Background Within trauma teams, effective communication is necessary to ensure safe and secure care of the patient. Deficiencies in communication are one of the most important factors leading to patient harm. Time is an essential factor for rapid and efficient disposal of trauma teams to increase patients’ survival and prevent morbidity. Trauma team training plays an important role in improving the team’s performance, while the leader of the trauma team faces the challenge of coordinating and optimizing this performance. Aim The overall aim of this thesis was to analyse how members of trauma teams communicated verbally and non-verbally during trauma team training in emergency settings, and how the leaders were positioned or positioned themselves in relation to other team members. The aim was also to investigate the use of a communication tool, closed-loop communication, and the time taken to make a decision to go to surgery in relation to specific factors in the team as well as the leader’s position. Methods Eighteen trauma teams were audio and video recorded and analysed during regular in situ training in the emergency room at a hospital in northern Sweden. Each team consisted of six participants: two physicians, two nurses, and two enrolled nurses, giving a total of 108 participants. In Study I, the communication between the team members was analysed using a method inspired by discourse psychology and Strauss’ concept of “negotiated orders”. In Study II, the communication in the teams was categorized and quantified into “call-outs” and “closed-loop communication”. The analysis included the team members’ background data and results from Study I concerning the leader’s position in the team. Poisson regression analyses were performed to assess closed-loop communication (outcome variable) in relation to background data and leadership style (independent exploratory variables). In Study III, quantitative content analysis was used to categorize and organize the team members’ positions and the leaders’ non-verbal communication in the video-recorded material. Time sequences of leaders’ non-verbal communications in terms of gaze direction, speech time, and gestures were identified separately to the level of seconds and presented as proportions (%) of the total training time. The leaders’ vocal nuances were also categorized. The analysis in Study IV was based on the team members’ background data, the results from Study I concerning the leader’s position in the team, and the categorization and quantification of team communication from Study II. Cox proportional hazard regression was performed to assess the time taken to make a decision to go to surgery (outcome variable) in relation to background data, the leader’s position, and closed-loop communication (independent variables). Results The findings in Study I showed that team leaders used coercive, educational, discussing, and negotiating repertoires to convey knowledge and create common goals of priorities in work. The repertoires were used flexibly and changed depending on the urgency of the situation and the interaction between the team members. When using these repertoires, the team leaders were positioned or positioned themselves in either an authoritarian or an egalitarian position. Study II showed that closed-loop communication was used to a limited extent during the trauma team training. Call-out was more frequently used by team members with eleven or more years in the profession and experience of trauma within the past year, compared with team members with no such experience. Scandinavian origin, an egalitarian team leader and previous experience of two or more structured trauma courses were associated with more frequent use of closed-loop communication compared to those with no such origin, leader style, or experience. Study III showed that team leaders who gained control over the “inner circle” used gaze direction, vocal nuances, verbal commands, and gestures to solidify their verbal messages. Leaders who spoke in a hesitant voice or were silent expressed ambiguity in their non-verbal communication, and other team members took over the leader's tasks. Study IV showed that the team leader’s closed-loop communication was important for making the decision to go to surgery. In 8 of 16 teams, decisions on surgery were taken within the timeframe of the trauma team training. Call-outs and closed-loop communication initiated by the team members were significantly associated with a lack of decision to go to surgery. Conclusions The leaders used different repertoires to convey and gain knowledge in order to create common goal in the teams. These repertoires were both verbal and non-verbal, and flexible. They shifted depending on the urgency of the situation and the interaction within the team. Depending on the chosen repertoire, the leaders were positioned or positioned themselves as egalitarian and/or authoritarian leaders. In urgent situations, the leaders used closed-loop communication as part of a coercive repertoire, and called out commands and directed requests to specific team members. This repertoire was important for making the decision to go to surgery; the more closed-loop communication initiated by the leader, the more likely that the team would make a decision to go to surgery. Problems arose if the leaders were positioned or positioned themselves as either an authoritarian or an egalitarian leader. The leaders needed to be flexible and use different repertories in order to move the teamwork forward. It was notable that higher numbers of call-outs and closed-loop communication initiated by the team members decreased the probability of making the decision to go to surgery.

En cherchant à répondre à la question centrale de la différence entre les équipes d’experts et les équipes expertes (Fiore et Salas, 2006), la recherche en sciences du travail et en sciences du sport a montré que la simple association d’individus experts ne suffisait pas à produire des performances collectives (Sève, Bourbousson, Poizat et Saury, 2009). Toutefois les études engagées sur ce thème ne permettent pas de répondre directement à la problématique de la construction de l’expertise collective (Bourbousson et al., 2008 ; Bourbousson et Sève, 2010 ; Eccles et Tenenbaum, 2004). Notre travail de thèse a pour objectif de répondre à cette problématique par l’analyse de la construction de la coordination interpersonnelle entre des footballeurs d’une même équipe, au sein d’un centre de formation professionnel. En respectant une démarche naturaliste, nous avons mis en place une méthodologie qualitative (non invasive à partir d’entretiens d’autoconfrontation et semi-directifs, et de notes ethnographiques), longitudinale (22 mois de suivi) et multiniveau (une analyse du dispositif de formation, de l’activité des formateurs et une analyse de l’activité des joueurs en situation). Les résultats sont présentés en trois chapitres : 1) l’étude de l’évolution des consciences collectives de la situation (Endsely, 1995), 2) les différents processus d’apprentissage collectif mobilisés par les joueurs au cours des 6 sessions de formation ; 3) l’influence du dispositif de formation et de l’activité des formateurs sur l’activité des joueurs en situation. Nos résultats ont été discutés au regard de la littérature des sciences du sport et de la psychologie ergonomique. Finalement notre travail de thèse propose des avancées méthodologiques, conceptuelles et pratiques. / In order to answer the main question about the difference between a team of experts and an expert team (Fiore et Salas, 2006), research in work sciences and sport sciences showed that the association of expert individuals was not sufficient to produce collective performances (Sève, Bourbousson, Poizat et Saury, 2009). However, the present studies on this theme do not allow to answer directly the question of collective expertise construction (Bourbousson et al., 2008; Bourbousson et Sève, 2010; Eccles et Tenenbaum, 2004). Our thesis work aims to answer this question through the analysis of interpersonal coordination construction between football players in a team, within a professional training center. With a naturalist approach, we created a methodology which is qualitative (non-invasive with autoconfrontation semi-guided interviews, and ethnographic notes), longitudinal (22 months followup) and multi-level (analysis of the training plan, of trainers’ activity and analysis of players activity).Results are exposed in three chapters: 1) study of the evolution of the group awareness regarding thesituation (Endsely, 1995), 2) the different collective training processes mobilized by players during the 6 training sessions; 3) the influence of training plan and trainers’ activity on players activity in situation.Our results have been discussed in relation with literature in sport sciences and ergonomic psychology. Finally, our thesis work offers methodologic, conceptual and practical advances.

Research has indicated that offering support and services for people who experience mental health problems and their families is a complex and contested area. Despite the controversies surrounding therapeutic interventions with families, it has now been recognised that relatives and other supporters of people with mental health problems should be included in their care. Whole- family interventions and partnership working with carers and families is now central to secondary care UK mental health policies and clinical practice guidelines. However, for many families/ carers this remains an aspiration rather than a reality. The way in which we successfully developed family focused mental health practice, as well as specialist family interventions (FI) for people who have been given a diagnosis of psychosis, has therefore aroused considerable interest. The Somerset Partnership NHS Foundation Trust has adopted a Strategy to Enhance Working Partnerships with Carers and Families, developed best practice guidance and has established two complementary workforce development projects - the development of specialist family intervention services and the widespread training of mental health staff to create a ‘triangle of care’ with service users and their families. This has resulted in widespread adoption of systemically informed, ‘whole-family’ practice. In response to the widespread difficulties experienced following other staff- training initiatives we developed specialist family interventions (FI) services by means of an innovative one-year course delivered in partnership with Plymouth University. This training initiative has been widely acknowledged for its novel integration of psycho-educational and systemic approaches and the effective in-situ, multi-disciplinary service development model. An advantage of this approach is that by the end of the course a local FI Service has been established and staff experience fewer difficulties in applying their new skills than people trained in other programmes. We then ensure the continued development of clinical skills by means of a service structure that emphasises on-going supervision. Regular audits of the service and in-depth research studies clearly indicate that the service is effective and highly valued by users. Our ‘cognitive-interactional’ approach, which integrates systemic therapy with psychosocial interventions (individual- and family-CBT) within a collaborative therapeutic relationship, enables us to meet the needs of families in a flexible, tailored manner. The FI teams are able to deliver early interventions for people with first episode psychosis, as well as meeting the NICE guidelines for people with longstanding symptoms. Recognising that many families do not require formal family interventions/ therapy, we also have been designing ‘stepped-care’ family intervention services. We have developed, and extensively evaluated, short training packages to enhance working partnerships with families throughout our mental health services. We have used this three-day package to train a range of community and inpatient teams. We have also encouraged family- inclusive practice with the establishment of a trustwide steering group, practice guidelines and the establishment of ‘family liaison’ posts to facilitate family meetings on inpatient units, as part of the assessment process. Both training initiatives explicitly focus on developing systemic thinking, by integrating CBT and systemic therapy. The involvement of families/ carers in the design and delivery of both training initiatives is also crucial.