Background

Trauma and emergency surgery teams include a group of specialists (comprising surgeons, emergency physicians, anesthesiologists, and nurses, among others) cooperating to provide patients with high-quality care. Such professionals operate under challenging circumstances, high stress, and time pressures. They often have little awareness of the trauma’s causes, the patients’ identities, current conditions, and care preferences [1]. While team dynamics appear fundamental to ensuring the best quality of care from a patient-centric perspective, knowledge translation and sharing processes [2, 3] are essential to patient-centered care and the inviolable patient-physician relationship [4]. Indeed, the clinical team might lack time to examine the various possibilities and treatment options with the patients, including prognostic information [5, 6].

The value of shared decision-making (SDM) in patient-centered care is well recognized in the context of contemporary healthcare. Healthcare professionals and patients are encouraged to engage in SDM to jointly make decisions, considering the best available evidence and the patients’ values and treatment choices. SDM is anticipated to improve patient treatment compliance and, consequently, health outcomes. In particular, SDM is the most advantageous choice for judgments that must consider the patient’s preferences and wishes. When two or more comparable treatment options are available, healthcare professionals should support the patient in selecting his or her best option, depending on how each patient rates the benefits and hazards of each choice [7]. Therefore, SDM stands as a pillar of patients’ autonomy, and clinicians have the moral and ethical duty to support patients in making decisions that embrace their values and priorities [8]. Still, engaging in effective SDM practices is not a surgical care panacea. Barriers may emerge due to a gap in the clinical knowledge between the patient and the physician, the feelings and concerns that the patient may have, the complexity of interactions among diagnoses and treatments, and the lack of time or training to conduct a fruitful discussion with the patient and the family or caregivers. This means that both clinicians and patients should find effective ways and tools to translate and share knowledge, despite their differences in terms of backgrounds, medical mastery, concerns, and doubts [3, 9]. The recent clinical literature has highlighted the relevance of adequate facilitators to support such a practice [2, 10], including the role of non-technical skills in improving communication [5, 11, 12].

Recent experiences and studies in trauma and emergency settings have underlined how the implementation and measurement of SDM are complex [8]. Indeed, sometimes the patient’s life may be in danger, leaving little time to make a clinical decision. Still, other times, conditions may allow physicians hours or more before the treatment begins, giving patients time to learn about the potential alternatives and make an informed decision about the next medical steps. The surgical literature [13] has stressed the benefits of applying SDM in trauma and emergency surgery, including better clinical outcomes by enhancing the quality of patient’s recovery [14], better managing the patient’s expectations [15], and limiting surgical interventions when they are not necessary [16]. Benefits can also be gathered from the hospital’s organization, as SDM provides better patient management and flow [17], stimulating patient-centric care [18] and leading to patient empowerment and co-production practices [19, 20]. All in all, when SDM is employed in trauma and emergency settings, patients and their families enjoy a better hospital experience [21] while physicians comply with ethics and moral norms [22]. Training and counseling appear as the most common facilitators for the effective implementation of SDM in trauma and emergency settings [21, 23]. Time and resource limitations make it difficult for the in-charge physician to have a fruitful conversation with the patient. When the patient load is heavy, there is little opportunity to spend time with a single patient who needs to understand and decide from a range of clinical alternatives.

Starting from these premises and research gaps, the paper aims to deepen the barriers, facilitators, and dynamics of SDM in trauma and emergency settings, by employing a multi-national survey endorsed by the World Society of Emergency Surgery (WSES).

Methods

Design and setting

Our exploratory study of the international trauma and emergency surgeons’ community used a population-based online questionnaire to gather demographic, knowledge, and practice-based information regarding their SDM understanding and dynamics. The online questionnaire was conducted in English through Google Forms [4, 6], and followed the Checklist for Reporting Results of Internet E-Surveys (CHERRIES), as reported in Appendix 1 [24].

A steering committee within the WSES was created, involving a multidisciplinary panel of practitioners and scholars in the fields of trauma and emergency surgery, healthcare management, innovation, and organization science. No Institutional Review Board (IRB) approval was needed, as non-interventional studies do not necessarily require approval by an ethics committee. The survey participants were exclusively clinicians who decided to participate voluntarily. No significant identifying information about the participants is possible. The study was conducted following the principles of the Declaration of Helsinki.

Starting from a review of the literature, a research protocol was conceived and shared by the principal investigators (LC and FDM) with the steering committee. The leading references to create the protocol and the survey structure were gathered from Woltz et al. [8], Mathijssen et al. [7], Cobianchi et al. [4], and Dal Mas et al. [2]. Before the initiative’s official launch, the research protocol and the online survey were reviewed by the steering committee and filled in by a sample of surgeons to avoid mistakes.

The survey was launched at the end of November 2021 and remained open until mid-August 2022. An e-mail invitation to participate in the initiative was sent out within the WSES newsletter to all 917 WSES members and disseminated through the society’s website and Twitter profile. Moreover, an e-mail invitation was sent out to the mailing list of the Team Dynamics Study Group [4, 6]. Four reminders followed through the same channels. Although WSES membership was not a prerequisite for enrollment, we expect that most of the participants come from the 917 WSES members to whom the research initiative was advertised, obtaining, therefore, a response rate close to 70%.

The invitation e-mail comprised detailed information about the initiative’s rationale and aims, the expected duration (approximately 10 min), and the opportunity of signing up in the Team Dynamics Study Group to continue investigating and sharing the findings. The participants’ identities were kept anonymous. The research protocol and the investigators’ names were kept confidential as well.

Survey

The first group of questions aimed at understanding the participants’ characteristics. The same questions were gathered from the previous Team Dynamics investigation [4, 6], and they included gender, the number of years of experience in trauma/emergency surgery, the kind of institution (academic vs non-academic), the country, the position held, the eventual participation within a trauma team (institutionalized or not, and of which kind), the type of trauma leader, the educational courses attended, and the presence of diverse team members.

The second group of questions aspired to understand trauma and emergency surgeons’ perception and knowledge of SDM by employing a yes/no question and an open question, following Woltz et al. [8].

The third group of questions wanted to investigate the frequency and perception of SDM starting from a list of items gathered from Woltz et al. [8] and Mathijssen et al. [7] to be rated on a 5-point Likert scale.

The fourth and last group of questions aimed at exploring the barriers and facilitators to SDM, to be rated on a 5-point Likert scale. More specifically, barriers were gathered from the study of Mathijssen et al. [7], while facilitators were inspired from the original list of 32 items mentioned by Dal Mas et al. [2], which were later grouped into nine categories, as also reported by other investigations [4].

The survey’s questions related to SDM are reported in Appendix 2.

Statistical analysis

Descriptive statistical analysis was conducted using the software R [25].

Manual coding was also employed concerning the qualitative questions. Concerning the understanding of SDM, participants were then asked to provide a definition of SDM through an open question. Results were manually coded by two researchers (LC and FDM), who rated each statement as concordant, discordant, or inconclusive, following the analysis of Woltz et al. [8] and Cobianchi et al. [4]. The same methodology was applied concerning the situations or conditions where SDM could be used. Two researchers (LC and FDM) coded all the statements to group them into meaningful categories.

Results

Participants

The questionnaire was filled in by 650 surgeons. Participants came from 71 countries on the five continents. Still, the sample was not equally distributed, with most surgeons coming from Europe (477, 73%) and especially Italy (251, 39%). The ten countries with the highest number of participants globally accounted for 465 respondents (72%).

The sample was made up of 118 female surgeons (18%), 531 males (82%), and one participant preferring not to disclose their gender. Surgeons had a range of 1–35 years of experience in the field, with a mean of 12. Most participants came from academic institutions (499, 77% of the sample), with 540 of them officially part of an emergency surgery team (83%). The roles declared varied, with the majority of surgeons being senior consultants (233, 36%). One hundred and fourteen (18%) were departmental heads.

Table 1 reports the descriptive statistics about the participants and institutions involved in the study, while Table 2 highlights some statistics about the number of respondents according to their locations.

Table 1 Descriptive statistics about surgeons and institutions participating in the investigation
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Table 2 Number of respondents according to their location
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Understanding of SDM

Regarding the understanding of the concept of SDM, surgeons were first asked if they were familiar with the term. Four hundred and eighty-four of them (74%) replied they were, and the remaining 166 (26%) declared they were not. As specified, each given statement was rated as concordant, discordant, or inconclusive.

To be rated as concordant, definitions needed to stress the concept of surgeons (or multidisciplinary trauma or emergency team) involving the patient in the clinical decisions. Interestingly, less than half of the participants (290, 45% of the sample) provided definitions that could be rated as concordant according to the abovementioned criterion. 93 participants (14% of the sample) gave responses that were incomplete, showing only a partial view of the phenomenon, being so rated as inconclusive. The remaining 267 surgeons (41%) gave answers that were not fitting the general definition of SDM. Interestingly, while some participants declared that they did not know what SDM meant, or did not provide any concrete answers (73, equal to 11%), most (194, 30% of the sample) stressed the multidisciplinary aspect of emergency care and the need to decide within the clinical team, not even mentioning the possibility to include the patient in the picture.

Table 3 reports some examples of answers that were rated as concordant, inconclusive, and discordant [4, 8].

Table 3 Examples and ways of rating the given answers to the question: What is your understanding of SDM?
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Engaging in SDM

Surgeons were asked to rate 15 items gathered from the studies of Woltz et al. [8] and Mathijssen et al. [7] using a 5-point Likert scale where 1 meant “not important” and 5 “very important.”

Although all 15 items got a mean evaluation of over 3.78, some of them got a major agreement. Findings reveal a significant relationship between an SDM mindset and a patient-centric view. In particular, surgeons recognized the value of informing the patient about the pros and cons of the chosen treatment plan (mean 4.62, with a standard deviation of 0.67), and explaining the chance of those favorable or adverse outcomes happening. Decision-making seems a very relevant concept to trauma and emergency surgeons, as they recognized the importance of sharing the fact that a decision has to be made.

Among the less rated items, we underline the need to spend time investigating the patient’s preferences (mean 3.78, with a standard deviation of 1). Interestingly, there was one more similar item in the list, reported as “Understanding the patient’s references,” which got a higher evaluation (mean 4.21, with a standard deviation of 0.89). The less rated item was about asking the patient to bring someone (maybe a family member or caregiver) to the consultation (mean 3.78, with a standard deviation of 1.03).

Table 4 reports the results related to the relevant items to SDM.

Table 4 Relevant items to SDM
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The survey also included a list of potential barriers that could make it challenging for surgeons to engage in SDM practices. Those items were gathered from the investigation of Mathijssen et al. [7], to be rated using a 5-point Likert scale where 1 meant “not important” and 5 “very important.”

The participants stressed that in emergency contexts, decisions often need to be taken in within a very short period of time (mean 4.11, standard deviation 0.88). They also claimed that emergency and trauma teams collaborate successfully (mean 3.83, standard deviation 0.94). Surgeons denied that SDM practices might be in contrast with clinical guidelines (mean 2.16, standard deviation 1.2). Therefore, that would not represent a barrier to its practical application.

Full results and ratings are reported in Table 5.

Table 5 Barriers to SDM
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Situations or diagnoses in trauma and emergency surgery suitable for SDM

Through an open question, participants were asked to name any situation and/or clinical condition in which SDM practices may be successfully applied. As anticipated, statements were coded and grouped into meaningful categories.

Part of the sample named some situations. For instance, 84 participants claimed that any situation may be suitable for SDM practices if the patient or a substitute (namely, a family member or caregiver) is available to discuss with the physician. 82 surgeons named some trauma situations, with the patient still able to interact with the clinical team. 20 participants were not able to provide examples. Interesting enough, 11 of them claimed that no situation in trauma or emergency contexts would be suitable for SDM practices.

The other part of the sample preferred to name some specific conditions or diagnoses. Among the most rated, we can recall appendicitis/diverticular disease (116), acute abdomen (54), non-urgent oncological issues (37), acute cholecystitis (36), and bowel obstruction (31).

The full list of items is reported in Table 6.

Table 6 Situations/diagnoses suitable for SDM
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Facilitators

Surgeons were asked about the facilitators that could support SDM practices. Those which recorded the highest importance were training (mean 4.3/5), time to engage patients (mean 4.19/5), clinical guidelines and cases (mean 4.18/5), and cultural competence (mean 4.17/5). The less rated item was that of electronic medical records (mean 3.74/5). Results are reported in Table 7.

Table 7 Facilitators to SDM
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Discussion

SDM represents one of the pillars of the modern healthcare scenario [26]. Scholars, policymakers, and healthcare institutions advocate the right of the patient to actively participate in clinical decisions, along with the physicians or medical team in charge. The advantages of SDM are numerous [13], and they recall better satisfaction and hospital experience for the patient [14], and better alignment with the chosen treatment [19, 20].

While in some medical specialities, like oncology, SDM is widely applied [27, 28], previous studies have underlined difficulties in engaging in SDM practices in emergency and trauma contexts [8]. Suppose some of such barriers refer to the fact that sometimes patients’ lives are in danger, or the patient is unconscious and maybe his/her identity is unknown. Still, there may be some emergency and trauma situations in which SDM can be applied, as there may be hours or more time available before the treatment begins.

Our investigation, endorsed by the WSES, had to aim to deepen the dynamics, understanding, barriers, and facilitators of SDM practices, enquiring trauma, and emergency surgeons. Results are in line with the previous literature [8], and some interesting findings emerge.

While most of the surgeons declared that they were familiar with the term “SDM,” open responses about its meaning depict a completely different image. Indeed, only 45% of the participants were able to provide a definition that matched the concept of the patient being involved in the clinical decisions. More than 11% of our participants had no idea about what SDM entailed, and the 30% of them had a completely different (and wrong) meaning in mind. Hundreds of surgeons saw SDM as the clinical trauma or emergency team members co-deciding and discussing the treatment options for the patient. The word “multidisciplinary” was named several times to stress the effort to join forces by enquiring colleagues with different backgrounds or expertise. Still, the process was seen as “doctors-only.” Interestingly, several surgeons name the need to find a solution “in the best patient’s interests” to underline how much physicians care about the best possible outcome for their patients. Still, it seems like it is neither doable nor useful to engage the patient and the family in the decision-making process. Clinical teams know how to do their job, and together they can reach the best clinical decision according to the situation. All the efforts are, indeed, dedicated to adequate knowledge translation and communication processes within the team, involving also non-technical skills like leadership [1, 4].

Similar results can also be gathered when deepening the topics of engaging in SDM processes in terms of practices and barriers. Surgeons generally recognize the importance of informing the patient about a specific treatment option’s advantages and hazards and aligning (whenever possible) the treatment to the patient’s values and wishes. However, surgeons seem less available to “investigate” such preferences when they are not transparent or maybe when a communication effort is required to engage with the patient. Barriers are defined mainly in the lack of time that often characterizes trauma and emergency contexts. Still, when enquired about possible situations or conditions when SDM might be successfully applied, surgeons did provide several examples. Among the facilitators to support such practices, participants named training but also clinical guidelines, while surgeons seem to have less trust in technological devices and online tools.

Our investigation underlined how trauma and emergency surgeons seem more concentrated on making things work within their teams rather than engaging in dialogues with their patients, with a lack of an in-depth understanding of the benefits of such a practice. Such results are not surprising, not only as emergency and trauma situations often need to be managed within minutes, but also when we consider the debate going on in such a specific surgical speciality. Indeed, team dynamics are deemed crucial to reaching the best clinical outcomes, and much effort (also from scientific societies like the WSES) has been concentrated on topics like communication, non-technical skills, etc. It seems like surgeons see the best value in making their teams work smoothly than looking at what is happening outside.

As said, the literature has underlined how engaging in SDM practices requires adequate tools and facilitators, as the competencies and emotional gap between the patient and the physician may be broad [29]. Still, a patient-centric philosophy of care cannot leave such topics behind, even when it comes to challenging situations like those connected to trauma or emergencies. While surgeons strongly believe in training, they also rely on clinical guidelines, which should encompass such principles and values even when reporting tough clinical situations or conditions. In this perspective, the role of scientific societies like the WSES is again crucial to take the lead in stimulating a paradigm shift, in which team dynamics are essential, but so are the relationships with the patients. In such a view, other team members may support surgeons in successfully dealing with such dynamics, for example, nurses, who usually spend more time with patients and their families [30,31,32,33].

Last but not least, an open issue arises about using technologies to support SDM practices. Do such technological tools represent minor or weak support for SDM, or is there a problem connected to the digital culture among healthcare professionals? The fact that such an item records the highest standard deviation (1.11) highlights a significant divergence in opinions. Therefore, such an issue deserves further investigation in future studies.

Limitations

Although our sample is numerous, with 650 participants, it is not equally distributed. Indeed, most participants work in Europe and, more specifically, in Italy. The specific situation of the Italian and European contexts (including the features of National Healthcare Systems) may have biased some of our results. Moreover, most participants are men and belong to academic institutions. Again, such situations may have impacted some views or responses. Our limitations, along with the perceived interest of the international community on the topic of SDM, may stimulate new in-depth studies and investigations on such a relevant and up-to-date theme.

Conclusion

In concluding our work, we should begin from the premise that inspired it. SDM represents a crucial and “hot” topic in today’s healthcare atmosphere, involving all medical specialities. Emergency and trauma contexts often represent challenging situations in which SDM may look difficult to apply. Surprisingly, only less than half of the inquired surgeons are familiar with the term and meaning of SDM. The 30% of the participants of our study wrongly identify SDM as multidisciplinary decision-making among medical team’s members, not seeing the value of involving the patient in the process. Modern patient-centered ethics sees a call for all medical professionals to find ways to engage patients in clinical decisions whenever possible. Such a call involves emergency and trauma surgeons as well.

Our results suggest the need for scientific societies like the WSES, undergraduate and postgraduate educational institutions, and healthcare managers and policymakers to stimulate an SDM culture, also through training courses and formalized guidelines. Therefore, our findings may be relevant to support practical actions.