Background
Trauma is the leading cause of death among people aged 1–44 years and the fourth most common cause of death in the western world [
1]. When managing trauma cases, the member of an emergency and trauma surgical team must work under tremendous pressure in a stressful and complex environment while aiming to communicate effectively, and decisions must often address ethical dilemmas [
2]. Indeed, trauma teams must deal with extreme stress and time constraints, not rarely with no awareness of the trauma causes nor the patients’ identity, current circumstances or conditions, or patients’ desires about the treatment options, and must cope with the risk of unanticipated incidents. Within this context, traditional organizational practices are less effective, and integrative mechanisms such as team assembly decisions might be the only opportunity to coordinate team member actions and increase performance [
3].
In such scenarios, urgent decision-making in trauma surgery raises a number of ethical concerns. When faced with ethical dilemmas, clinicians must rapidly consider the potential outcomes of their choices, as well as the limited information they have about their patients [
4]. Ethics also involves communication and sharing of eventual options and decisions to patients and their loved ones with consistency and compassion. The emergency situation rarely allows time to investigate recommendations from the relevant literature or guidelines or ask other colleagues for second opinions. As a result, there is a high risk of making mistakes or facing ethical dilemmas when managing injured patients, and this seems to be particularly true during the early assessment and resuscitation processes when lifesaving procedures are made [
5]. Similarly, the time or opportunity to inform the patient might be limited or completely lacking. In this perspective, the topic of consent is critical. Because of the sudden and unexpected nature of trauma or the emergency, healthcare providers must be trained to think and respond fast in the patient's best medical interest. Trauma patients frequently have transitory impairments in their ability to make autonomous and informed decisions. This often results in
presumed consent for medically necessary treatment [
4].
Emergency surgery teams are made up of a multidisciplinary group of people from different specialities such as anesthesia, emergency medicine, surgery, nursing, and supporting staff, all of whom provide simultaneous inputs into the trauma assessment and treatment, with a team leader who will be coordinating their activities [
1]. Therefore, in trauma and emergency situations, team dynamics are critical [
6].
A crucial aspect refers to the role of the trauma leader who, as an ethical leader and guided by strong ethical principles, “can experience conflicting obligations to stakeholders during these emotional and complex debates and must lead with strength, compassion, fairness, and justice while eliminating implicit and explicit biases” [
7]. Indeed, while decision-making is often seen through the lens of an individual's internal cognitive process, the ability to put certain decisions into action necessitates the ability to seamlessly organize all team members to achieve the desired objective [
5]. Trauma leaders have the challenging role of managing their team through potentially challenging ethical situations.
Interestingly, current teaching and assessment approaches for these advanced cognitive skills are subjective, lack standardization, and are vulnerable to errors [
5,
6]. Therefore, knowledge translation and knowledge transfer mechanisms are cornerstones to allow team members to bridge their differences and communicate effectively, boosting the potential of multidisciplinary teams [
8]. Fostering a continuous learning requirement on these matters is essential to enable trauma teams to overcome ethical dilemmas in an efficient and effective way [
9].
Diversity in surgery is a rising topic within the surgical community. It has been defined as “a broad representation of viewpoints, socioeconomic backgrounds, gender, sexual orientation, disability status, race, and ethnicity” [
10]. Emergency surgery teams are diverse by definition, as they include professionals of different specialities and variable backgrounds [
1], who do need interpersonal skills [
5,
6] to ensure effective care to trauma patients. The literature highlights how global performance has been shown to be better when the environment of medical care is diverse, and patient satisfaction is also improved in such contexts [
11,
12]. Still, recent studies have also underlined how diversity needs dedicated organizational and management policies to reach its full potential [
8,
11,
13]. Interestingly, to the best of our knowledge, little has been said about the possible influence between diversity and ethics in emergency and trauma teams.
To fill this gap, this study aims at investigating the different perceptions of trauma surgeons on three ethical-related matters. First, the study investigates the feelings of surgeons regarding the importance of patient consent. Second, the research focuses on their perceptiveness of the ethical role of the trauma leader. Third, the study deepens the perceived importance of ethics as an educational subject. This study builds on these foundations by undertaking an international survey under the auspices of the World Society of Emergency Surgery (WSES) to investigate the factors that can enhance these three ethical aspects in trauma and emergency surgery. The dataset is analyzed focusing on the role of gender, kind of institution (academic or not), and membership to an officially set trauma team and to a diverse group.
Discussion
Our results aim to understand the factors that can influence how three ethical matters are perceived in trauma surgery teams. Through the analysis of 402 fully filled questionnaires by surgeons working in 72 different countries, three main ethical topics were investigated through the lens of gender, membership of an academic or non-academic institution, of a trauma team, and a diverse group.
Regarding the importance of obtaining consent from the injured patient, results highlight greater attention paid by surgeons belonging to academic institutions, official trauma teams, and diverse groups. The topic of surgical consent has been changing its meaning over time. While once it was considered more as a legal and administrative duty before the operation, the recent literature has underlined how informed consent is an essential tool to communicate with the patient, understand his or her wishes and concerns [
4,
20,
23] toward the relevance of a shared decision-making [
15]. In this perspective, the more recent paradigm sees the surgeons needing to “speak less and listen more” [
20] to ensure better knowledge translation with their patients [
8]. This may shine a light to ethical issues in trauma and emergency surgery [
4], as understanding the patient’s wishes is not always feasible.
Surgeons working in academic environments and belonging to trauma teams pay greater attention to the topic of consent. This may depend on the patient-centric organizational culture and ongoing debate concerning patients’ consent which appears to be more assertive in academic institutions and within formalized trauma teams. Diverse groups record outstanding results rather than those from non-diverse ones. While diversity in practice may be challenging due to the differences among members, it has been proven to lead to exceptional outcomes. It may be reasonable that professionals who are already focused on bridging the difference with their peers are likely to do so even with their patients.
The second topic is the role of the trauma leader as an ethical leader, able to merge strong ethical principles within his or her clinical decision-making. Those belonging to formalized trauma teams and diverse groups are keener about the importance, for a trauma leader, to include ethics in his/her role. Once again, surgeons of diverse teams gave the highest evaluation in terms of their agreement. Therefore, we can claim that those actively engaging with diverse groups of people feel that ethics is crucial in ensuring smooth team dynamics and better patient outcomes.
Ethical training is the third topic analyzed, highlighting similar results. While, generally speaking, most surgeons recognize the importance of getting proper ethical training, participants from academic institutions, formalized trauma teams, and diverse groups show more significant interest. Again, the surgical literature has underlined the need to employ training related to non-technical skills [
24‐
27], with ethics belonging to such skills [
18]. Scientific societies have taken the lead on such topics. Therefore, without surprise, those closer to this debate (namely academics and formalized trauma team members) seem to be more focused on recognizing this as a relevant issue. Non-technical skills have proven to be essential to foster knowledge translation dynamics within teams, especially when groups can be defined as diverse [
8,
19]. Again, diversity seems to stimulate the need for ethical training, which is considered a central element.
Surgeons have been stereotyped as “abrasive, arrogant and difficult to work with” [
28,
29], and those simplified images have influenced the way they interact with colleagues and patients. Informed consent is the ethical expression of respect for the patient’s autonomy. While previous studies showed that physicians in general no longer make paternalistic decisions for patients, our results show that less diverse trauma teams might pay less attention to patient wishes.
Limitations and bias
This study is not without limitations. Among these, although our response rate may be considered satisfactory, our investigation may suffer from selection bias [
30]. Indeed, our sample may be unrepresentative of the entire Trauma community, and this may impact the goals of our survey research. For instance, the academic settings (to which many of our participants belong) may be more sensitive toward the current debate on the topics of multidisciplinarity, diversity, and inclusion. Moreover, although we cover 72 different countries on all the continents, respondents are concentrated in some geographical areas than others [
2]. Cultural and technical aspects (like the medical background of the trauma leader, e.g., as a surgeon or an anesthesiologist) and the massive presence or not of specific phenomena (like gun violence) may also affect our results.
Conclusions
Our study has highlighted how embracing cultural diversity forces trauma teams to deal with different mindsets. While previous studies have shown that different cultures (e.g., more physician-centric vs patient-centric) can coexist within organizations [
31], our results underline that some organizational factors (e.g., the fact that the team belongs to a university context or is more diverse) might lead to the development of a higher sensibility on patient consent and ethical matters. Organizations willing to promote a more patient-centric view with trauma teams focused on ethical issues should consider those elements in defining their organizational procedures. Indeed, in the context of trauma teams, where time pressure and timely action are the normal conditions rather than an exception, traditional coordination mechanisms are less effective, and teams must rely more on different strategies and tools for coordinating their actions. According to our results, integrative mechanisms such as team composition might work effectively, facilitating ethical behaviors and a more patient-oriented culture.
Qualitative studies may further deepen such dynamics, defining and sharing best practices to enable trauma teams to handle ethical issues in the best possible way.
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