprojectwererecorded(OnlinelogavailableinAppendixtoarticle

three).

Commentsandevaluations

Alltheparticipantsmadeevaluationsimmediatelyafterthecourses,n=61.Theygavewritten

quantitativeevaluationsandrespondedtoashortsurveyoffourquantitativequestionsplusan

optionforafreeassessmentcomment(Appendix1).Thestudentsandresidentswereencouraged

100

toreflectonthecourseinwrittenevaluationsafterthecourse.Afterreceivingeditedvideoclips

showingtheirpersonalperformanceduringthetwocoursedays,thestudentsandresidentswere

sentasurveywith14questions(AppendixII).

Analysis

Abductionasamethod

Anabductiveapproachtoresearchmakesitpossiblefortheresearchertopresentaqualified

presumption(educatedguessorinference)67whencommencinghisinvestigation.Basedonhis

findings,heacquiresnewknowledge,hemightalter/adaptthisnewknowledgetothe

presumptionandtheprocessstartsover.Thisprincipleisthefoundationofmorecontemporary

methodse.g.GroundedTheoryorQualitativeContentAnalysis.

QualitativeContentAnalysis

Alltext-baseddataweregatheredintoonesinglepdf-documentandsearchedforkeywordsand

sentencesdescribingthecontentofthecourse,andthewordswereinterpretedinameaningful

context.ThemethodwasQualitativeContentAnalysis,conventional,andinductive:Themes

emergedinandabductive–inductiveprocess,abductivebecausetheconductorhadhis

presumptionsforthecourse–inductivebecausethefindingsadjustedthepresumptions.When

themeswereestablishedtheprocessbecamedirectedbythethemes,thustheprocessbecame

deductive.Thewordsweregroupedintothreethemes(table5,6,and7)accordingtothe

assumptions(asdescribedinthebackgroundsectionandintable3)andfindingsinthedataset.

Thewordswereinterpretedinameaningfulcontext.

Threekeywordswereimportantforthecoursethoughrarelyverbalized:videofootagewas

searchedforTrance,ApprenticeshipandTransformationbasedontheconductor’sassumptionsfor

thecourse.‘Trance’isanexperience,‘apprenticeship’isanoverallimportantteachingconcept,

‘transformation’isanaim,butnoneofthosekeywordswereexplicitlyverbalizedduringthecourse

(table5).

Videofootagewasreviewedseveraltimes,andeditedwiththeaimofexemplifyingthethemes

describedabove.

101

Results

20three-hourcoursedayswerecompletedintheperiodJanuary–May2015,threecoursedays

werecancelledbecauseoflackofparticipation.Sevenparticipantswerenotabletoattendcourse

daytwobecauseoftimepressurefromotheractivities(table1).

Writtenqualitativeevaluationswerereceivedonedaytofivemonthsafterthecoursefrom20of

38participants(53%).Thevideomaterialwaseditedto332smallvideoclipsandeachparticipant

wassenttheirpersonalvideostogetherwithanewsurvey.Thesesurveyswerereceived2·5–10

monthsafterthecourse,14e-mailremindersweresentandtenofthe38participantsresponded

(26%).Unsolicitedcommentsreceived24monthsafterthecoursefromfourofthe38participants

(10%).Inaddition,two‘blinded’studentswrotenon-guidedreflectiononthecoursebasedonthe

contentoftheirtranscriptionsoffourcoursedays.Theseconsiderationsareincludedinthedata

set.

Threethemesemerged:Table5,Learningenvironment.Table6,Pedagogics.Table7,Learninggoals

–theconductor’sfocus.

Allthemesarehighlightedwithquotesaccordingtowhethertheyweremadeduringthecourses

illustratingwhattookplaceduringthecourses(table9)(comprehensiveinappendixIII)orwere

providedinevaluationsafterthecourses,reflectingthoughtsfromthecourseuptotwoyearslater

(table10and11)(comprehensiveinappendixIV).

Tenshortvideoswereeditedaccordingtothethemesandproducedfromthe22:12hoursof

footagefromthecourses.Thevideosallgiveanimpressionofthelearningenvironmentand

includelaughter.Thevideosandthethemestheyareillustratingarepresentedintable12.

Table12,Video1showsa‘changeofsetting’fortheresidentsandtheimpactofbeingchallengedto

conductasimplechildren’ssong.Giventhedifficultchallengeofbeatinga‘basicfour-beatpattern’

(ill.1andtable12,video1)theparticipantsbecamemorestressedinanalreadystressfulsituation,

andthisrevealedpersonalphysicalchallengesandinterference–theycouldthenbeassessedby

theconductor.

Thevideo(video1)showclearsignsofparticipantsfeelinginsecure:twistingtheirhands,scratching

theirneck,shakingtheirshouldersorhead,laughing–mouthwideopen,hidingtheirhandsintheir

102

lapsandshowinganxietywhilelaughingwasinterpretedasparticipantsfeelingstressed,findingthe

taskverydifficultandstrugglingtosolvethechallenge.

Theparticipants’discomfortanduncertaintyledthemtopaymoreattentiontotheconductor–

andstrengthenedthecohesionamongtheparticipantswhenlaughingateachother.

Learningenvironment

Selectedcommentsareshownbelowinthethemes.Alldataaredescribedintable5and6,quotes

arepresentedintable9and10aswellasAppendixIIIandIV.

Learningenvironment

‘Manypointsandalotoflearningarereceivedbestinasafeenvironmentandwhenplaying,whichonemust

saythatthecoursefulfils’.

[S13],twomonthsafter

Safe,enjoyablelaughterhadasignificantimpactonthecourseindicatingthattheparticipantsfelt

safeandenjoyedparticipating.

Reflectionsaboutthelearningprocesswerefound.Thisfurtherconfirmsthattheparticipantsfelt

safetospeakupandsharereflectionsaboutthecontentofthecourse.

Trance

Itwasobservedthatatrance-likestatefrequentlyoccurredbetweentheleaderandtheteam

duringtheexercises,asshowninvideo6,7and9andtable8and9,aswellasAppendixIIIandIV.

Apprenticeship/‘Straighton’feedback

Participantsrecognizedthattheconductorwasaspecialistwho,throughhisprofession,had

acquiredtheabilitytofocusonnon-verballanguage(Table6).Partofthelearningprocessthrough

apprenticeshipistheverydirectpersonalfeed-back(Table12,Video3).Theconductorworkedwith

theparticipants’bodypostureandaddressedsimplephysicalelements:hands,neck,chin,back,

chestetc.Thiswasdoneinordertoemphasizedifferentpersonalphysicalissueswhileexplainingto

theteamtheirimpactandimportance.Furthermore,participantsobservedhowpersonal

instructionmadeabigimpactonthepersonwhoreceivedtheinstruction,andexperiencedhow

individualfeedbackimmediatelyinfluences,transformsandstrengthenstheleader’scredibilityin

frontoftheteam.15participantsstatedthattheyfeltthatthefacultyfullyunderstoodthe

103

challengestheyfaced(‘gotundertheirskin’)(Table7:Stressandobstacles).17participantsstated

thattheygreatlyappreciatedthispersonaland‘straighton’feedback(Table9and9:

Apprenticeship).

Transformation

15participantsduringthecourseand21participantsafterthecoursestatedthattherehadbeen

significantdevelopmentintheindividualparticipant’sbehaviour.(Table5:Transformationand

appendixIIIandIV).

Learninggoals–theconductor’sfocus

Describedintable7.

Physics

‘Itwasalsoveryclearthattheparticipantsgainedamuchgreaterbodyawareness.Theybecameawareofhow

theycommunicate,whattheysignalwiththeirbodylanguageandwhatallthisdoeswiththemessagetheyare

goingtoconvey’

‘Blinded’student2

47participantsexpressedthattheyhadbecomeawareoftheimportanceofbodylanguagewhen

communicating.

Authority

‘Thegoodthingaboutpracticingnon-verbalcommunicationwastoexperiencecalmness,whichcouldalsobe

createdinanemergency.Therewasnotsomuchnoiseintheformofpeoplespeakingallatonce,butIalso

experiencedaninnercalmnessincommunicatingmymessageclearlyandwaswellawarethattherecipient

hadunderstoodtheorder,andIwasabletoconcentrateonthenextpartofthetreatmentalgorithm.’

[R8],fourmonthsafter

17participantsspecificallystatedthattheyhaveachievedinteractionbetweenbodylanguage,

appearanceandauthority–andunderstoodwhythisleadstocalmnessandself-confidence–

confidencefortheleaderaswellforthemembersoftheteam.

‘SowhenIfeelthatI’mcalm–youcanseeittoo.’

[S5]dialoguefromacourse

Eye-contact

104

‘Especiallyasadoctorandateamleaderinanemergencysituationwherethereisagreattendencyforthings

togetmessyandcommunicationisnotefficient,youcanpassordersandcommunicatethroughmimics,body

languageandyoureyes.'’

[S3],onemonthafter

Eightparticipantsduringthecourseandtenparticipantsafterthecoursestatedthattheyhad

learnedthateye-contactisapowerfultoolforensuringthatdecisionsarecommunicated,received

andunderstood.

Presenceatthespecificmoment

‘Wearenotgoodatbeingpresent…Iamnot.Butitisimportanttobepresentwhenleadingalargegroupof

people…Presencecanbeusedinalotofcontexts!’

[S4],dialoguefromthecourse

Theimportanceoflistening,beingattentiveanddemonstratingawarenesswasatopicintroduced

repeatedlybythefacultyduringthecourses.Theparticipantunderstandstheimportanceof

presenceinpromotingthequalityofcooperationwiththeteamandeightparticipantsstatedthis

explicitly.

Responsiveness

’Yes,IfeltthatIgotthemmore...undercontrol.Becausewhenyoulookatpeople–you’llknowexactlywhere

theyare–andwhereIammyself’

[R7],dialoguefromacourse

Theparticipantslearnedthatinthiscoursecontextitwasvalidtotalkaboutandexpresssubjective

perceptions(Ifeel,Icansee,itseemslike,Icansense,Icantell).Sentientperceptionswerestated

by11participants.

Stressandobstacles

’IwaspushedtothelimitatthesametimeasIneededtousewhatwasnewlylearned,whichwasaproductive

challenge’

[S21],threemonthsafter

15participantsstatedthattheywerepushedoutoftheircomfortzone,however19participants

acknowledgedthattheenvironmentwasneverthelesssafe.Afewscepticalcommentsfromone

participantandone‘blinded’studentwereidentified(presentedintable11):independentlyof

eachother,theyfoundittoocomplicatedand,intermsoftheclinic,irrelevantfordoctorstolearn

conductingtechniques.

105

Communication

‘…Impressivetoseehowmuchyoucansaywithoutwords,justbodylanguageandmimic.’

[S10],fivemonthsafter.

Participantsweresurprisedandimpressedtoseehowmuchtheycouldcommunicateandhow

explicitandnuancedtheycouldmaketheirdemandswithoutspeaking.

‘Unbelievablehowmuchyoucansayandaskforwithoutusingwords’

[S3]dayone

Non-verbal,Smile/Grin

Conductor:Theverybest:that’syoursmilewhenitsucceeded!Whenyousucceed,youlooksoproudand

happy!Andwearesohappytobepartofyourprideandyourproject.[S7]agrees:Whenyougivethatsmile,

wegetsucha‘Yes!Ididitright!’

Dialoguefromacourse

Non-verbal,Smile/Grin:Thewords‘smile’and’grin’wasfoundinthreecontexts:Safelearning

environment:Itwasfrequentlyobservedandregisteredthattheparticipantsactuallylaughedand

smiledduringthecoursewhentheywereenjoyingthemselves.Anxietyandstress:Itwasalso

observedandrecordedthatduringthecoursetheparticipantslaughedandsmiledasan

involuntaryandnervousreactiontostress.Non-verbalcommunication:Asmileespeciallycan

expressverynuancedanddifferentemotions:kindness,pride,appreciation,embarrassment,

compassion,sillinessandconfusionetc.Assuch,howandwhentouseasmilewhen

communicatingasaleaderwasdiscussedindepth–i.e.whenitpromotesandwhenitinterferes

withtheleadership.

Engagement

...IfeltlikeIwasapartofyour[project].Youwereengaged!Becauseifyouwerenot,you’djusthave

proceeded,andthenI’djustgo:‘Well,whocaresanyway’

[S5]dialoguefromacourse

Participantsexperiencedthat,inordertodemonstrateauthorityandleadershipinaconvincing

manner,itwasnecessaryfortheleadertoshowhewasfullyabsorbedintheproject.

Additionalfindings

(Presentedintable9,aswellasAppendixIV)

106

Theadditionalfindingsweremainlyguidedbyonesurprisingfactor;formostoftheparticipants

transferringthenewlyacquiredleadershipcompetenciesfromamusicalsettingtoafullscaleCPR

simulationturnedouttobeaproblem(Table11,video10,andtable9,aswellasAppendixIV).A

reasonableexplanationwasthat,whenchallengedontheirclinicalknowledge,theparticipants

forgotaboutnon-verbalcommunicationandleadership(thereforeanewthemewasintroduced:

Trainingalgorithmsandleadership).However,theparticipantswereexcitedaboutthecontentof

thecourseandconsideredthecompetenciestobeimportantfortheirfutureworkasdoctors(new

theme:Relevance).Thisproblemledtodiscussionsaboutwhenineducationwouldbetheideal

timetolearntheseskills(Whentolearn).Thesediscussionsandthewrittenevaluationsconfirmed

thatthecourseaddressedimportanttopicswhichwerenotcoveredinformaleducation(Missing

angleattheuniversity).Aninterestingfindingwasthatthecourseparticipantsconsideredthatthe

coursecouldbeusedinmanyothercontextsbesidesthemusicalandclinical(Generallyapplicable).

Thesethemesconcernedtheperspectiveofthelessonslearnedfromthecourses,andtheyare

presentedintable8.

Trainingalgorithmsandleadership

14oftheparticipantsstatedthattheyhadbenefitedfromtheCPRexercise,butthemajority

showedtheyforgotthenewlylearnedlessonswhenchallengedonclinicalknowledge(oneexample

intable12,Video10).Fourparticipantsstatedthatitwasadvantageoustotrainleadership

separatelyfrommedicalcompetence.

Whentolearn

Thenursesrespondedmostpositivelytothecourse(figure1).Theaverageageinthisgroupwas

over50,approximately20yearsolderthanthetwoothergroups,whichindicatesthatafteryears

ofexperiencethisgroupwasawareofhowfatalitcouldbewhentheteamleaderfailed.Thisview

wasconfirmedbythreeparticipantswhopointedoutthattheidealtimetoattendthiscoursein

relationtothemedicaleducationprogrammewouldbeafterclinicalknowledgeandclinicalroutine

/experiencehadbeenacquired.

Relevance

’…withouttheabilitytocommunicate,sixyearsofstudyaretosomeextentalmostuseless’

[S7],dayone

35oftheparticipantsagreedthatthecoursewashighlyrelevantfortheirclinicalpractice.

107

’Anyonecouldneeditinthedailywork’

Nurse1,dayone

Twoyearsafterthecourse,fourparticipantsstatedthatithadchangedtheirprofessional

behaviour.

“Ipersonallythinkthecoursehasbeenagoodfoundation,nowthatI’vestartedasaresident.”

[S14],unsolicitedcomment,24monthsafter(bye-mail)

MissingangleattheUniversity

11participantsstatedthatthecontentofthecoursehadanimportantobjectivewhichwaslacking

inteachingattheuniversity.

Generallyapplicable

‘IfeltabigimprovementwhenattendinganoralexaminationlastMonday...Igotridoftheworstofmybad

habits!Socool!’

[S5]daytwo

13participantsstatedthatthesubjectwasrelevanttoeducationalcontexts,clinics,when

collaboratingingeneral,daytodaywork,doctors’work,instructingcross-fit,swimminglessons,

publicspeakingandattendingoralexams.

’ThinkIwillbenefitfromthisbothprofessionallyandprivately…’

[S11],dayone

Newknowledge

Asshowninfigures1and2,allcourseparticipantsrespondedpositivelytothecourse.80·4%stated

thattheyacquirednewideas.Nursesyieldedthehighestresult,95·7%reportedthattheyacquired

agreatdealofnewknowledge.

Discussion

Summaryofmainfindings

Thetransferofaconductor’sskillsimprovedandprofoundlychangedtheparticipatingstudents’,

nurses’andresidents’behaviourandintroducedamethodtohandleanxietyanddemonstrate

calmnessandauthority.

108

Webelievethatthiscourserepresentsthemissinglinkbetweenwhattheresearchershavedone

andwhattheresearchershaveknownandsoughtformorethanthreedecades.

Thecourseworksinanareathatgoesbeyondlanguage,demonstratingasharedperceptionin

collaborationwhencreatingmusictogether.ThephilosopherSusanKLangermadethisa

prerequisiteandexplaineditwhenshestated:‘thelimitsoflanguagearenotthelastlimitsof

experience,andthingsinaccessibletolanguagemayhavetheirownformsofconception’.82This

leadstotheconceptdescribedas‘trance’inthisarticlewheretimeandplacedissolve.

Whencollaborationisoptimalwhenworkingwithanorchestra,astatecanoccurwheretimeand

placearedissolvedasdescribedinflow-psychology.“Flow”isdefinedbythepsychologist

Csikszentmihályias:“thecreativemomentwhenapersoniscompletelyinvolvedinanactivityfor

itsownsake.Theegofallsaway.Timeflies.Everyaction,movement,andthoughtfollowsinevitably

fromthepreviousone…”(Interview,Wiredmagazine,September2006issue,p.21.)…“Theflow

statemustbeageneralpedagogicalidealbecauseitisoftenextremelygoodlearning,asyouare

optimallychallenged,fullyfocusedandemotionallyinvolvedsoyoutendtorememberverymuch

ofwhatyouaredealingwith”(TL’stranslation).75

Animportantpartofthereflectiontakesplaceduringdialoguesduringthecourse.Atthebeginning

ofthefirstday,theconductoruseswordsheconsidersimportantinrelationtoteaching.He

introducesconceptssuchas‘assumingleadership’,‘radiateauthority’,‘presenceatthespecific

moment’andshowing‘engagement’.Gradually,reflectionandfeedbackarelefttothestudents

who,equippedwiththeseobjectivesandvocabulary,assesseachother’sperformances.Itshould

bementionedthatthereisadelicatebalancebetweencourseparticipantsactuallyacquiringthis

newknowledgeandsimplyrepeatingthewordsoftheconductor.

Expressingsafetyorsheeravoidancemanoeuvre?(Table12,video5)Whentheparticipantsare

dancing,makingcaricatures,andflirtingwiththemembersofteamasdemonstratedinthisvideo,

itisdebatablewhethertheyaredoingsoasanexpressionofwell-beingandsecurityorinorderto

drawattentionawayfromtheirpersonalsenseofinsecurityinthespecificsituation.Thisisa

recurringtopicforthecourse:stressandobstaclesgohandinhandwithsafetyandhappiness.

Itisinterestingtoascertainthattheskillsandcompetencesaddressedinthecoursearesituatedon

ameta-levelandareaprerequisitefortheteaching:thefacultyhastobeabletoassumethe

leadershiproleaseducatorswhoareabletoimprovisewhenteaching.Everyparticipantbringsin

109

hisownexperiences,perceptionsandemotions(table12,video11).Itisveryimportantforthe

facultytobeabletodemonstrate‘presenceatthespecificmoment’and‘responsiveness’inorder

toappearcredibleasteachersandrolemodels.

Itispossibletouseexistinglearningtheoriestodefineandexplainwhythecoursehasahuge

impactontheparticipants,buttheprojecthascreatednewlearninggoalsandamethodologyofits

own.

‘Ithinkthecourseisagreatopportunitytoworkwithyourselfinasafebutchallengingway,andthereisa

greatdealofpraisefortheinstructorstoensuringagoodframework’

[S10],videosurvey,fivemonthsafter

Limitations

Itispossibletoarguethatthecoursewasaclinicalchallengeandsettingwhileaconsultantand

fellowstudentswerepresent,andthattheparticipants’professionalknowledgewastherefore

challengedandtheywereincompetitionwitheachother.Butastheresultsinthevideosandthe

text-analysisshow,themajoritystatedthattheyperceivedthelearningenvironmentassafe.

Beyondlimitsoflanguage:wordscannotexpresssubstantialpartsofhumanperceptionand

experience.However,inordertounderlinewhichobjectiveswereaddressedduringthecourse,this

isdemonstratedprimarilybywordsintheformofquotes.Thechallengeinherentinthisarticleisto

documenttheconductor’shighlyqualitativeapproachinintroducingnon-verbalcommunicationin

aclinicalresearchtradition.Itshouldbementionedthatallthevideospresentedintable12arein

factmoreexplanatorywhendocumentingthenuancesinthecontentofthecourse.

Perspectives

Ifthiscourseinleadershipistobeintroducedasacompulsorypartoftheeducatingofdoctors,

considerationshouldbegiventowhenitistobeimplemented.Ourresultsindicatetheidealtime

wouldbeafterclinicalskillshavebeenacquired,experiencegainedandroutinesunderstoodinthe

clinic.

Conclusion

Theaimofthisprojectwastotransferthecompetenciesfromanorchestralconductortoresidents

inhealthcareinemergencies.Thefocuswasonappearance,authorityandnon-verbal

communication.Thetransferofaconductor’sskillsimprovedandprofoundlychangedthe

110

participatingstudents’,nurses’andresidents’behaviourandintroducedamethodtohandle

anxietyandshowcalmnessandauthority.Thiscourseseemstoaccommodatetheneedforan

operationalandtargetedtrainingoftheteamleaderinemergencies,addressingawaytoachieve

confidenceinastressful,butsafelearningenvironment.Inadditiontheoutcometurnedouttobea

profoundtransformationofparticipants’self-understanding.

Contributors

TLarsenhadfullaccesstoallthedatainthestudyandhadfinalresponsibilityforthedecisionto

submitforpublication.TLundertookthecollectionofdata,developedtheanalysisstrategy,and

wroteuptheresults.TL&RBeier-Holgersen,conceivedanddesignedtheprojectand

interpretationoftheresults.PDieckmannandDØstergaardprovidedadviseandcriticallyrevised

themanuscript.

Declarationofinterests

Wedeclarenocompetinginterests.

Roleofthefundingsource

ThisprojectwassupportedbyagrantfromTrygFoundation,TheResearchCouncilandtheHR

DepartmentatNordsjællandsHospital,andtheLaerdalFoundation.Theopinionsexpressedinthis

Reviewdonotnecessarilyreflectthoseofthefunders.

111

Population Participationincourse.January–May2015 Day1(3hours) Day2(3hours) Day(3hours) (11coursedays) (7coursedays) (2coursedays)Residents 15 11 0Medicalstudents 23 20 4Nurses 23 0 0Total 61 31 4

Table1.Populationandparticipationincourse

TheConductor TheTeamLeader1 Hastheprofessionalcompetencetocontrolthe

processHastheprofessionalcompetencetocontroltheprocess

2 Themusicianshaveclearlydefinedtasksintheteam

Thespecialistshaveclearlydefinedtasksintheteam

3 Worksinaprocessthattakesplaceovertime.Aprocessthatcannotbeinterrupted

Worksinaprocessthattakesplaceovertime.Aprocessthatshouldnotbeinterrupted

4 Theindividualmusiciansmustbeledtostepforwardandperformtheirtasksandstepbacktoletothersperformtheirroleintheprocess

Theindividualteammembersmustbeledtostepforwardandperformtheirtasksandstepbacktoletothersperformtheirroleintheprocess

5 Hashisscorebutisopentosoloist’sinput(musicalinterpretation)

Hashisalgorithmbutisopentoinputfromtheteammembers

6 Mustcontinuouslyadjustandadapttheworkintermsofhowtheconcertisevolvingandrespondingtothemusicians’efforts

Mustcontinuouslyadjustandadapttheworkintermsofhowtheprocessisevolvingandrespondingtothemembers’efforts

7 Mustbeabletoreadtheorchestraasagroupaswellastheindividualmusicians,andtorespondtopeopleandshowempathy

Mustbeabletoreadtheteamasagroupaswellastheindividualmembersandtorespondtopeopleandshowempathy

8 Mustbepreparedtohandlecrisesandconflictsintheorchestraandtosolveproblemsinstantly

Mustbepreparedtohandlecrisesandconflictsattheteamandtosolveproblemsinstantly

9 Top-downmanagement/authoritativeleadership Top-downmanagement/authoritativeleadership10 Managesateamofprofessional,highlytrained

musicianswhoseskillsdefinetheirrolesManagesateamofprofessionalhighlyskilledspecialistsandisawareofwhatskillsexistintheteamandhowthesearebestused

11 Providesnothinginitself,nohands-on.Thetaskisdefinedasoverview,communicationandleadership

Cancontributeactivelyintheteambutshouldbeawareoftheriskofhead-down.Thetaskisdefinedasoverview,communicationandleadership

12

Workinginaculturewhereallmusicianslookattentivelyatthehead,focusontheirowntask,respondtotheother’sefforts,andtrustinhisresponsibilityandoverview

Workinginaculturewhereeyecontactandnonverbalcommunicationarenotrecognizedtools13 Workinginaculturewheregestures,eyecontact,

facialexpressionsandbodylanguageisdefinedastheonlytoolincommunication.Used,sentandreceivedinstantly

14 Keeptheleadershipfromstarttotheveryend.Butthemusiciansisinsomeextentabletooverruletheconductoriftheydon’tfindhimcapableatconductingtheconcert

Anotherteammembermayclaimtheleadershipintheprocess

15 Cannotuseverbalcommunicationattheconcert Verbalprescriptionsarestandardincommunication

Table2:Aparallelizationbetweentheconductorandteamleader’sfunction

112

TheconductorsfocusAppearanceimmediate,intuitivedecodingAppearsconfidentAppearseasilyreadableAppearscomfortableProfessionallyfocused(Authority,engaged)Leadership–ShowsPowerLeadership–Isdemanding(oppositecaring)Presencetothemoment(Intense)Presencetothemoment(listening)Presencetothemoment(payingattention)AbsorbedinhisprojectPhysique,exactobservations:controlofbodyAppearscalmAppearsrelaxedSeekingeyecontactRelaxeduseoffacialexpressionsRelaxeduseofEyesRelaxeduseofEyebrowsRelaxeduseofsmilesShouldersbackRaisedchinIncontrolofhandsIncontroloflegsDisturbingelements,exactobservationsVeryindividualcharacteristics.Examples:Fixedgrin.Unintendedsmile.Lickingtheirlips.Veryraisedeyebrows.Awkwardlocationofhand.Noddinghishead.Leaningviolentlyforward.Touchinghisface.Scratchesontheneck,showingstressanddiscomfort,etc.

Table3

113

Musicalexercises,course-dayoneExercise Content Objectives CommentInitiateasound(classandsimulationroom)

Traineesmustinturngettheotherstosing‘ah’initiatedbyasimpleConductinggesture

Calmness,authorityandrequireanaction.

Thisexercisewasreplacedbyconducting‘FrereJacques’aftertwocourses

Beatingabasic4/4pattern(musicroom)

Asimpleconductingexercisethatfocusesonthecorrectmovementsofhands

Necessarypreparationforthefollowingexercise.Anapparentlysimplebutinfactdifficultobstacle

Abigobstacle,requiresagreatattention

‘FrereJaques’(musicroom)

Conductingachoir Authority,presencetothemoment,‘firstmeeting’andnon-verbalcommunication

Obstacles,disorientingdilemma,discomfort,stressandanxiety

GhettoBlasterorchestra,(classroom)

ConductaGhettoBlasterorchestra,improvisingw.threesounds

Leadingamultidisciplinaryteam.Authority,presencetothemoment,appearanceandcommunicatingwithoutwords.

Experiencetheintensityinthecommunicationwhenconductinganorchestra‘achievingastateoftrance’

Musicalexercises,course-daytwoGhettoBlasterorchestra,(classroom)

ConductaGhettoBlasterorchestra,improvisingwithtensounds

Leadingamultidisciplinaryteam.Authority,presencetothemoment,appearanceandcommunicatingwithoutwords.

Experiencetheintensityinthecommunicationwhenconductinganorchestra‘achievingastateoftrance’

Mastery,(classroom))

Theconductortellsandshows

Experiencethestrongauthority,presencetothemoment,appearanceandnonverbalcommunicationfromaprofessionalconductor.

Thepowerofeye-contactanduseofempathy

GhettoBlasterorchestra(classroom)

ConductaGhettoBlasterorchestra:followascore

Leadingacomplexsituationfollowingacomposedscore.Aparalleltoaclinicalalgorithm.Adifficultobstacle

Obstacle,disorientingdilemma,discomfort.Leadershipinanextremelycomplicatedexercise.

CPRalgorithmwithsoundsonGhettoBlasters(classroom)

SoundswerecomposedtoillustratethedifferenttaskstobeperformedataCPRemergency.TheyweretobeperformedaccordingtotheCPRalgorithm

Transfertotheclinic

Thisexercisewasremovedfromthecourseaftertwocourse-days.

CPRsimulation(Simulationroom)

PerformafullCPRsimulationasteamleaderwithamedicalteam

Transferofthelearnedleadershipcompetenciestotheclinic

Itwasaproblemtrainingleadershipandmedicalalgorithmssimultaneously

Emergency,course-daythreePersonalvideos Watchingvideosfromthe

firstcourse-dayReflectingonthecourseandthetopicsandownperformance

Majorimpactontheparticipants

Emergencysimulation(Simulationroom)

Performafullemergencysimulationasteamleader

Incl.todiagnose.Apossibilityforcalling‘time-out’ifproblemsoccur

Mostparticipantsexperiencedthissimulationasregularacutetraining

Table4

114

Illustration1.Beatingtimelikeaconductor:abasicfour-beatpattern

Learningenvironment Video:Table12 QuoteLaughter Theparticipantisenjoyingthe

course:laughing,dancing,playing,actingsillyetc.

Video1,3&5 Table10:‘Learningenvironment’and‘Non-verbal,grin/smile

Reflection Inordertoaddressanxietyitisessentialtocreateasafelearningenvironment.

Table9and9:Allcommentsexpressareflection.Bothduringthecoursesandafterthecourses

Table5

Pedagogics Video:Table12 QuoteTrance

Itwasimportanttogivetheparticipantsafeelingoftheintensecommunicationwhenleadinganorchestranon-verbally.

Video6,7,and9 Table9:TranceTable10:Trance

Apprenticeship/’Straighton’feedback

Aconductorisusuallytrainedthroughapprenticeshipanditisthereforenaturalthatthislearningmethodisappliedtothiscourse.

Video1,2,3,and8 Table9:ApprenticeshipTable10:Apprenticeship

Transformation Thepurposeofthecourseistoprovideparticipantswithtoolstoactconvincinglyandcalminstressfulandunpredictablesituations,thatis:apossibilitytobeabletochangeofbehaviour.

Video8,plusprogressanddevelopmentfromvideo4to9

Table9:TransformationTable10:Transformation

Table6

Learninggoals–theconductor’sfocus Video:Table12 QuotePhysics

Appear/look/stand,arm,back,body–posture/body–language/body–position,chest,chin,ear,face/mimic,hands,head,mouth,shoulder,straight,upright

Video3 Table9:PhysicsTable10:Apprenticeship/Non-verbalcommunicationandPhysicsTable11:Physics

Authority Authority,calm,command,confident,control,credible,decisive,demand,determines,issuingorders,leadership,manage,overview,power,

Video9 Table9:AuthorityTable10:Authority

115

relaxed,safe,super,sureEye-contact Eyecontact,eyebrows,eye,gaze,

lookVideo2,6,7,8,and9 Table9:Eyecontact

Table10:EyecontactPresencetothemoment

Attentive,concentrated,conscious,empathy,focus,hear,informed,listening,present

Video6,7and9 Table9:PresencetothemomentTable10:Presencetothemoment

Responsiveness Feel,look/see,perceive,seem,sense/tell

Video6,7and9 Table9:Responsiveness

Stress&obstacles

Chaos,difficult,disturb,doubt,personallimits,nervous,panic,pressure,pulse,stress,tense/strain,uncertain

Video1,4and8 Table9:Stress&obstaclesTable10:Stress&obstaclesTable11:Stress&obstacles

Communication Clear,communication,contact,message,react,respond,signal,vague

Video6,7and9 Table9:CommunicationTable10:Communication

Non-Verbal:Grin/Smile

Smile/Grinexpressing:nervousreaction,kindness,proudness,appreciation,embarrassment,compassion,sillinessorconfusion

Video1,3,4,5and6 Table9:Non-Verbal:Grin/SmileTable10:Non-Verbal:Grin/Smile

Engagement Absorbed,busy,engaged/enthusiastic,excited,happy/lookingforwardto.Intense,shine,thrilled

Video1,6,7,and9 Table9:Engagement

Table7

Additionalfindingsrevealedbyanalysingthedata.Lessonslearnedfromthecourse

Video/figure Quote

Trainingalgorithmsandleadership

Trainingalgorithmsisaboutacquiringknowledgeinastrained,‘slower,moredeliberateandeffortfulformofthinking’whichrequiresallattentionandfocus.

Table12:video10 Table10:Trainingalgorithmsandleadership

Whentolearn Threeparticipantsstatedthatonlywhenmedicalknowledgeandknowledgeofalgorithmshavebeenacquireditispossibletodealwithleadership.

Table10:Whentolearn

Relevance Morethan80%oftheparticipantsstatedthattheywouldimplementthenewideasintheirdailyworktoahighextent.Therestoftheparticipantsstatedthattheywouldimplementthenewideasintheirdailyworktosomeextent.

Figure1and2 Table10:Relevance

Missingangleattheuniversity

Severalparticipantsmentionedthatthecontentofthecoursehadanimportantobjectivewhichwaslackinginteachingattheuniversity.

Table10:Missingangleattheuniversity

Generallyapplicable Itwasmentionedthatthesubjectisrelevanttoeducationalcontexts,clinics,collaborationingeneral,daytodaywork,doctorswork,instructcross-fit,swimminglessons,publicspeakingandattendingoralexam.

Table10:Generallyapplicable

Table8

116

Table9Thetablecontainsselectedcitationsfromparticipantsduringthecourse.Intheleftcolumnkeythemesisgiven,intherightcolumncitationsfromtheparticipantsisgiven.S=Student,R=Resident,BS=‘Blinded’Student,CS=Consultant,C=ConductorLearningenvironment[Video1,2,3and5]

Laughterisnotaspokenword,butaregisteredanddescribedeventthatoccursfrequentlyonthecoursedays.(Laugh,grin,fun,smile)Thisindicatesthatthecourseparticipantsfeelcomfortableandsafeatthecourses.Reflectionisfrequentlytakingplaceatthecourse–whichindicatesthatparticipantsfeelcomfortabletospeakupandsharethoughtsonthelearning.

Trance[Video6,7,and9]

[S1]:...Ialsofeltcompletelyinmyownworld.Itwasareallyamazingfeeling.[S1]:It’sjustreallycoolwhenyougetthatfeeling.Thatkindof‘flow’whereyoucanmanageeverything.

Apprentice-ship/RoleModel

[S7]toConductor:Youarecompletelyoffthescale…ifthisisakindofscatterplotthenwearehere–andyouareallthewayuphere.It’samazing![S13]toConductor:Well,therearelotsofthingsIcan’tsee.Withoutfindingitoutfromyou…Ireckon…

Transfor-mation[Video8,plusdevelop-mentfromvideo4to9]

[S10]:Yes,it’scrazy![CS]:It’sreallyamazingwhathashappenedsincewhenyoufirstwalkedthroughthatdoor,whenwestarted[S10]:Yeah...(scrunchinghereyebrowsandshakinghishead)...two[CS]and[S10]together:...hoursago![CS]:Yeah![R3]:Ijustthink,youknow,itwasjustsogreattoseeyouguys,or–IsupposeIhavetriedmyselfaswell–butanyway,justtobeabletosee!Howmuchyouhaveallprogressedwiththiscourse.I’mjustsatherethinkingshit,wow!

Physics[Video3]

[R3]:YoucanreallytellthedifferencewhenyoustraightenyourselfupConductor:I’mtryingtofind…howaboutthisword?Tryingtogiveyouakindofbodily”pointzero”…Imeanwhereyouareinbalance.Andafteryouhavethis”pointzero”–that’swhenyoucanstarttoaddasmileor…angerorempathyorwhatever,butwithabodyyouareabletocontrol.

Authority[Video9]

[S5]to[S10]:Itreallylookedlikeyouwereincontrolandyouweretotallyconfident…[C]:Youwereinthemomentnow.[CS]:Anditwasyouthatledmealltheway.[S1]:Ialsothinkitwas…itwasreallycool!You

findthiskindofcalmness.Thatyoucanjustbepresent,youknow?That’swhatithastobelikewhenyoubecomeadoctor.

Eyecontact[Video2,6,7,8,and9]

[S5]:(makesatunnelshapewithherhandsbetweenConductor’sfaceandher’s)Youalmostfeltthatyougotkindofa…tunnel(mimesthe”tunnel”eagerly)andthatyoulookandhavethis”connection”.[C]:We’reBOTHgonnafigurethisout…‘YouandI’[S1].Thereisnodoubtaboutit.Youmakeeyecontact[S1]:Iagree.Iwasinnodoubtthatyouwereincontrolofus.Youlookedreallyintenselyatus![R3]:Yeah,itwasasifbefore,peoplewerejustlookingforthesakeoflooking.Butnow!(Pointsathereyes)You’relookingatus!

Presencetothemoment[Video6,7,and9]

[S1]:ThatwasalsowhyIjustwantedtolistentohowitsounded.Youknow,juststandingtherelisteningtoallthedifferentpartscomingtogether.[R1]to[R2]:Youwerereally”likethis”,”likethis”…everytimeyoumadeachangeyoujustdidthis…withalittlenodwithyourheadlikethis…andthen,”wow,NOWitsoundsgood!”

Responsive-ness[Video6,7,and9]

[R5]:IthinkIgotalotoutofit,inthesensethatitwasclearthatitwasyoumakingthedecisions,butyouwerealsoveryempathetic.[R4]to[R3]:youreyeswereveryintense…so…therewasnodoubtingwhatyouwanted…[S1]:ButIcanreallysenseyourenergy,especiallyyou(Conductor).Itwasawesome!

Stress&challenges[Video1,4,and8]

[R7]:It’schaotic,Ican’tfindmywayandthenIgetstressed.Thenitbecomesevenmorechaotic![S10]:It’sacrazychallenge!

Communi-cation[Video6,7,and9]

[S3]:YeahwellIfeltthatwhenItookyouingroupsoftwo,therewasn’tanydoubtwhatyoutwowantedand…[CS]:Inrealityyoucommunicatedagreatdealwithoutsayingaword.

Non-VerbalGrin/Smile[video1,3,4,5,and6

[C]:Soifyoushowasillylaugh,they’llthink:”Well,whythatsillylaugh?”[S3]:Phew!Idon’thaverhythm!(grinning,wavingherhands)

Engagement[Video1,6,7,and9]

[C]:Yougiveoutthisamazingpresenceand:nowlet’sdothis!![R6]overjoyed:Ican’twait![C]:Yes,andwhathappensisyoureyesjustclosedown.Youarenotpresentatall[S1]:Yes,Icanfeelithappening[C]:Youarenotinthisroomatall

117

Table10Thetablecontainsselectedcitationsfromparticipantsafterthecourse.Intheleftcolumnkeythemesisgiven,intherightcolumncitationsfromtheparticipantsisgiven.S=Student,D=Resident,BS=‘Blinded’Student,CS=Consultant,C=ConductorLearningenvironment[Video2][Video5]

[S6],14daysafter:FrereJacqueswasagreatwaytostartthecourse,anditwascarriedoutinawaythatmadeito.k.tolaughatourselvesandateachother.Atthesametimeyoumanagedtokeepitseriousenoughthatitdidn’tbecomenonsensical.Wecoulduselaughtertomakeiteasiertogetoutsideourcomfortzones,butwithoutaclearpurposethewholethingwouldhavecollapsed.Idon’tknowhowyoudidit,butyoudeservecreditforit.[S9],onemonthafter:…creatingasafeandsecurelearningenvironmentinthespaceofafewminutes,whichmakesforasteeplearningcurve.Especiallywhenthefirsttaskissomethingasoutoftheordinaryasconductingachoir.[S11],threemonthsafter:Youwereallowedto“failinYourappearance”.[BS1]:Itwasreallygreatthatyouaskedthestudentswhattheywereexperiencingandletothersgivecritique.Tureissometimesabitquickoffthemarktosaywhathethinksandexperiences.Thissometimesaffectswhattheotherssayandsometimesitfeelslikethestudentsjustagreewithhiminsteadofsayingwhattheythink.

Trance[Video6,7,and9]

[BS2]:[S5]lookswithhermouthwideopen,impressed.Theothersaredeepinfocus…Thelightsgoout,nobodyreactsThemusicintensifies,[S5]smiles,[S10]looksquicklytooneside…Everyoneisfullyfocused–trance-like.Conductorendsthesession:Isn’tthisfun?

Apprentice-ship/’Straighton’feedback[Video1,2,3and8]

[S11],threemonthsafter:Unbelievablygoodteaching!ReallygreatthatTuresaidwhathethoughtyoucoulddobetter,straighttothepointwithoutbeatingaboutthebush.Solid,clearandgoodteaching![S12],sixmonthsafter:[wasfeedbackfromtheinstructoranyhelp?]Yestoagreatextent.Especiallywhenyoufeltthatthefeedbackfromtheinstructorwasspot-onandIthinkthiswasthecasetoaverylargedegree.[S9],twomonthsafter:Solidlearning!Wewerereallyallowedtoworkwithourexpressiveness.

Apprentice-ship/Non-verbalCommuni-cation[Video1,2,3,and8]

[S13],twomonthsafter:Duringtheconductingexercisesitwasreallyusefultogetfeedbackonourposture,mimicandgesture.Tobemadeawareofwhatsignalsyousendnon-stop,whetheryouwanttoornot.[S9],twomonthsafter:Therewaslotsoflearninghere.Especiallyasyouweregoodtocatchthesmalldetailsthattheuntrainedeye

doesn’tsee,butreactstoanyway.”Trans-formation[Video8,plusprogressfromvideo4to9]

[S10],fivemonthsafter:Allthreeofusprogressedagreatdealinashortspaceoftime,anditwasincrediblyfascinating.[S6],dayone:Ilearnedsomegeneralthingsandthingsaboutmyself.[S20],onemonthafter:…it’sinterestingthattheskillswelearnfromyouarealreadyinthebackofourmindreadytouseonlyafterashorttime

Physics[Video3]

[S11]threemonthsafter:IthinkIhavegoodcontroloverhowIstandandmovemyarms,butmyfacegoesamokwithoutmenoticingit;itclearlymakesmeappearveryuncertain..

Authority[Video9]

[S19],sixmonthsafter:Yourexpressionbecomesmoreauthoritativeafteryougetfeedbackandyougiveoffmore”leader-charisma”.[Nurse2],dayone:Itisagoodthingtobeabletoappearauthoritative.Beawareofthis

Eyecontact[Video2,6,7,8,and9]

[S8],dayone:Eyecontactisimportant,therebygivingpossibilityfornon-verbalorders[S18],dagone:Ibecameveryawareofeyecontactandrelaxedbodylanguage

Presencetothemoment[Video6,7and9]

[S7],threemonthsafter:Iwasquiteexcitedabouttrainingwhatitistorelaxandrestwithinyourselfandyourbodywhenyouarestandinginfrontofagroupofhighlyqualifiedstrangers.Keepingcalm,leadershipandtheupperhandmentally,andlettingitshowinyourbodylanguage.Itreallycrossedmypersonalboundariesbutitwasveryuseful!

Stress&challenges[Video1,4,and8]

[BS2]:Myexperiencewasthatitwasareallygoodenvironmenttolearnin.Theywereforcedcompletelyoutoftheircomfortzoneandwere”brokendown”,inthesensethattheywereinasituationtheyhadneverbeeninbefore,andhadthereforenoestablishedstrategiestheycouldusetodealwiththechallenge.[S6],fivemonthsafter:Inanycase,itfeltabitliketurningpartofyourselfinsideout,standinginfrontofallofyou.

Communi-cation[Video6,7,and9]

[S10],fivemonthsafter:Itwasveryimpressivetoexperiencehowmuchyoucansaywithoutwords,justwithbodylanguageandmimics.[NURSE2],dayone:Incrediblewhatyoucanmanagewithoutlanguage

Non-VerbalGrin/Smile[video1,3,4,5,and6

[S6],14daysafter:Wecoulduselaughtertomakeiteasiertogetoutsideourcomfortzones

Training

[S14],sixmonthsafter:Maybetojumpfromthe

118

algorithmsandleadership[Video10]

exercisestothecardiacarrestscenariowasalittlesudden…?Inanycaseyouforgeteverythingyouhavelearnedwhenyouarestandinginfrontofthatbed.[S12],sixmonthsafter:Butabitdifficulttotransfersomeofthesmalldetailswhenyouarenot100percentcertainofthecardiacarrestalgorithm.

Whentolearn

[S9],twomonthsafter:Istillthinkthatitshouldbecombinedwithin-depthknowledgeofthecardiacarrestalgorithm,aspartofadoctor’sconfidenceandbodylanguageisconnectedwithhavingtheirknowledgeinplace.However,whenthisknowledgeisacquired,thereisalottobegainedfromthistypeofmusictraining,asyouarestrippingthedoctorofhisorherknowledgeandputtinghiminanenvironmentwhereonlytheirbodylanguagecounts.[S3],onemonthafter:Myonlycriticismwouldbethatasayoungerdoctor/medicinestudent,youhavetoomuchfocusonyourprofessionalknowledgeandofcourseyouprioritisethiswhenyouareinanemergencysituation,andunfortunatelyyoudon’thaveenoughresourcestothinkaboutandmakeuseofthenon-verbalcommunicationtraining.Ontheotherhand,itcouldbeanappropriatecourseformoreexperienceddoctorsthathavetheirknowledgeandexperienceinplace-theywouldhavetheresourcesneededtomakeuseofthenon-verbalcommunicationtraining.

Relevance

[BS2]:Anotherimportantthingisthatyoucanbeverybrightintermsofyourmedicalknowledge,butifyoudon’tmanagetocommunicateinawaythatgetsthroughtopeople,yourknowledgeiseffectivelyreducedtonothing.Inotherwords,beingadoctorisaboutalotmorethanbeingabletorememberwhatisinthetextbooks.[S6],dayone:ItwasmuchbetterthanwhatIexpected.Averypositiveexperience.Beatsothercommunicationcoursesmanytimesover[S13],twomonthsafter:Trainingintakingdecisionswhileeverybody’seyesareonyouishighlyrelevantfordoctorsandmedicalstudents.[S5],fourmonthsafter:…thenervousnessandmyreactionwerecompletelythesame.AndthewayIhavetolearntotackleitisalsothesame,regardlessofwhetherIamwithapatientinaward,orinaclassroomwithmedicalstudents.

Missingangleattheuniversity

[S7],dayone:Crazilyimportantaspectofadoctor’swork,whichIneverrealizedwasmissingfromourexistingeducationbeforetoday.[S3]dayone:Veryimportantlearningaroundwhatitistobeateamleader,whichyouneverthinkaboutonadailybasisorreceiveinstructioninitwhilsttraining.[S15]dayone:Superexcitingandveryrelevantinrelationtothefuturejob.Asubjectthatismissinginourtraining.[R1],twomonthsafter:Atthesametimeitisaroleinwhichyourarelyreceiveformalteachingduringtraining.[S16],onemonthafter:IngeneralareallygreatcoursewhichIhopebecomesanobligatorypartofthetraining.Ithinkeveryonecouldbenefitfromit!

Generallyapplicable

[NURSE1]:’Everybodycouldneeditintheirday-to-daywork’[S17]dayone:Canbeusedinateachingcontext,inaclinic,andmanymoresituations[S7],threemonthsafter:Unfortunately,Ihaven’thadtheopportunitytotryoutthesenewlylearnedskillsintheclinicyet.ButIinstructalittlecross-fitteam,andIcanreallyuseitthere![S4]oneweekafter:Also,haveyouplannedanymorecoursesformedicinestudents?Ihaveamateortwowhothinkthatsoundsinteresting.’

Table11Scepticism.D=Resident,BS=‘Blinded’StudentStressandobstacles

[BS1]:ThefirstgamewithFrereJaquesfocusesonsomethingthatistootechnicallycomplicatedinrelationtoamedicalbenefit[R2],twomonthsafter:IsometimesfeltYoufocusedonsomedetailsthatwereindifferenttousasdoctors.I.e.IthinktoomuchtimewasspentonthecorrectfactortoconductFrereJaques

Physics

[R2],twomonthsafter:Istillthinkthattoomuchemphasiswasplacedonnothavingtosmile/shouldlookveryserious.

119

11videos(hyperlinks).Allvideosgivesanimpressionofasafelearningenvironmentandshowsenjoyinglaughter1.Trainingbeatingafourbeatpatternyoutu.be/WW898db57Zw

Duration:0:38.Achangeofsetting:fourmaleandfourfemaleparticipantsaretrainingbeatingabasicfour-beatscheme.Focusedattention,handlingadifficultobstacle.Cohesionontheteam.Theme:Stressandobstacles

2.Apprenticeshipyoutu.be/EnHlustj3F0

Duration:1:50.Theconductorexplainsandshowscarefornineparticipantsinordertomaketheindividualparticipantsobtainafeelofcalmnesswhenperformingasaleader.Theconductorstandsasarolemodel.Themes:Apprenticeship,Eye-contact,Presencetothemoment,Responsiveness,Communication,Non-verbal,Engagement.

3.‘Straighton’Feedbackyoutu.be/fwbgfTNf_e8

Duration:2:04.13participantsreceivevery’Straighton’personalfeedbackfromtheconductorwhogoestothelimit.Themes:Apprenticeship/‘Straighton’feedback,Physics,Authority,Stressandobstacles,Communication,Non-verbal.

4.Discomfort&Obstaclesyoutu.be/UmIFk9VXuCQ

Duration:2:12.21participantsshowdiscomfort:shaketheirheads,laughnervously,scratchtheirneck,showrollingeyes,hidethefaceintheirhands,smileapologeticetc.Themes:Stressandobstacles,non-verbal

5.Asafeenvironmentyoutu.be/_ZmUYjI-T4E

Duration:2:24.19participantsshowtheyfeelsafe,foolaroundandlaugh.Femaleparticipantoftendoesthe‘shimmy’,smalldancemovements,playswithahatetc.Themes:Safelearningenvironment

6.Theintensityincommunicationwhenconductingyoutu.be/3sPmMQCne_E

Duration:0:29.Fourparticipantsconductteam.Theyareshowingexcellentleadershipandareina‘stateofTrance’withtheirteam.Themes:Trance,Authority,Eye-contact,Presencetothemoment,Responsiveness,Communication,Non-verbal,Engagement.

7.Achievingastateofflowyoutu.be/KcyZf3_QfMk

Duration:1:12.Oneparticipantconductscompletelyabsorbedformorethantenminutes.Theteam(orchestra)isn’tmoving,fullyfocusedontheconductor.Lightgoesoutat0:20(2:37)butnobodypaysattentiontothis.Themes:Trance,Authority,Eye-contact,Presencetothemoment,Responsiveness,Communication,Non-verbal,Engagement

8.ATransformationyoutu.be/GW7XPdnf-EU

Duration:6:54.Arealtransformation(Englishsubtitles).Showshowthetrainers‘getsundertheskin’oftheparticipants.Showsthereflectiononthelearningandthesupportfromtheotherparticipants.Theparticipantinfocusgoesfromsaying“Mypalmsaretotallysweaty”and“Ithinkit’shorrible”tosay:“Iwisheveryonecouldtrythis”and“Itisveryimpressive”.Themes:Trance,Transformation,Authority,Eye-contact,Presencetothemoment,Responsiveness,Stressandobstacles,Communication,Non-verbal,Engagement

9.EndPointyoutu.be/IQtMa0VJgjw

Duration:1:55.16participantsshowingexcellentleadershipwhenconducting.Incontroloftheirbody,attentivetotheproject,confident,absorbedandinfullcontrolofthesituation.Themes:Trance,Authority,Eye-contact,Presencetothemoment,Responsiveness,Communication,Non-verbal,Engagement

10.ABreakdownyoutu.be/f5BiNFL_zDU

Duration:1:21.Aparticipantbreakdown.Afterattendingthetwocourse-daysconcerningleadershipshetriestotransferthelearnedskillstotheclinicinamedicalacutesimulation.Whenconfrontedwithherlackofmedicalknowledgesheforgetsalltrainedleadershipskillsandlosescontrolofthesituation.Themes:Physics,Stressandobstacles,Non-verbal,Trainingalgorithmsandleadership.

11.Uniqueindividualsyoutu.be/Bdok4ArYXcM

Everyparticipantbringsintheirownexperiences,perceptionsandemotions

Table12

https://youtu.be/WW898db57Zw

https://youtu.be/WW898db57Zw

https://youtu.be/EnHlustj3F0

https://youtu.be/fwbgfTNf_e8

https://youtu.be/UmIFk9VXuCQ

https://youtu.be/_ZmUYjI-T4E

https://youtu.be/3sPmMQCne_E

https://youtu.be/3sPmMQCne_E

https://youtu.be/KcyZf3_QfMk

https://youtu.be/GW7XPdnf-EU

https://youtu.be/IQtMa0VJgjw

https://youtu.be/f5BiNFL_zDU

https://youtu.be/Bdok4ArYXcM

120

Figure2.DidIgetnewideas?n=61participants.Answersfromcoursedays1and2,atotalofn=96answers

Figure3.WillIapplyinformationandideas?n=61participants.Answersfromcoursedays1and2,atotalofn=96answers

0

20

40

60

80

100

Very high

Some A little None

Perc

ent

New knowledge and ideas

All participants Students

Young Doctors Nurses

0

20

40

60

80

100

Very high

Some A little None

Perc

ent

Influence on behaviour

All participants Students

Young Doctors Nurses

121

AppendixI:

AppendixII:

Videosurveysenttothestudentsalongwithfour-eightvideoclipsshowingtheindividualparticipant’sperformanceasteamleaderatthetwocoursedaysAboutthevideosusabilityasalearninginstrumentWhichofthevideosmadeanimpressiononyouandwhy?Doyouhavecommentsontheindividualvideos?Doyouwanttoreturnandgobacktothevideos?Aboutthelearningmethod,whendidyouexperiencelearningInthemoreclassicalteachingsituations?Whenyouwereinstructedyourself?Whenyouobservedothersbeinginstructed?Intheimmediatereactionsoftheotherswhenyoureceivedinstruction?Wasthepersonalfeedbackfromtheinstructorapplicable?Wastheconversationsbetweenthecourseparticipantsrewarding?Wasitusefulthattheinstructorscameclosetoyou?Wasthereasafeenvironmentontheteam?Wasiteasytobeheard?Weretheexercisesrelevanttoyourperformanceasteamleaderinthecardiacarrestscenario?Doyouhavefurthercommentsaboutyourfirstreviewafterwatchingthevideos?

122

APPENDIX

Abstractto“TeamManagement-Canmusiccontributetobetterunderstanding?”

AIM:totrainmedicalstudentstousenon-verbalcommunicationliketheconductorofanorchestra.

Theoverallgoalwastoimprovecommunicationinmedicalteams.

METHOD:inordertoexplaintothestudentshowtotakecontrolasateamleader,communicate

moreeffectivelyandworkwellinateam,theconductordescribedtheskillsrequiredtoconductan

orchestra.Heexplainedhowtouseeyecontact,bodylanguageandgesturesandsetthestudents

twomusicalexercisestoperformandthengaveindividualfeedbackontheirperformance.These

skillswerethentransferredtoasimulatedmedicalemergencysituationinwhicheverystudentwas

giventheopportunitytoplaytheteamleader.

RESULTS:thestudentsfoundtheexperienceunexpectedlyusefulasitenabledthemtofocusonthe

skillsrequiredofaleaderandthisresultedingreaterself-awareness,enhancedself-confidenceand

bettercommunication.

CONCLUSION:medicalstudentscanbenefitgreatlyfromapplyingaconductor'sskillstoamedical

situation:theirleadershipability,degreeofcooperationandprofessionalcompetenceare

considerablyenhanced48

ONLINEAPPENDIX

Articleone

AppendixII:Foundopinionsaboutleadershipinemergenciesandviewsontheidentifiedleadership

measurementtoolsinthesystematicreview.Comprehensiveresultofqualitativecontentanalysis

(conventional):turelarsen.dk/Appendix/TER-AppendixII.pdf

Articletwo

AppendixI:Opinions,attitudes,experiencesorviewstoidentifyanychallengesorbarrierswhich

leadershiptrainingforresidentsinemergenciesneedstoaddress.Identifiedconsensusonwhat

characterizesagoodclinicalteamleader:learninggoals.Comprehensiveresultofqualitative

contentanalysis(directed):turelarsen.dk/Appendix/B-AppendixI.pdf

http://turelarsen.dk/Appendix/TER-AppendixII.pdf

http://turelarsen.dk/Appendix/B-AppendixI.pdf

123

Articlethree

AppendixIII:Commentsmadebytheparticipantsduringthecoursesillustratingthethemesfound.

Comprehensiveresultofqualitativecontentanalysis:turelarsen.dk/Appendix/CET-AppendixIII.pdf

AppendixIV:Commentsmadebytheparticipantsafterthecoursesillustratingthethemesfound.

Comprehensiveresultofqualitativecontentanalysis:turelarsen.dk/Appendix/CET-AppendixIV.pdf

11editedvideosshowingresultsfromqualitativecontentanalysis:

turelarsen.dk/Appendix/11videos.pdf

Logfromthecourse:turelarsen.dk/Appendix/Log2015.pdf

Supplementarymaterial

Beforeandaftervideos:turelarsen.dk/Appendix/BA-videos.pdf

http://turelarsen.dk/Appendix/CET-AppendixIII.pdf

http://turelarsen.dk/Appendix/CET-AppendixIV.pdf

http://turelarsen.dk/Appendix/11 videos.pdf

http://turelarsen.dk/Appendix/Log 2015.pdf

http://turelarsen.dk/Appendix/BA-videos.pdf

124

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