Table 1 Facilitators and barriers, linked to the theoretical domains framework, illustrated by qualitative and quantitative results
TDF domain | Factors affecting implementation | Facilitator (F) Barrier (B) | Sources Team Survey data n = 86 Team interview data n = 15 Patient outcome data n = 2389 | Questions/sample quote/patient outcome data | Result | ||||
|---|---|---|---|---|---|---|---|---|---|
Knowledge (an awareness of the existence of something) | Not knowing what to do to activate a major trauma call | B | Team survey (Descriptive statistics) | Do you know how to activate a major trauma call? | |||||
a. All the time | 66.3% (n = 53) | ||||||||
b. Sometimes | 3.5% (n = 4) | ||||||||
c. Never | 30.2% (n = 26) | ||||||||
Unaware of team members roles | B | Team survey (Descriptive statistics) | Are you aware of other team member’s activities during a major trauma? | ||||||
a. All the time | 72.1% (n = 62) | ||||||||
b. Sometimes | 25.6% (n = 22) | ||||||||
c. Never | 2.3% (n = 2.3) | ||||||||
Knowledge of trauma system | F | Team interview (Thematic analysis) | Everyone now knows how the system works and where they fit into it | ||||||
Skills (an ability or proficiency required through practice) | Non-technical skill of closed loop communication not used | B | Team survey (Descriptive statistics) | Team members practise closed loop communication | |||||
a. All the time | 59.3% (n = 51) | ||||||||
b. Sometimes | 37.2% (n = 32) | ||||||||
c. Never | 3.5% (n = 3) | ||||||||
Multidisciplinary training is needed if you work clinically in a multidisciplinary team | F | Team interview (Thematic analysis) | There is no point in doctors and nurses’ training separately as we are treating together | ||||||
Trauma Team Training teaches non-technical skills | F | Team interview (Thematic analysis) | I found the teaching of the non-technical skills most beneficial | ||||||
The skills learnt in simulation trauma team training are not used in real life resuscitation | B | Team interview (Thematic analysis) | The simulation environment is not realistic as it does not deal with the reality of multiple traumas and the impact this has on teamwork | ||||||
Social/professional role and identity (a coherent set of behaviours and displayed social qualities of an individual in a social or work setting) | Team hierarchy | B | Team interview (Thematic analysis) | I think we have a power gradient and if we could break this down I think our team would function better | |||||
Professional disharmony | B | Team interview (Thematic analysis) | Some doctors rather their opinion over a nurse no matter how much you train and work with them | ||||||
Professional role unclear | B | Trauma team members know each other’s roles and responsibilities | |||||||
a. All the time | 69.6% (n = 60) | ||||||||
b. Sometimes | 26.7% (n = 23) | ||||||||
c. Never | 3.5% (n = 3) | ||||||||
Beliefs about capabilities (professional confidence, beliefs, self-confidence, self-esteem, empowerment) | Perception that clinical judgement is better than cognitive aids in resuscitation practice | B | Team survey (Descriptive statistics) | Team members use cognitive aids to assist trauma management | |||||
a. All the time | 53.5% (n = 46) | ||||||||
b. Sometimes | 38.4% (n = 33) | ||||||||
c. Never | 8.1% (n = 7) | ||||||||
Team members are empowered to speak up | F | Team interview (Thematic analysis) | Everyone seems comfortable to ask for clarification or question what is going on | ||||||
Belief about consequences (belief, outcome expectancies, consequences) | Standardised operating procedures assist trauma service delivery | F | Team survey (Descriptive statistics) | Prior planning and preparation assist the team to manage a major trauma. | |||||
a. All the time | 91.9% (n = 77) | ||||||||
b. Sometimes | 5.8% (n = 5) | ||||||||
c. Never | 2.3% (n = 2) | ||||||||
Standardising trauma care optimises team performance. | F | Team interview (Thematic analysis) | Everyone knowing their roles made the resus run smoothly and the team were faster to assess and treat the patient. | ||||||
Leader-follower synergy promotes team work | F | Team interview (Thematic analysis) | You need to include all parties as a team leader by themselves means nothing | ||||||
Motivation and goals (mental representations of outcomes or end states that an individual wants to achieve, e.g. intention, goals, target setting, action planning, goal priority) | The team does not know the management plan as it evolves. | B | Team survey (Descriptive statistics) | The team leader updates the team by recapping the treatment plan | |||||
a. All the time | 60.5% (n = 52) | ||||||||
b. Sometimes | 37.2% (n = 32) | ||||||||
c. Never | 2.3% (n = 2 | ||||||||
Shared mental models are used by the trauma team. | F | Team interview (Thematic analysis) | The treatment goal is established and we all work to achieve that goal | ||||||
Time to critical operation and mortality was reduced | F | Patient outcome data (Pre-post study) | ED to Critical Operation (hrs) | n | Pre Median (IQR) | n | Post Median (IQR) | ||
141 | 2.63 (1.23–5.12) | 149 | 0.55 (0.22–1.27) | ||||||
Mortality: | % | % | |||||||
Died | 35 | 24.80% | 25 | 16.80% | |||||
Survived | 106 | 75.20% | 124 | 83.20% | |||||
Memory, attention and decision processes (decision-making, cognitive overload, attention control, memory) | Shared decision-making | F | Team survey (Descriptive statistics) | Decisions are made with input and shared knowledge from team member | |||||
a. All the time | 72.1% (n = 62) | ||||||||
b. Sometimes | 23.3% (n = 20) | ||||||||
c. Never | 4.7% (n = 4) | ||||||||
Collaboration is needed to enhanced team decision-making | B | Team interview (Thematic analysis) | It was one of the most poorly managed traumas and I was so upset because they would not listen to us and made the wrong decision | ||||||
Environmental context and resources (environmental stressor, resources, salient events, organisational culture) | Environment is prepared | F | Team survey (Descriptive statistics) | Is the resuscitation equipment checked and assembled as needed? | |||||
a. All the time | 90.7% (n = 78) | ||||||||
b. Sometimes | 7.0% (n = 6) | ||||||||
c. Never | 2.3% (n = 2 | ||||||||
Relevant resources are notified | F | Team survey (Descriptive statistics) | Are relevant support staff and services notified (radiology, blood bank) notified? | ||||||
a. All the time | 80.2% (n = 69) | ||||||||
b. Sometimes | 17.5% (n = 15) | ||||||||
c. Never | 2.3% (n = 2) | ||||||||
Noise and chaos in a resuscitation impacts patient safety | B | Team interview (Thematic analysis) | When it’s a big mess with too many people and too much noise, we are too slow and you end up missing the boat with this patient | ||||||
Trauma team has constantly changing membership | B | Team interview (Thematic analysis) | One of the challenges is the highly mobile workforce that keep changing so the skills of the team keep changing | ||||||
Optimism (the confidence that things will happen for the best or the desired goals will be attained) | There is a prompt response when the trauma team is activated | F | Team survey (Descriptive statistics) | On activation of a major trauma call do team members attend promptly? | |||||
a. All the time | 80.2% (n = 69) | ||||||||
b. Sometimes | 16.3% (n = 14) | ||||||||
c. Never | 3.5% (n = 3) | ||||||||
The size and composition of the trauma team is appropriate for managing major trauma. | |||||||||
The trauma team was the right size to assist service delivery | F | Team survey (Descriptive statistics) | a. All the time | 82.5% (n = 71) | |||||
b. Sometimes | 14.0% (n = 12) | ||||||||
c. Never | 3.5% (n = 3 | ||||||||
Better care is now provided as the team is co-ordinated. | F | Team interview (Thematic analysis) | A co-ordinated team response has got to be better for the patient as they get immediate assessment, then everything is reviewed and titrated to their clinical needs | ||||||
Social influences (those interpersonal processes that can cause individuals to change their thoughts, feelings and behaviours) | Team is confident to question decisions made by team leader | F | Team survey (Descriptive statistics | Is there is a reluctance to question decisions or actions of a senior doctor/team leader during a trauma? | |||||
a. All the time | 15.1% (n = 13) | ||||||||
b. Sometimes | 80.2% (n = 69) | ||||||||
c. Never | 4.7% (n = 4) | ||||||||
Poor conflict resolution | B | Team survey (Descriptive statistics) | The team leader discusses areas of concern/conflict with the team and explains rationale for decisions made | ||||||
a. All the time | 52.3% (n = 45) | ||||||||
b. Sometimes | 33.7% (n-29) | ||||||||
c. Never | 13.9% (n = 12) | ||||||||
Team members do not know each other | B | Team survey (Descriptive statistics | Do trauma team members know each other’s roles and responsibilities? | ||||||
a. All the time | 69.6% (n = 60) | ||||||||
b. Sometimes | 26.7% (n = 23) | ||||||||
c. Never | 3.5% (n = 3) | ||||||||
Not confidence to speak up | B | Team survey (Descriptive statistics | I am confident to ‘speak up’ to communicate a problem to other members of the team | ||||||
a. All the time | 51.2% (n = 44) | ||||||||
b. Sometimes | 47.6% (n = 41) | ||||||||
c. Never | 1.2% (n = 1) | ||||||||
Psychological safety enhanced communication | F | Team interview (Thematic analysis) | found it helpful as it gave ou permission to talk in a way that previously would have been viewed as touchy feely | ||||||
Escalation ignored by medical staff | B | Team interview (Thematic analysis | I remember thinking you know us, we do not make a fuss unless we are concerned so why are you not listening to us and they end up making poor decisions | ||||||
Team conflict impacts patient care | B | Team interview (Thematic analysis) | Everyone managing this resusitation trauma was involved in a previous one where there was conflict in the team and I feel this conflict continued in this resusitation. | ||||||
Emotion (fear, anxiety, affect, stress, dealing with a personally significant matter/event) | Lack of trust and respect | B | Team survey (Descriptive statistics) | Is there mutual respect and trust between trauma team members? | |||||
a. All the time | 69.8% (n = 60) | ||||||||
b. Sometimes | 24.4% (n = 21) | ||||||||
c. Never | 5.8% (n = 5) | ||||||||
B | Team interview (Thematic analysis) | I observe that when people are not familiar with each other there is tension and conflict and this affects the team | |||||||
Behavioural regulation (anything aimed at managing or changing objectively observed or measured actions, i.e. self-monitoring, action planning) | There is compliance with nonverbal communication techniques | F | Team survey (Descriptive statistics | Are coloured role tags worn by each team member? | |||||
a. All the time | 72.1% (n = 62) | ||||||||
b. Sometimes | 26.7% (n = 23) | ||||||||
c. Never | 1.2% (n = 1) | ||||||||
Procedural compliance | F | Team survey (Descriptive statistics) | Is the pre-notification handover displayed on board in resus? | ||||||
a. All the time | 90.7% (n = 78) | ||||||||
b. Sometimes | 7.0% (n = 6) | ||||||||
c. Never | 2.0% (n = 2) | ||||||||
Teamwork is practised in real life resuscitations. | F | Team interview (Thematic analysis) | Yes, I do see teamwork being practised by the doctors and nurses | ||||||
Reinforcement (increasing the probability of a response by arranging a dependant relationship between the response and a given stimulus) | Standardisation of operating procedures helps to reinforce team members’ roles and responsibilities. | F | Team survey (Descriptive statistics) | The Team Leader identifies him/herself to the treating paramedic | |||||
a. All the time | 75.6% (n = 65) | ||||||||
b. Sometimes | 22.1% (n = 19) | ||||||||
c. Never | 2.3% (n = 2) | ||||||||
Reminders | F | Team interview (Thematic analysis) | The nursing team leader is very good at prompting me when I forget things | ||||||
Intentions (a conscious decision to perform a behaviour or a resolve to act in a certain way) | The team leader leads | F | F Team survey (Descriptive statistic | The team leader maintains a ‘hands free’ approach to leading the trauma. | |||||
a. All the time | 86.0% (n = 74) | ||||||||
b. Sometimes | 10.5% (n = 9) | ||||||||
c. Never | 3.5% (n = 3) | ||||||||