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Background: Traumatic injuries are a leading cause of deaths in Norway, especially among younger males. Trauma-related mortality can be reduced by structural measures, such as organization of a trauma system. Many hospitals in Norway treat few seriously injured patients, one of the reasons for development of the Norwegian trauma system. Since its implementation, there has been continuous improvement of this system, including trauma team training. Regular trauma team training is compulsory, with the aims of compensating for lack of experience and maintaining competence. The purpose of this study was to present an overview of current trauma team training activities in Norway., Methods: For this observational study, the authors developed an online questionnaire and mailed it to local trauma coordinators from 38 Norwegian hospitals-including four trauma centers and 34 acute hospitals with trauma function. The study was performed during April-June 2020, with a two-month response window. Trauma team training frequency was assessed in four predefined intervals: < 5, 5-9, 10-15 and > 15 times per year. The response rate was 33 of 38, 87%., Results: All responding hospitals conducted regular trauma team training. The frequency of training increased significantly from 2013 to 2020 (Chi square test, Chi 2 8.33, p = 0.04). All hospitals described a quite homogenous approach. The trauma centres trained more frequently as compared to the acute care hospitals (Chi square test, Chi 2 8.24, p = 0.04)., Conclusions: All responding hospitals performed regular trauma team training using a homogenous approach, which is in line with previous assessments. We observed a minor improvement in frequency compared to prior assessments. Our findings suggest that Norwegian trauma teams likely maintain their competence through team training. All hospitals followed the current recommendations from the National Trauma Plan., (© 2022. The Author(s).)

Background: High quality team leadership is important for the outcome of medical emergencies. However, the behavioral marker of leadership are not well defined. The present study investigated frequency of behavioral markers of shared mental models (SMM) on quality of medical management., Method: Training video recordings of 27 trauma teams simulating emergencies were analyzed according to team -leader's frequency of shared mental model behavioral markers., Results: The results showed a positive correlation of quality of medical management with leaders sharing information without an explicit demand for the information ("push" of information) and with leaders communicating their situational awareness (SA) and demonstrating implicit supporting behavior. When separating the sample into higher versus lower performing teams, the higher performing teams had leaders who displayed a greater frequency of "push" of information and communication of SA and supportive behavior. No difference was found for the behavioral marker of team initiative, measured as bringing up suggestions to other teammembers., Conclusion: The results of this study emphasize the team leader's role in initiating and updating a team's shared mental model. Team leaders should also set expectations for acceptable interaction patterns (e.g., promoting information exchange) and create a team climate that encourages behaviors, such as mutual performance monitoring, backup behavior, and adaptability to enhance SMM.

Background: Trauma systems have improved outcomes for injured patients, but might be challenging to implement. We assessed the implementation of a trauma system in Norway after recommendations for a national trauma system were published in 2007, with a focus on elements in acute care hospitals., Methods: All hospitals in Norway, except for the four regional trauma centres, admitting injured patients at the time of the study were included in a telephone survey. The questionnaire was administered during May 2013 by the regional trauma coordinators who interviewed the local trauma coordinator and/or the local doctor responsible for trauma care in all the acute care hospitals. The main categories were availability of the trauma team and team training, written procedures, preparedness and training of personnel. The compliance to a set of 17 predefined trauma system criteria was evaluated at each institution., Results: Of the 35 acute care hospitals in Norway admitting trauma patients at the time of the survey, all were included. The median number of fulfilled criteria was 14. Major deficiencies were found in fulfilling competence criteria, maintaining a local trauma registry, and trauma audits. The number of fulfilled criteria correlated strongly with the size of the hospital and the frequency of trauma team activation., Conclusions: Shortcomings in requirements for lower-level trauma care hospitals correlate to hospital size and frequency with which the trauma team is activated. In order to fulfill the minimum requirements, smaller hospitals should receive more attention., (© 2015 The Authors. The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.)

Background: The treatment of trauma victims is a complex multi-professional task in a stressful environment. We previously found that trauma team members perceive leadership as the most important human factor. The aim of the present study was to assess the experience and education of Norwegian trauma team leaders, and allow them to describe their perceived educational needs., Methods: We conducted an anonymous descriptive study using a point prevalence methodology based on written questionnaires. All 45 hospitals in Norway receiving severely injured trauma victims were contacted on a randomly selected weeknight during November 2009. Team leaders were asked to specify what trauma related training programs they had participated in, how much experience they had, and what further training they wished, if any., Results: Response rate was 82%. Slightly more than half of the team leaders were residents. The median working experience as a surgeon among team leaders was 7.5 years. Sixty-eight percent had participated in multi-professional training in non-technical skills, while 54% had passed the advanced trauma life support(ATLS) course. Fifty-one percent were trained in damage control surgery. A median of one course per team leader was needed to comply with the new proposed national standards. Team leaders considered training in damage control surgery the most needed educational objective., Conclusions: Level of experience among team leaders was highly variable and their educational background insufficient according to international and proposed national standards. Proposed national standards should be urgently implemented to ensure equal access to high quality trauma care.

Background: Trauma team training using simulation has become an educational compensation for a low number of severe trauma patients in 49 of Norway's 50 trauma hospitals for the last 12 years. The hospitals' own simple mannequins have been employed, to enable training without being dependent on expensive and advanced simulators. We wanted to assess the participants' assessment of using a standardized patient instead of a mannequin., Methods: Trauma teams in five hospitals were randomly exposed to a mannequin or a standardized patient in two consecutive simulations for each team. In each hospital two teams were trained, with opposite order of simulation modality. Anonymous, written questionnaires were answered by the participants immediately after each simulation. The teams were interviewed as a focus group after the last simulation, reflecting on the difference between the two simulation modalities. Outcome measures were the participants' assessment of their own perceived educational outcome and comparison of the models, in addition to analysis of the interviews., Results: Participants' assessed their educational outcome to be high, and unrelated to the order of appearance of patient model. There were no differences in assessment of realism and feeling of embarrassment. Focus groups revealed that the participants felt that the choice between educational modalities should be determined by the simulated case, with high interaction between team and patient being enhanced by a standardized patient., Conclusion: Participants' assessment of the outcome of team training seems independent of the simulation modality when the educational goal is training communication, co-operation and leadership within the team.

Background: Trauma is the leading cause of death for young people in Norway. Studies indicate that several of these deaths are avoidable if the patient receives correct initial treatment. The trauma team is responsible for initial hospital treatment of traumatized patients, and team members have previously reported that non-technical skills as communication, leadership and cooperation are the major challenges. Better team function could improve patient outcome. The aim of this study was to obtain a deeper understanding of which non-technical skills are important to members of the trauma team during initial examination and treatment of trauma patients., Methods: Twelve semi-structured interviews were conducted at four different hospitals of various sizes and with different trauma load. At each hospital a nurse, an anaesthesiologist and a team leader (surgeon) were interviewed. The conversations were transcribed and analyzed using systematic text condensation according to the principles of Giorgi's phenomenological analysis as modified by Malterud., Results and Conclusion: Leadership was perceived as an essential component in trauma management. The ideal leader should be an experienced surgeon, have extensive knowledge of trauma care, communicate clearly and radiate confidence. Team leaders were reported to have little trauma experience, and the team leaders interviewed requested more guidance and supervision. The need for better training of trauma teams and especially team leaders requires further investigation and action.

Background: Norway has 50 trauma hospitals serving a geographically disperse population (4.6 million) and many have low trauma case loads. We showed that personnel find functioning as a team especially challenging, and developed a 1-day training course, arranged locally at each hospital, focused on team training in communication, leadership, and cooperation during simulated patient treatment. This study evaluates the effects of training on participants' knowledge, confidence, and perceived trauma team performance, controlling for hospital size and the participants' previous experience., Methods: Anonymous, written questionnaires were answered by 4,203 participants (28% physicians, 55% nurses) in 44 hospitals before and immediately after training courses, and by 1,368 trauma team members in 26 of the hospitals 6 months after their last training course. Outcome measures were knowledge and confidence concerning the respondent's own role, and evaluation of trauma team performance in live trauma resuscitations., Results: There was a significant increase in self-reported knowledge and confidence among all participants. Community hospitals and participants without recent trauma experience had the lowest preintervention scores, but reached levels comparable to participants at the other hospitals after training. The effects increased after 6 months, with trauma team performance evaluated as having improved, even by team members who had not participated in the training., Conclusions: Practical team training in hospitals improved the participants' perceived knowledge and confidence, which continued to increase for 6 months after training independent of participants' experience level, suggesting that small hospitals may reach levels comparable to major hospitals.

Background: Most Norwegian hospitals have systematically trained trauma teams in cooperation with the BEST Foundation: Better & systematic trauma care. A group of general practitioners, ambulance personnel and primary care nurses have modified this training concept for use in general practise, with the aim to strengthen acute medical competence within Norwegian primary health care. This study describes experience gained with a training method for dealing with receival and stabilisation of victims of injury in multiprofessional teams in primary health care., Material and Methods: Multiprofessional training courses were held in 10 municipalities in Finnmark county in northern Norway. The course consisted of two hours of lectures on handling of critically injured patients in the primary care setting, followed by practical training with simulated patients. Communication, leadership and cooperation was emphasised during the training. The simulation sessions with dolls were video recorded and evaluated after each session. Individual questionnaires were distributed before and after training., Results: Most municipalities that we contacted responded positively. Training was arranged for 22 teams and 145 participants completed questionnaires. The participants reported a significantly improved confidence in their own role and the correct order of necessary procedures. 91% would recommend the course to a colleague., Interpretation: This group of different health professionals reported a great need for training and a high outcome after the intervention. The findings support further dissemination of this training method in Norwegian primary health care.

Background: The geography of Norway has led to an initiative to train teams from rural hospitals in damage control surgery using a team-oriented approach based on Crew Resource Management. Our aim was to evaluate this approach and its impact on trauma care in rural hospitals across Norway., Methods: Thirty-eight teams from 21 hospitals participated in 10 courses (during the years 2003-2006) where providers from the same hospital trained as a team. Each course consisted of interactive lecture modules and operative sessions on live porcine models that emphasize communication, collaboration and team-based problem solving. The data collection tools were a postcourse questionnaire and a phone survey of participating hospitals., Results: Teams consisted of surgeons (34%), operating room nurses (35%), and anesthesiology staff (31%). Almost all course participants (N = 228, 99%) reported a dramatic increase in their proficiency with damage control techniques. There was a mean increase of 2.3 points in proficiency with extraperitoneal pelvic packing and 1.5 points with emergency thoracotomy on a 5-step Likert scale. The team approach was perceived as crucial by 218 (94%) of participants. The phone survey revealed 12 cases of lifesaving rural damage control operations by course participants in the past 3 years (estimated cost: $15,075 per life saved). Of the 18 hospitals surveyed, 17 modified their trauma protocols as a result of the course., Conclusion: Teaching damage control surgery using a team-oriented approach is an innovative educational method for rural hospitals.

Background: Systematic and multiprofessional trauma team training using simulation was introduced in Norway in 1997. The concept was developed out of necessity in two district general hospitals and one university hospital but gradually spread to 45 of Norway's 50 acute-care hospitals over the next decade. Implementation in the hospitals has varied from being a single training experience to becoming a regular training and part of quality improvement. The aim of this study was to better understand why only some hospitals achieved implementation of regular trauma team training, despite the intentions of all hospitals to do so., Methods: Focus group interviews were conducted with multiprofessional respondents in seven hospitals, including small and large hospitals and hospitals with and without regular team training. Interviews were transcribed and analyzed using a Grounded Theory approach., Results: 'Keeping the spirit high' appeared to be the way to achieve implementation. This was achieved through 'enthusiasm,''strategies and alliances,' and 'using spin-offs.' It seems that the combination of enthusiasts, managerial support, and strategic planning are key factors for professionals trying to implement new activities., Conclusions: Committed health professionals planning to implement new methods for training and preparedness in hospitals should have one or more enthusiasts, secure support at the administrative level, and plan the implementation taking all stakeholders into consideration.

Background: Because the hospitals in Norway are mostly rural community hospitals that see life-threatening trauma only infrequently, we developed a course in damage control surgery based on a live porcine model in 1999. The course also focuses on teamwork and leadership training based on crew resource management principles. The aim of this study was to evaluate the direct educational benefit from the course and whether participants had used the damage control techniques in their subsequent daily practice., Study Design: A total of 103 participants completed 2 questionnaires about the self-efficacy for damage control surgery, the first at completion of the course and the second at least 6 months after the course., Results: There was a significant increase in the number of trauma team members who felt comfortable performing damage control surgery (from 17% before the course to 62% at followup; p < 0.001). Almost half the surgeons and operating room nurses reported using damage control techniques in their subsequent practice. Participants considered the focus on team-oriented training important. Four of every five participants thought this course had improved their ability to handle severely injured patients., Conclusions: This study shows that a team-oriented operative trauma course is not only beneficial in the short term, but the principles and techniques learned are subsequently applied by the graduates in their daily practice. Course content and structure, particularly the emphasis on integral operating room teams working together, is especially suitable for the rural setting.

Background: During the last decade there has been an increased interest in the organisation and quality of trauma care in the Nordic countries. Still, most patients are initially cared for at hospitals with low caseloads of severe trauma. More than 200 hospitals offer initial care to trauma patients. Training of trauma teams using simulators or simulated patients has evolved in the same period, as one important factor to overcome lack of practical training. This overview describes the present state of trauma team training in the Nordic countries., Methods: Members of a Nordic working group on the use of simulation in medicine reviewed present literature on training with simulation and described the present use of team training in their own countries during winter 2004., Results: There is an increasing amount of evidence indicating that training of teams with simulation reduces treatment errors and improves performance. The training activities do not need to be complex, but skilled debriefing seems necessary. Few Nordic hospitals train their trauma teams. The training activities vary considerably between and within countries., Conclusion: There is considerable evidence supporting an increased use of experience gained in other high-risk domains where training in communication, leadership and decision-making is the focus for safety and improvement efforts. There is a need for more widespread training of trauma teams. The different training activities actually undertaken should be scientifically evaluated.

Background: Medical emergencies and major trauma require optimal team function. Leadership, co-operation and communication are the most essential issues. Due to low caseloads such emergencies occur rarely in most Norwegian hospitals. Team training of personnel between real emergencies is expected to improve performance in comparable settings. Most hospitals have cardiac arrest teams, but it is known that the training of such multiprofessional teams varies widely. We wanted to know if this also was the case for trauma teams and resuscitation teams for newborns., Methods: A telephone survey of training practices in all the Norwegian hospitals with acute cover was conducted in 2002. Information was obtained on whether trauma teams and neonatal resuscitation teams had participated in practical multiprofessional training during the previous 6 or 12 months., Results: Information was obtained from all 50 hospitals. Of the acute care hospitals, 30% had trained their trauma teams during the previous 6 months, and an additional 18% when considering the previous year, while 38% of neonatal wards had multiprofessional training during the previous 6 months, and additionally 13% had had training during the previous year. Additionally four neonatal wards had had regular training of nurses only. More than 80% of all respondents judged regular team training to be achievable, and none considered this training impossible., Conclusion: Only half the Norwegian acute care hospitals reported at least yearly training of trauma and neonatal resuscitation teams. Regular team training represents an underused potential to improve handling of low-frequency emergencies.