Learning gain of an ATLS®-based interprofessional and multidisciplinary in-situ simulation training of trauma resuscitation

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Lock, Sarah König, Oliver Happel, Mila M. Paul This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8192330/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 17 Mar, 2026 Read the published version in European Journal of Trauma and Emergency Surgery → Version 1 posted 9 You are reading this latest preprint version Abstract Purpose Team performance in polytrauma management determines patient outcome and is crucially shaped by Crew Resource Management (CRM). This study aimed to evaluate the effects of an interdisciplinary, interprofessional, in-situ, simulation- and ATLS®-based trauma team training with a focus on CRM principles. We conducted a retrospective analysis based on self-assessed questionnaires. As trauma teams were composed of multiple subspecialties with heterogeneous levels of expertise, we hypothesized that different subgroups might benefit to varying degrees from the training. Methods Between 03/2022 and 11/2023, 36 training sessions including 238 participants took place at a German Level I trauma center. Participants completed post-intervention questionnaires and subgroup analysis including exploratory factor analysis was performed. Results Participants came from anesthesiology, surgery and radiology in equal proportions and differed in working experience, professional role, and exposure to polytrauma management. Exploratory factor analysis identified the three CRM dimensions: i) personal operational competence, ii) team communication, and iii) decision making. Learning gains were evident across all subgroups, however, providers demonstrated particularly high improvements in personal operational competence compared to experts (p < 0.01). Conclusion In-situ trauma team training enhanced CRM-related competencies in all professions and subspecialties, regardless of prior experience or trauma exposure. Thus, such trainings are well suited to improve team performance in polytrauma care at a high-volume trauma center. CRM simulation team training polytrauma ATLS® factor analysis Figures Figure 1 Figure 2 INTRODUCTION Resuscitation and management of polytrauma patients involve complex and time-critical tasks, where survival depends on coordinated team performance. Worldwide, many organizations have formed multi-professional healthcare teams to manage critically ill patients, which can improve outcomes of severely injured patients [ 1 ]. In line with typical clinical practice, communication within these teams represents a unique challenge as they are frequently assembled spontaneously (‘ad-hoc’) and on short notice due to structural constraints. Individual members of the trauma team arise from distinct subspecialties such as trauma surgery, general surgery, anesthesia, radiology, and others. Whilst each member may have received a specific training in their respective disciplines, systematic preparation for interprofessional team performance and communication under acute stress is often lacking. For years, there has been a recommendation to provide training for healthcare professionals in teamwork and other non-technical skills [ 2 ]. Moreover, growing scientific evidence on Crew Resource Management (CRM) training effectiveness in medicine has globally spread this training principle in the past decades [ 3 ]. Recent systematic reviews further confirmed the effectiveness of simulation-based trauma team training in improving both technical and non-technical skills [ 4 – 6 ]. CRM, originally derived from the aviation industry, has demonstrated positive effects on teamwork and patient safety [ 7 ]. As one of 23 Level I trauma centers in Bavaria, Germany, the University Hospital in Wuerzburg launched an interdisciplinary and interprofessional in-situ team training (iSRST) based on ATLS® (Advanced Trauma Life Support) principles and simulation scenarios in March 2022. Since then, trainings have taken place twice a year. It was designed to reflect the challenges in multidisciplinary, interprofessional and interpersonal collaboration. The educational concept consists of trauma patient scenarios and includes a theoretical introduction, two in-situ simulations followed by structured debriefings within a 4-hour program. Training concept and implementation received high acceptance and overall satisfaction [ 8 ]. To evaluate training effects, we applied Kirkpatrick’s framework of educational evaluation [ 9 ]. Since our design relied on self-assessed retrospective questionnaires, the analysis corresponds primarily to level 2 (‘Learning’). While self-assessment may only weakly correlate with objectively measured performance [ 10 , 11 ] it is frequently used for feasibility reasons and to capture learner perceptions. We hypothesized that participation would improve self-assessed competencies in defined CRM principles. However, it remains unclear whether different professional subgroups benefit equally, as transfer to real-life trauma care may depend on prior experience and role [ 1 ]. Therefore, this study aimed to identify underlying CRM principles in participant’s learning gains and to explore subgroup-specific differences. We formulated the following research questions: Which CRM-related competencies can be identified as underlying constructs in the self-assessed learning gains of participants in ATLS®-based in-situ trauma team training? Do different subgroups (profession, role, level of experience) benefit differently from the training in terms of CRM competencies? What implications arise for the curricular integration of interprofessional simulation trainings in trauma care? METHODS Structure of the team training The iSRST concept was developed by an interdisciplinary team consisting of physicians from the Departments of Trauma Surgery, General Surgery, Anesthesiology, and the Institute of Radiology, in collaboration with the simulation team of the Department of Anesthesiology, Intensive Care, Emergency and Pain Medicine at the University Hospital of Wuerzburg [ 12 ]. For voluntary participation, physicians from the mentioned departments and nurses from emergency department and anesthesia, as well as radiologic technologists (RT) were invited. This recruitment strategy ensured that training groups closely mirrored the real-life composition of ad-hoc trauma teams. The trainings were accompanied by audio and video recordings (SIMStation GmbH, Vienna, Austria) used to support structured debriefings. In the implementation of the trauma patient scenarios, a simulation phantom (Resusci Anne Simulator, Laerdal Medical AS, Stavanger, Norway) as well as standard non-sterile consumables simulated materials (e.g., mock blood products) were utilized. For radiological assessment, anonymized ultrasound and computed tomography (CT) images from actual clinical cases were provided. Each training session followed a standardized scheme: interactive team discussions regarding ATLS® and CRM-principles followed by a phase to ensure participants were familiar with the technical environment (‘familiarization’). Next, training groups were engaged in two simulation scenarios starting with the patient’s announcement, following the standard algorithm for polytrauma care in the in-situ environment. Details of all simulation scenarios used in the years 2022 and 2023 including ATLS®-relevant decision points, are provided in Supplementary Table 1. Scenarios were followed by structured debriefings using video and audio recordings. The training concluded with an oral feedback round. Finally, participants were asked to voluntarily and anonymously answer the questionnaires distributed at the end of each training session. Questionnaires Data collection was conducted anonymously and on a voluntary basis. The initial questionnaire included demographic data and items on course satisfaction. In November 2023, the instrument was revised to additionally assess self-perceived learning progress regarding predefined learning objectives. The complete questionnaire, including the main question categories with scale values and items, is available Supplementary Table 2. The subgroup analysis was conducted based on the demographic data regarding specialty (Surgery, Anesthesiology, Radiology), employment status (physician and non-physician positions), and work experience. In terms of work experience, the following groups were classified as ‘experts’: specialist physicians and assistants with more than 5 years of experience, physicians with advanced training and ATLS® certification, and physicians with at least weekly trauma care practice and 3–5 years of experience. The remaining participants were labeled as ‘providers’. Since this study concentrated on the self-assessed retrospective pre-test/ post-test agreements to predefined CRM-concepts, Box 1 displays the original German wording of these items. Evaluation items were adapted from CRM principles outlined by Rall and Gaba [ 13 ]. Items were streamlined and to focus on team-related attitudes rather than practical instructions (e.g., the original item ‘use mnemonics and look up’ was omitted). Statistical Analysis Analyses were conducted using descriptive statistics, including mean (M), minimum (Min), maximum (Max), standard deviation (SD), and skewness (Skew) of all questionnaire items. Mean individual and group learning gains were firstly calculated as a composite sum score (‘CRM-score’). We subjected the retrospective pretest assessments for CRM-criteria to an exploratory factor analysis (EFA) using maximum likelihood estimation and promax rotation to identify underlying dimensions of CRM-related constructs. Criteria for adequacy were p 0.50. The KMO coefficient indicated a high level of sampling adequacy (0.84), and Bartlett’s test of sphericity yielded a significant result (χ2 = 1158.707; df = 45; p < 0.001). Internal Consistency was evaluated using Cronbach’s alpha (α), where a value above 0.7 was deemed good, while between 0.6 and 0.7 was considered acceptable. Between-groups differences were analyzed using ANOVA and Welch-test. Pearson-correlation coefficients were computed to examine associations between items. Ethics approval The local institutional review and ethics board deemed the project not to constitute medical or epidemiological research on human subjects and therefore applied a simplified assessment protocol. The study design was reviewed by the Ethics Committee of the University of Wuerzburg, which confirmed that no formal consultation was required in accordance with § 15 of the Professional Code of Physicians (Decision No. 2022101101). Survey data from the questionnaires were retrieved anonymously using the EvaSys® platform (Lueneburg, Germany). Participation was voluntary, and data were processed and stored in compliance with local data protection regulations and the EU General Data Protection Regulatio. Audio and video recordings served exclusively to support structured debriefings during training and were not analyzed for research purpose. RESULTS Demographics In 2022 and 2023, a total of 238 doctors, nurses and RTs participated in the interdisciplinary team training (Fig. 1 , Table 1 ). The response rate for the questionnaires distributed at the end of each training session was 100%. Thus, 238 participants provided responses regarding their self-assessed learning gains in relation to CRM principles. Of these, 230 questionnaires were fully completed. During the period of this study, eight trauma scenarios were performed. Training groups consisted of eight individuals on average. Characteristics of training participants are listed in Table 1 . There was an even distribution between females (53%) and males (47%). According to in-house standards, teams were built by staff from Anesthesiology, Trauma and General Surgery, and Radiology. Nurses from surgery departments are listed as emergency department staff, radiology technicians (RT) were included in the subgroup of radiology (explaining the high number of participants, n = 28.1%). Nearly half of the participants were resident doctors, only 10.6% were specialists (senior doctors or consultants) and only 2% had senior positions (e.g., deputy head or director). 39.6% of all participants were trainee nurses, registered nurses or RTs. In terms of working experience, participants with 3–5 years prevailed (38.1%). About 50% of the study group stated that they participated at least weekly in polytrauma management (Table 1 ). Table 1 Characteristics of the study group. The table highlights demographic characteristics of all training participants in 2022 and 2023 constituting the study group. Absolute numbers and percentages are reported for age groups, gender, department, professional role, working experience and frequency of participation in polytrauma care. subgroup n = 238 n [%] Age [years] 60 4 1.7 Gender female 125 52.7 male 112 47.3 Department anesthesiology 84 35.7 general surgery 27 11.5 trauma surgery 28 11.9 radiology 66 28.1 emergency department staff 28 11.9 Professional role resident physician 144 47.8 specialist physician 32 10.6 senior medical position 6 2.0 trainee nurse 10 3.3 registered nurse 68 22.6 radiologic technician 41 13.7 Working experience < 1 year 25 7.9 1–2 years 38 12.1 3–5 years 120 38.1 6–9 years 44 14.0 10–19 years 55 17.5 ≥ 20 years 33 10.5 Frequency of participation in polytrauma care rarely 8 3.4 occasionally 60 25.8 monthly 29 12.4 weekly 96 41.2 daily 40 17.2 Table 2 Factor composition based on the exploratory factor analysis (EFA) for self-reported pre-test values. Cross-loadings with lower coefficients are not shown. Personal operational competence Team communication Decision making 1. I am familiar with my work environment in the trauma bay. 3. I can voice my concerns at any time. 9. I consider conducting short team meetings (10-for-10) relevant. 2. I feel like an active member of the team. 4. My opinion is heard. 10. I discard regular reevaluations according to the ABCDE approach to be meaningful. 5. The workflow in the trauma bay is clear to me. 7. I can ask for help anytime. 6. The task distribution within the trauma team is clear to me. 8. I recognize fixation errors and can avoid them. Analysis of self-estimated learning gain Between-group comparisons were conducted regarding the sum retrospective learning gains for all items, defined as the ‘CRM score’ difference (Δ = post – pre). Taking the ten items on the five-point Likert-scale into consideration, the highest theoretically attainable CRM-Score for an individual was 40. In the whole cohort, learning gain scores ranged between minimum − 3 and maximum 24 with a low mean value of ± SD of 4.95 ± 4.80 (12.4% of the possible 40-point gain). The average sum pre-test CRM-score was high at 37.94 points (76% of 50; SD = 6.46). In the post-test, the entire group showed even a higher average of 42.85 points (86% of 50; SD = 4.07). The cumulative retrospective learning gain was higher for female participants (5.16 ± 5.04) than for males (4.75 ± 4.37; F [23/205] = 1.66; p < 0.05). However, there was no difference among the groups based on department, professional role, working experience, and frequency of participation in polytrauma care (Supplementary Table 3). The effect sizes of the mentioned subgroups were consistently high and varied between 0.08 (department) and 0.16 (gender). Regarding the higher-level categories mentioned above, there was a higher self-assessed learning gain for providers (6.02 ± 5.69) than experts (4.13 ± 3.59; F [1/228] = 9.44); p < 0.01). Regarding training experience, no difference was found between the groups in terms of the CRM score (F [1/,72] = 0.67; p = 0.42). Subgroup analysis of underlying CRM principles Based on the criteria outlined in the statistical analysis section, a three-factor solution was found to offer the most suitable fit and demonstrated good internal consistency. We describe these three factors as follows (Fig. 2 ): personal operational competence : the self-assessed competence within the trauma bay working environment including knowledge about structural resources and role distribution and processes, number of items = 5 team communication : the knowledge that personal opinions are heard within the team and can be freely expressed without social pressure, number of items = 3 decision making : the awareness that the situation needs to be dynamically reevaluated and team time-outs are necessary, number of items = 2 The corresponding factor loadings are detailed in the Supplementary Material (Supplementary Table 4). In total, the three factors accounted for 52% of the item variance. Moderate Pearson correlation coefficients (0.31–0.54; p < 0.001) indicate a strong discriminative ability of the scales. Cronbach's α for the three factors was 0.68, representing acceptable internal consistency without evidence of redundancy. Mean sum pre-test and post-test scores for the three factors revealed no significant differences across the departments. Regarding prior working experience, significant differences were found for the first two factors in pre-test and post-test values (p < 0.001). The professional role did not influence pre-test and post-test ratings of any factor. Learning gains (Δ = post – pre) were computed for each CRM factor (Fig. 2 ). Between group analyses demonstrated no significant difference across departments (p = 0.848). Prior simulation training experience did not affect learning gains on the factors (p > 0.05). When groups were categorized by professional experience (experts vs providers), providers demonstrated larger gains in Personal operational competence (F [1/231] = 9.24; p 0.05). No differences by professional affiliation (physicians vs. non-physician participants) were observed for any factor (all p > 0.05). Paired t-tests confirmed significant pre–post improvements across all subgroups and factors (all p < 0.001, Fig. 2 ). DISCUSSION For trauma resuscitation and management of polytrauma patients, interprofessional communication and teamwork in the trauma bay are critical factors that largely contribute to sentinel events. Simulation-based team trainings is therefore a plausible approach to practice both technical and non-technical skills under realistic conditions. This is in line with findings from recent systematic reviews and meta-analyses demonstrating that simulation-based training improves team performance and human factor skills across diverse healthcare settings [ 14 , 15 ]. In this context, it improves both technical and non-technical skills [ 16 , 17 ]. Whereas the literature strongly supports the benefits of interprofessional CRM trainings in medical teams regarding communication and coordination [ 14 , 18 , 19 ], there is limited evidence on which CRM dimensions benefit for which subgroups. In this study, we evaluated an individually designed simulation-based interdisciplinary trauma team training at a Level I trauma center in Germany based on ATLS® principles. Our aim was to characterize the structure of learning gains across CRM dimensions and to examine subgroup differences by role, profession, and prior experience to inform instructional design. Recent studies have addressed particularly needs for team training in ad-hoc teams and report performance gains even without stable team constellations [ 20 , 21 ]. In line with Kirkpatrick’s framework, our evaluation corresponds to level 2 (‘Learning’) and relies on retrospective self-assessed competence gains [ 9 ]. While medical education literature suggests a weak correlation between self-assessment and objective performance measures [ 10 ], self-reports are pragmatic and minimize testing reactivity[ 11 ]. Due to the course concept involving voluntary participation, implementation of a structured summative assessment was not applicable. Given voluntary participation, summative performance testing was not feasible. The EFA revealed a three-factor model comprising personal operational competence, team communication, and decision making. Internal consistency was acceptable, and inter-item correlations indicated related yet distinct. While the first factor ( personal operational competence ) primarily addressed technical aspects within the working environment, the other two factors focused on non-technical team interaction. Within this framework, the largest mean learning gains occurred in items related to operational/ technical knowledge, particularly among less experienced participants (‘providers’). In healthcare training, technical and non-technical skills are typically regarded as two distinct concepts, both of which are crucial in managing and preventing critical or adverse events [ 22 , 23 ]. Non-technical skills are generally seen as cognitive and social skills, whereas technical skills involve the use of medical equipment and drugs, along with specific medical expertise [ 24 ]. The factors team communication and decision making showed highly significant gains across participant groups. These aspects touch upon the utilization of all available personnel resources without restriction, for example, due to existing hierarchies. Previous work in context of trauma teams support flatter structures [ 25 , 26 ], allowing team members to interact and communicate on an equal footing with a high amount of psychological safety [ 27 ]. Regarding team communication , no subgroup differences by department, experience, or profession were observed pre-post, indicating that all groups benefit from the training intervention. Our findings confirm that simulation-based training within trauma teams enhance communication and performance irrespective of prior job-related experience, with particularly pronounced gains in personal operational competence (workplace/ process) among less experienced participants. Therefore, it is reasonable not only to include members at all levels of experience in the training, but also to design scenarios that explicitly address communication-related issues and reinforce flat hierarchies. Finally, the attitude that situations should be dynamically reevaluated and repeated team time-outs are necessary (summarized in decision making ) yielded high pre- and post-test self-evaluated scores across all subgroups without between-group differences. Given the relatively small subgroup sizes, additional data collection may reveal a positive trend in this aspect with repeated training sessions. To date, it remains unclear whether self-reported pre-test values change among participants attending multiple training sessions over time. In summary, the iSRST appears to improve collaboration within the specified team structures. The training proves advantageous for all participating subgroups, regardless of their professional background, expertise or prior training experience. This is consistent with previous studies that both surgeons and anesthetists’ benefit from simulation-based training [ 28 – 30 ]. Nonetheless, there are specific limitations that need to be addressed. Firstly, our evaluation was designed to cover the second level of Kirkpatrick’s framework (‘Learning’). However, the levels 3 and 4 (corresponding to ‘Did the intervention result in a change of behavior?’ and ‘Did the intervention influence performance?’), still need to be evaluated in detail. Previous studies have reported longer time spent on trauma patients [ 31 ]. For this purpose, long-term data collection and statistical evaluation is warranted. Previous studies have addressed Kirkpatrick’s level 3 by comparing video-records of preintervention and repeated post-intervention simulations [ 32 ]. The present analysis was not intended to detect changes in global clinical endpoints (e.g., mortality, morbidity, and length of stay), which refer to level 4 by Kirkpatrick. Interpretation of these outcomes must incorporate additional context information, as they are often the result of a constellation of multiple factors and are less under the team’s direct control. Secondly, the durability of effects after a single short session remains uncertain; mid- and long-term follow-up is needed. Some authors reported retained improvement in non-technical skills following one-day training sessions in short timespans of one or two months [ 33 ]. Comparable findings have also been demonstrated in trauma-focused ATLS®-based trainings [ 34 ] and in prehospital emergency simulation settings [ 35 ]. Thus, the iSRST needs to be mid- and long-term evaluated. In addition, repeated training sessions will likely be necessary to sustain improvement regarding the CRM-concepts. The optimal time frequency and duration require further investigation. Regarding our individual course concept, participants evaluated that a frequency of 1–2 trainings per year suited their expectations towards the training best. Thirdly, our data fully relied on subjective self-assessment. Evaluating self-assessed competencies and calculating retrospective learning gains may be limited indicators of actual knowledge gain. A meta-analysis on this topic indicates that while self-assessments are commonly used in literature for evaluation purposes, they may be imperfect and unreliable indicators of underlying true learning [ 11 ]. Furthermore, there is a lack of consensus in the interpretation of self-assessments, sometimes treated as a facet of reactions (analogous Kirkpatrick’s level 1) and sometimes as an indicator of knowledge levels (analogous Kirkpatrick’s level 2) (‘Is Teacher Immediacy Actually Related to Student Cognitive Learning?’ [ 36 ]). Fourthly, our analysis used a purpose-designed individual questionnaire. Additional training aspects may not have been captured to the full extend. The single questionnaire precludes any conclusion regarding the sustainability of training effects. Finally, this was a single-center study conducted in a specific institutional context, which may limit the generalizability. Future multi-center trials with objective outcome measures and longitudinal follow-up are warranted to strengthen the evidence base. CONCLUSIONS In this single-center study, an ATLS®-based, interprofessional in-situ trauma team training produced significant pre-post gains in CRM-related competencies across professions, experience and clinical role. Providers showed the largest improvement in personal operational competence, whereas team communication and decision-making were comparable across subgroups. These findings support embedding structured, simulation-based team trainings with structured debriefings as a routine component of quality management in trauma centers and as targeted scaffolding for early-career staff. Future work should determine durability and optimal training dose and evaluate behavioral (Kirkpatrick’s level 3) and patient/ process outcomes (level 4) using objective measures in multi-center, longitudinal designs. Declarations DATA AVAILABILITY The authors confirm that the data supporting the findings of this study are available within this article. For further inquiries, please contact the corresponding author. Conflict of interest JFL and MMP are active ATLS®-instructors and receive professional fees from the Akademie der Unfallchirurgie (AUC) GmbH. Moreover, the authors declare no competing financial or non-financial interests related to this manuscript. Authors contributions SH, JFL and MMP designed experiments. SH, JFL, SK, OH and MMP conducted the simulation and data collection. SH, JFL and MMP analyzed the data. SH and MMP drafted the manuscript, SK performed the language editing and all authors commented on and revised the manuscript. JFL and MMP coordinated the study and secured funding. All authors read and approved the final version. Acknowledgments This work was supported by grants from the IZKF Wuerzburg to MMP (ZZ-30). The authors thank the training organization team, especially C. Hofmann, M. Wunderling, A. Stenzel, H. Huflage, N. Matthes, F. Weber and D. Röder. We are grateful to all training participants, the hospital board approving the program and the directors of all departments for their ongoing support. References Georgiou A, Lockey DJ. The performance and assessment of hospital trauma teams. Scand J Trauma Resusc Emerg Med. 2010;18:66. doi: 10.1186/1757-7241-18-66. Capella J, Smith S, Philp A, Putnam T, Gilbert C, Fry W, et al. Teamwork training improves the clinical care of trauma patients. J Surg Educ. 2010;67(6):439-43. doi: 10.1016/j.jsurg.2010.06.006. Buljac-Samardzic M, Doekhie KD, van Wijngaarden JDH. Interventions to improve team effectiveness within health care: a systematic review of the past decade. Hum Resour Health. 2020;18(1):2. doi: 10.1186/s12960-019-0411-3. Barleycorn D, Lee GA. How effective is trauma simulation as an educational process for healthcare providers within the trauma networks? A systematic review. Int Emerg Nurs. 2018;40:37-45. doi: 10.1016/j.ienj.2018.03.007. McLaughlin C, Barry W, Barin E, Kysh L, Auerbach MA, Upperman JS, et al. Multidisciplinary Simulation-Based Team Training for Trauma Resuscitation: A Scoping Review. J Surg Educ. 2019;76(6):1669-80. doi: 10.1016/j.jsurg.2019.05.002. Zhang C. A Literature Study of Medical Simulations for Non-Technical Skills Training in Emergency Medicine: Twenty Years of Progress, an Integrated Research Framework, and Future Research Avenues. Int J Environ Res Public Health. 2023;20(5). doi: 10.3390/ijerph20054487. Salas E, Burke CS, Bowers CA, Wilson KA. Team training in the skies: does crew resource management (CRM) training work? Hum Factors. 2001;43(4):641-74. doi: 10.1518/001872001775870386. Paul MM, Westphale S, Huflage H, Helf D, Hofmann C, König S, et al. Etablierung eines interdisziplinären Schockraumsimulationstrainings an einem überregionalen deutschen Traumazentrum. Notfall + Rettungsmedizin. 2023. doi: 10.1007/s10049-023-01181-6. Kirkpatrick DL. Techniques for evaluation training programs. Journal of the American Society of Training Directors. 1959;13:21-6. Davis DA, Mazmanian PE, Fordis M, Van Harrison R, Thorpe KE, Perrier L. Accuracy of physician self-assessment compared with observed measures of competence: a systematic review. Jama. 2006;296(9):1094-102. doi: 10.1001/jama.296.9.1094. Sitzmann T, Ely K, Brown KG, Bauer KN. Self-Assessment of Knowledge: A Cognitive Learning or Affective Measure? Academy of Management Learning & Education. 2010;9(2):169-91. doi: 10.5465/amle.2010.51428542. Happel O, Papenfuss T, Kranke P. [Training for real: simulation, team-training and communication to improve trauma management]. Anasthesiol Intensivmed Notfallmed Schmerzther. 2010;45(6):408-15. doi: 10.1055/s-0030-1255348. Gaba DM. Crisis resource management and teamwork training in anaesthesia. British journal of anaesthesia. 2010;105(1):3-6. doi: 10.1093/bja/aeq124. Abildgren L, Lebahn-Hadidi M, Mogensen CB, Toft P, Nielsen AB, Frandsen TF, et al. The effectiveness of improving healthcare teams' human factor skills using simulation-based training: a systematic review. Adv Simul (Lond). 2022;7(1):12. doi: 10.1186/s41077-022-00207-2. Hauta A, Iacobescu RA, Corlade-Andrei M, Nedelea PL, Cimpoesu CD. Translating training to medical practice in trauma care, a literature review. Eur J Trauma Emerg Surg. 2024;50(5):2017-28. doi: 10.1007/s00068-024-02548-1. Sauter TC, Hautz WE, Hostettler S, Brodmann-Maeder M, Martinolli L, Lehmann B, et al. Interprofessional and interdisciplinary simulation-based training leads to safe sedation procedures in the emergency department. Scand J Trauma Resusc Emerg Med. 2016;24:97. doi: 10.1186/s13049-016-0291-7. Wayne DB, Butter J, Siddall VJ, Fudala MJ, Wade LD, Feinglass J, et al. Mastery learning of advanced cardiac life support skills by internal medicine residents using simulation technology and deliberate practice. J Gen Intern Med. 2006;21(3):251-6. doi: 10.1111/j.1525-1497.2006.00341.x. Daniels K, Auguste T. Moving forward in patient safety: multidisciplinary team training. Semin Perinatol. 2013;37(3):146-50. doi: 10.1053/j.semperi.2013.02.004. Fung L, Boet S, Bould MD, Qosa H, Perrier L, Tricco A, et al. Impact of crisis resource management simulation-based training for interprofessional and interdisciplinary teams: A systematic review. J Interprof Care. 2015;29(5):433-44. doi: 10.3109/13561820.2015.1017555. Steinemann S, Berg B, Skinner A, DiTulio A, Anzelon K, Terada K, et al. In situ, multidisciplinary, simulation-based teamwork training improves early trauma care. J Surg Educ. 2011;68(6):472-7. doi: 10.1016/j.jsurg.2011.05.009. Jogerst KM, Cassidy DJ, Coe TM, Monette D, Sell N, Eurboonyanum C, et al. Interprofessional Trauma Team Training: Leveraging Each Specialties' Expertise to Teach Procedural-Based Skills. J Surg Educ. 2022;79(6):e273-e84. doi: 10.1016/j.jsurg.2022.09.010. Innocenti F, Tassinari I, Ralli ML, Bona A, Stefanone VT, Audisio R, et al. Improving technical and non-technical skills of emergency medicine residents through a program based on high-fidelity simulation. Intern Emerg Med. 2022;17(5):1471-80. doi: 10.1007/s11739-022-02940-y. Gamborg ML, Salling LB, Rolfing JD, Jensen RD. Training technical or non-technical skills: an arbitrary distinction? A scoping review. BMC Med Educ. 2024;24(1):1451. doi: 10.1186/s12909-024-06419-6. Fletcher GC, McGeorge P, Flin RH, Glavin RJ, Maran NJ. The role of non-technical skills in anaesthesia: a review of current literature. British journal of anaesthesia. 2002;88(3):418-29. doi: 10.1093/bja/88.3.418. Ruchholtz S, Waydhas C, Aufmkolk M, Tager G, Piepenbrink K, Stolke D, et al. [Interdisciplinary quality management in the treatment of severely injured patients. Validation of a QM system for the diagnostic and therapeutic process in early clinical management]. Unfallchirurg. 2001;104(10):927-37. doi: 10.1007/s001130170033. Schaser KD, Melcher I, Stockle U, Bail HJ, Puhl G, Settmacher U, et al. [Interdisciplinarity in reconstructive surgery of the extremities]. Unfallchirurg. 2004;107(9):732-43. doi: 10.1007/s00113-004-0844-5. Kumar S. Psychological Safety: What It Is, Why Teams Need It, and How to Make It Flourish. Chest. 2024;165(4):942-9. doi: 10.1016/j.chest.2023.11.016. Flin R, Patey R, Glavin R, Maran N. Anaesthetists' non-technical skills. British journal of anaesthesia. 2010;105(1):38-44. doi: 10.1093/bja/aeq134. Gusgen C, Anger F, Hauer T, Willms A, Buhr HJ, Germer CT, et al. [Advanced training of general and visceral surgeons in life-saving emergency surgery : Results of a survey among participants of a surgery course]. Chirurg. 2020;91(12):1044-52. doi: 10.1007/s00104-020-01170-2. Heaton SR, Little Z, Akhtar K, Ramachandran M, Lee J. Using simulation to train orthopaedic trainees in non-technical skills: A pilot study. World J Orthop. 2016;7(8):475-80. doi: 10.5312/wjo.v7.i8.475. Haerkens M, Kox M, Noe PM, Van Der Hoeven JG, Pickkers P. Crew Resource Management in the trauma room: a prospective 3-year cohort study. Eur J Emerg Med. 2018;25(4):281-7. doi: 10.1097/MEJ.0000000000000458. Roberts NK, Williams RG, Schwind CJ, Sutyak JA, McDowell C, Griffen D, et al. The impact of brief team communication, leadership and team behavior training on ad hoc team performance in trauma care settings. Am J Surg. 2014;207(2):170-8. doi: 10.1016/j.amjsurg.2013.06.016. Yee B, Naik VN, Joo HS, Savoldelli GL, Chung DY, Houston PL, et al. Nontechnical skills in anesthesia crisis management with repeated exposure to simulation-based education. Anesthesiology. 2005;103(2):241-8. doi: 10.1097/00000542-200508000-00006. Kim MJ, Lee JG, Lee SH. The Effectiveness of Simulation Training in an Advanced Trauma Life Support Program for General Surgery Residents: A Pilot Study. Journal of Trauma and Injury. 2020;33(4):219-26. doi: 10.20408/jti.2020.0015. Abelsson A, Rystedt I, Suserud BO, Lindwall L. Learning by simulation in prehospital emergency care - an integrative literature review. Scand J Caring Sci. 2016;30(2):234-40. doi: 10.1111/scs.12252. Rodríguez JI, Plax TG, Kearney P. Clarifying the relationship between teacher nonverbal immediacy and student cognitive learning: Affective learning as the central causal mediator. Communication Education. 2009;45(4):293-305. doi: 10.1080/03634529609379059. Box 1 Box 1 is available in the Supplementary Files section Additional Declarations No competing interests reported. Supplementary Files Box1.docx SupplementaryMaterial.docx Cite Share Download PDF Status: Published Journal Publication published 17 Mar, 2026 Read the published version in European Journal of Trauma and Emergency Surgery → Version 1 posted Editorial decision: Revision requested 15 Jan, 2026 Reviews received at journal 14 Jan, 2026 Reviews received at journal 26 Nov, 2025 Reviewers agreed at journal 26 Nov, 2025 Reviewers agreed at journal 26 Nov, 2025 Reviewers invited by journal 26 Nov, 2025 Editor assigned by journal 25 Nov, 2025 Submission checks completed at journal 25 Nov, 2025 First submitted to journal 24 Nov, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Lock","email":"","orcid":"","institution":"University Hospital Würzburg","correspondingAuthor":false,"prefix":"","firstName":"Johan","middleName":"F.","lastName":"Lock","suffix":""},{"id":551398219,"identity":"2ac81cbd-6fd6-4d66-9bbb-6b628228e616","order_by":2,"name":"Sarah König","email":"","orcid":"","institution":"University Hospital Würzburg","correspondingAuthor":false,"prefix":"","firstName":"Sarah","middleName":"","lastName":"König","suffix":""},{"id":551398220,"identity":"09172241-64f5-4065-9bf1-fa79220474c8","order_by":3,"name":"Oliver Happel","email":"","orcid":"","institution":"University Hospital Würzburg","correspondingAuthor":false,"prefix":"","firstName":"Oliver","middleName":"","lastName":"Happel","suffix":""},{"id":551398221,"identity":"7dfdc4a2-acd2-44a8-859f-9f823bd5b5b0","order_by":4,"name":"Mila M. 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15:22:04","extension":"xml","order_by":7,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":129802,"visible":true,"origin":"","legend":"","description":"","filename":"72ea53875e9b4e24a4ff0c519c1501491structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-8192330/v1/890ce0bc9190c2f040e7e370.xml"},{"id":97460380,"identity":"fb8ba1e3-11d4-474b-a2b6-6b37bab12c0d","added_by":"auto","created_at":"2025-12-04 15:22:04","extension":"html","order_by":8,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":140757,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8192330/v1/e7945220c7aefaed57ef47ea.html"},{"id":97667974,"identity":"28b718e3-386c-417c-91b8-842068b80c20","added_by":"auto","created_at":"2025-12-08 09:24:34","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":745187,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eOriginal snapshots from training scenarios. \u003c/strong\u003eParticipants were trained in performing technical and non-technical skills in realistic, ATLS®-based polytrauma simulation cases.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8192330/v1/1fbc2cd8a395b8f537eecd55.png"},{"id":97460370,"identity":"ce22a53d-0998-4ecc-893d-03cf41368f6e","added_by":"auto","created_at":"2025-12-04 15:22:04","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":127728,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePre-test/ post-test differences in retrospective self-assessed competences by department, experience, and profession.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e***p \u0026lt; 0.001, significant between-group differences not visualized. White and grey boxes represent values before and after the training, respectively (pre-test/ post-test). In box plots, horizontal lines represent median, boxes quartiles and whiskers 10\u003csup\u003eth\u003c/sup\u003e and 90\u003csup\u003eth\u003c/sup\u003e percentiles. Scatter plots show individual outliers.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-8192330/v1/f71b5f5c6d515f27b6bd7340.png"},{"id":105224858,"identity":"57bf7a78-14f1-4a82-9298-0af7c60df003","added_by":"auto","created_at":"2026-03-23 16:16:47","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1915414,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8192330/v1/30cebf88-3e77-426d-b123-7c5b33a2d0d6.pdf"},{"id":97460367,"identity":"e2063a72-7103-4fe8-a290-0e25b317d56d","added_by":"auto","created_at":"2025-12-04 15:22:04","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":14222,"visible":true,"origin":"","legend":"","description":"","filename":"Box1.docx","url":"https://assets-eu.researchsquare.com/files/rs-8192330/v1/3e88775aa9925f55e6c90a2b.docx"},{"id":97667962,"identity":"bf37bdfc-aebd-4308-a415-e521c40bd134","added_by":"auto","created_at":"2025-12-08 09:24:33","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":24599,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryMaterial.docx","url":"https://assets-eu.researchsquare.com/files/rs-8192330/v1/e03859d8cd4244cfe315d053.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Learning gain of an ATLS®-based interprofessional and multidisciplinary in-situ simulation training of trauma resuscitation","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eResuscitation and management of polytrauma patients involve complex and time-critical tasks, where survival depends on coordinated team performance. Worldwide, many organizations have formed multi-professional healthcare teams to manage critically ill patients, which can improve outcomes of severely injured patients [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. In line with typical clinical practice, communication within these teams represents a unique challenge as they are frequently assembled spontaneously (\u0026lsquo;ad-hoc\u0026rsquo;) and on short notice due to structural constraints. Individual members of the trauma team arise from distinct subspecialties such as trauma surgery, general surgery, anesthesia, radiology, and others. Whilst each member may have received a specific training in their respective disciplines, systematic preparation for interprofessional team performance and communication under acute stress is often lacking.\u003c/p\u003e\u003cp\u003eFor years, there has been a recommendation to provide training for healthcare professionals in teamwork and other non-technical skills [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Moreover, growing scientific evidence on Crew Resource Management (CRM) training effectiveness in medicine has globally spread this training principle in the past decades [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Recent systematic reviews further confirmed the effectiveness of simulation-based trauma team training in improving both technical and non-technical skills [\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. CRM, originally derived from the aviation industry, has demonstrated positive effects on teamwork and patient safety [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAs one of 23 Level I trauma centers in Bavaria, Germany, the University Hospital in Wuerzburg launched an interdisciplinary and interprofessional in-situ team training (iSRST) based on ATLS\u0026reg; (Advanced Trauma Life Support) principles and simulation scenarios in March 2022. Since then, trainings have taken place twice a year. It was designed to reflect the challenges in multidisciplinary, interprofessional and interpersonal collaboration. The educational concept consists of trauma patient scenarios and includes a theoretical introduction, two in-situ simulations followed by structured debriefings within a 4-hour program. Training concept and implementation received high acceptance and overall satisfaction [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. To evaluate training effects, we applied Kirkpatrick\u0026rsquo;s framework of educational evaluation [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Since our design relied on self-assessed retrospective questionnaires, the analysis corresponds primarily to level 2 (\u0026lsquo;Learning\u0026rsquo;). While self-assessment may only weakly correlate with objectively measured performance [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] it is frequently used for feasibility reasons and to capture learner perceptions. We hypothesized that participation would improve self-assessed competencies in defined CRM principles. However, it remains unclear whether different professional subgroups benefit equally, as transfer to real-life trauma care may depend on prior experience and role [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Therefore, this study aimed to identify underlying CRM principles in participant\u0026rsquo;s learning gains and to explore subgroup-specific differences. We formulated the following research questions:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eWhich CRM-related competencies can be identified as underlying constructs in the self-assessed learning gains of participants in ATLS\u0026reg;-based in-situ trauma team training?\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eDo different subgroups (profession, role, level of experience) benefit differently from the training in terms of CRM competencies?\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eWhat implications arise for the curricular integration of interprofessional simulation trainings in trauma care?\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e"},{"header":"METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStructure of the team training\u003c/h2\u003e\u003cp\u003eThe iSRST concept was developed by an interdisciplinary team consisting of physicians from the Departments of Trauma Surgery, General Surgery, Anesthesiology, and the Institute of Radiology, in collaboration with the simulation team of the Department of Anesthesiology, Intensive Care, Emergency and Pain Medicine at the University Hospital of Wuerzburg [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. For voluntary participation, physicians from the mentioned departments and nurses from emergency department and anesthesia, as well as radiologic technologists (RT) were invited. This recruitment strategy ensured that training groups closely mirrored the real-life composition of ad-hoc trauma teams. The trainings were accompanied by audio and video recordings (SIMStation GmbH, Vienna, Austria) used to support structured debriefings. In the implementation of the trauma patient scenarios, a simulation phantom (Resusci Anne Simulator, Laerdal Medical AS, Stavanger, Norway) as well as standard non-sterile consumables simulated materials (e.g., mock blood products) were utilized. For radiological assessment, anonymized ultrasound and computed tomography (CT) images from actual clinical cases were provided. Each training session followed a standardized scheme: interactive team discussions regarding ATLS\u0026reg; and CRM-principles followed by a phase to ensure participants were familiar with the technical environment (\u0026lsquo;familiarization\u0026rsquo;). Next, training groups were engaged in two simulation scenarios starting with the patient\u0026rsquo;s announcement, following the standard algorithm for polytrauma care in the in-situ environment. Details of all simulation scenarios used in the years 2022 and 2023 including ATLS\u0026reg;-relevant decision points, are provided in Supplementary Table\u0026nbsp;1.\u003c/p\u003e\u003cp\u003eScenarios were followed by structured debriefings using video and audio recordings. The training concluded with an oral feedback round. Finally, participants were asked to voluntarily and anonymously answer the questionnaires distributed at the end of each training session.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eQuestionnaires\u003c/h3\u003e\n\u003cp\u003eData collection was conducted anonymously and on a voluntary basis. The initial questionnaire included demographic data and items on course satisfaction. In November 2023, the instrument was revised to additionally assess self-perceived learning progress regarding predefined learning objectives. The complete questionnaire, including the main question categories with scale values and items, is available Supplementary Table\u0026nbsp;2.\u003c/p\u003e\u003cp\u003eThe subgroup analysis was conducted based on the demographic data regarding specialty (Surgery, Anesthesiology, Radiology), employment status (physician and non-physician positions), and work experience. In terms of work experience, the following groups were classified as \u0026lsquo;experts\u0026rsquo;: specialist physicians and assistants with more than 5 years of experience, physicians with advanced training and ATLS\u0026reg; certification, and physicians with at least weekly trauma care practice and 3\u0026ndash;5 years of experience. The remaining participants were labeled as \u0026lsquo;providers\u0026rsquo;. Since this study concentrated on the self-assessed retrospective pre-test/ post-test agreements to predefined CRM-concepts, Box 1 displays the original German wording of these items.\u003c/p\u003e\u003cp\u003eEvaluation items were adapted from CRM principles outlined by Rall and Gaba [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Items were streamlined and to focus on team-related attitudes rather than practical instructions (e.g., the original item \u0026lsquo;use mnemonics and look up\u0026rsquo; was omitted).\u003c/p\u003e\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003eStatistical Analysis\u003c/h2\u003e\u003cp\u003eAnalyses were conducted using descriptive statistics, including mean (M), minimum (Min), maximum (Max), standard deviation (SD), and skewness (Skew) of all questionnaire items. Mean individual and group learning gains were firstly calculated as a composite sum score (\u0026lsquo;CRM-score\u0026rsquo;). We subjected the retrospective pretest assessments for CRM-criteria to an exploratory factor analysis (EFA) using maximum likelihood estimation and promax rotation to identify underlying dimensions of CRM-related constructs. Criteria for adequacy were p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 in Bartlett\u0026rsquo;s test of sphericity and a KMO coefficient\u0026thinsp;\u0026gt;\u0026thinsp;0.50. The KMO coefficient indicated a high level of sampling adequacy (0.84), and Bartlett\u0026rsquo;s test of sphericity yielded a significant result (χ2\u0026thinsp;=\u0026thinsp;1158.707; df\u0026thinsp;=\u0026thinsp;45; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Internal Consistency was evaluated using Cronbach\u0026rsquo;s alpha (α), where a value above 0.7 was deemed good, while between 0.6 and 0.7 was considered acceptable. Between-groups differences were analyzed using ANOVA and Welch-test. Pearson-correlation coefficients were computed to examine associations between items.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eEthics approval\u003c/h3\u003e\n\u003cp\u003eThe local institutional review and ethics board deemed the project not to constitute medical or epidemiological research on human subjects and therefore applied a simplified assessment protocol. The study design was reviewed by the Ethics Committee of the University of Wuerzburg, which confirmed that no formal consultation was required in accordance with \u0026sect;\u0026nbsp;15 of the Professional Code of Physicians (Decision No. 2022101101). Survey data from the questionnaires were retrieved anonymously using the EvaSys\u0026reg; platform (Lueneburg, Germany). Participation was voluntary, and data were processed and stored in compliance with local data protection regulations and the EU General Data Protection Regulatio. Audio and video recordings served exclusively to support structured debriefings during training and were not analyzed for research purpose.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eDemographics\u003c/h2\u003e\u003cp\u003e In 2022 and 2023, a total of 238 doctors, nurses and RTs participated in the interdisciplinary team training (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The response rate for the questionnaires distributed at the end of each training session was 100%. Thus, 238 participants provided responses regarding their self-assessed learning gains in relation to CRM principles. Of these, 230 questionnaires were fully completed. During the period of this study, eight trauma scenarios were performed. Training groups consisted of eight individuals on average. Characteristics of training participants are listed in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. There was an even distribution between females (53%) and males (47%). According to in-house standards, teams were built by staff from Anesthesiology, Trauma and General Surgery, and Radiology. Nurses from surgery departments are listed as emergency department staff, radiology technicians (RT) were included in the subgroup of radiology (explaining the high number of participants, n\u0026thinsp;=\u0026thinsp;28.1%). Nearly half of the participants were resident doctors, only 10.6% were specialists (senior doctors or consultants) and only 2% had senior positions (e.g., deputy head or director). 39.6% of all participants were trainee nurses, registered nurses or RTs. In terms of working experience, participants with 3\u0026ndash;5 years prevailed (38.1%). About 50% of the study group stated that they participated at least weekly in polytrauma management (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003e\u003cb\u003eCharacteristics of the study group.\u003c/b\u003e The table highlights demographic characteristics of all training participants in 2022 and 2023 constituting the study group. Absolute numbers and percentages are reported for age groups, gender, department, professional role, working experience and frequency of participation in polytrauma care.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003esubgroup\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003en\u0026thinsp;=\u0026thinsp;238\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003en [%]\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge [years]\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e84\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e35.4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e31\u0026ndash;40\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e111\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e46.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e41\u0026ndash;50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e9.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e51\u0026ndash;60\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e6.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;60\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eGender\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003efemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e125\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e52.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003emale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e112\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e47.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eDepartment\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eanesthesiology\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e84\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e35.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003egeneral surgery\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e27\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e11.5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003etrauma surgery\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e28\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e11.9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eradiology\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e66\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e28.1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eemergency department staff\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e28\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e11.9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eProfessional role\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eresident physician\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e144\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e47.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003especialist physician\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e32\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e10.6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003esenior medical position\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003etrainee nurse\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eregistered nurse\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e68\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e22.6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eradiologic technician\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e41\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e13.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eWorking experience\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;1 year\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e7.9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1\u0026ndash;2 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e38\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e12.1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3\u0026ndash;5 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e120\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e38.1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6\u0026ndash;9 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e44\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e14.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10\u0026ndash;19 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e55\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e17.5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026ge;\u0026thinsp;20 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e10.5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eFrequency of participation in polytrauma care\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003erarely\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3.4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eoccasionally\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e60\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e25.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003emonthly\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e12.4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eweekly\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e96\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e41.2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003edaily\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e40\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e17.2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003e\u003cb\u003eFactor composition based on the exploratory factor analysis (EFA) for self-reported pre-test values.\u003c/b\u003e Cross-loadings with lower coefficients are not shown.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePersonal operational competence\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTeam communication\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eDecision making\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1. I am familiar with my work environment in the trauma bay.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3. I can voice my concerns at any time.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e9. I consider conducting short team meetings (10-for-10) relevant.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2. I feel like an active member of the team.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4. My opinion is heard.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10. I discard regular reevaluations according to the ABCDE approach to be meaningful.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e5. The workflow in the trauma bay is clear to me.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7. I can ask for help anytime.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e6. The task distribution within the trauma team is clear to me.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e8. I recognize fixation errors and can avoid them.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eAnalysis of self-estimated learning gain\u003c/h3\u003e\n\u003cp\u003eBetween-group comparisons were conducted regarding the sum retrospective learning gains for all items, defined as the \u0026lsquo;CRM score\u0026rsquo; difference (Δ\u0026thinsp;=\u0026thinsp;post \u0026ndash; pre). Taking the ten items on the five-point Likert-scale into consideration, the highest theoretically attainable CRM-Score for an individual was 40. In the whole cohort, learning gain scores ranged between minimum \u0026minus;\u0026thinsp;3 and maximum 24 with a low mean value of \u0026plusmn;\u0026thinsp;SD of 4.95\u0026thinsp;\u0026plusmn;\u0026thinsp;4.80 (12.4% of the possible 40-point gain). The average sum pre-test CRM-score was high at 37.94 points (76% of 50; SD\u0026thinsp;=\u0026thinsp;6.46). In the post-test, the entire group showed even a higher average of 42.85 points (86% of 50; SD\u0026thinsp;=\u0026thinsp;4.07). The cumulative retrospective learning gain was higher for female participants (5.16\u0026thinsp;\u0026plusmn;\u0026thinsp;5.04) than for males (4.75\u0026thinsp;\u0026plusmn;\u0026thinsp;4.37; F \u003csub\u003e[23/205]\u003c/sub\u003e\u0026thinsp;=\u0026thinsp;1.66; p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). However, there was no difference among the groups based on department, professional role, working experience, and frequency of participation in polytrauma care (Supplementary Table\u0026nbsp;3). The effect sizes of the mentioned subgroups were consistently high and varied between 0.08 (department) and 0.16 (gender). Regarding the higher-level categories mentioned above, there was a higher self-assessed learning gain for providers (6.02\u0026thinsp;\u0026plusmn;\u0026thinsp;5.69) than experts (4.13\u0026thinsp;\u0026plusmn;\u0026thinsp;3.59; F \u003csub\u003e[1/228]\u003c/sub\u003e\u0026thinsp;=\u0026thinsp;9.44); p\u0026thinsp;\u0026lt;\u0026thinsp;0.01). Regarding training experience, no difference was found between the groups in terms of the CRM score (F \u003csub\u003e[1/,72]\u003c/sub\u003e\u0026thinsp;=\u0026thinsp;0.67; p\u0026thinsp;=\u0026thinsp;0.42).\u003c/p\u003e\n\u003ch3\u003eSubgroup analysis of underlying CRM principles\u003c/h3\u003e\n\u003cp\u003eBased on the criteria outlined in the statistical analysis section, a three-factor solution was found to offer the most suitable fit and demonstrated good internal consistency. We describe these three factors as follows (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e):\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e\u003cem\u003epersonal operational competence\u003c/em\u003e: the self-assessed competence within the trauma bay working environment including knowledge about structural resources and role distribution and processes, number of items\u0026thinsp;=\u0026thinsp;5\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e\u003cem\u003eteam communication\u003c/em\u003e: the knowledge that personal opinions are heard within the team and can be freely expressed without social pressure, number of items\u0026thinsp;=\u0026thinsp;3\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e\u003cem\u003edecision making\u003c/em\u003e: the awareness that the situation needs to be dynamically reevaluated and team time-outs are necessary, number of items\u0026thinsp;=\u0026thinsp;2\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e\u003cp\u003eThe corresponding factor loadings are detailed in the Supplementary Material (Supplementary Table\u0026nbsp;4). In total, the three factors accounted for 52% of the item variance. Moderate Pearson correlation coefficients (0.31\u0026ndash;0.54; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) indicate a strong discriminative ability of the scales. Cronbach's α for the three factors was 0.68, representing acceptable internal consistency without evidence of redundancy.\u003c/p\u003e\u003cp\u003eMean sum pre-test and post-test scores for the three factors revealed no significant differences across the departments. Regarding prior working experience, significant differences were found for the first two factors in pre-test and post-test values (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The professional role did not influence pre-test and post-test ratings of any factor. Learning gains (Δ\u0026thinsp;=\u0026thinsp;post \u0026ndash; pre) were computed for each CRM factor (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Between group analyses demonstrated no significant difference across departments (p\u0026thinsp;=\u0026thinsp;0.848). Prior simulation training experience did not affect learning gains on the factors (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). When groups were categorized by professional experience (experts vs providers), providers demonstrated larger gains in Personal operational competence (F \u003csub\u003e[1/231]\u003c/sub\u003e\u0026thinsp;=\u0026thinsp;9.24; p\u0026thinsp;\u0026lt;\u0026thinsp;0.01), whereas Team communication and Decision making did not differ between groups (all p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). No differences by professional affiliation (physicians vs. non-physician participants) were observed for any factor (all p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). Paired t-tests confirmed significant pre\u0026ndash;post improvements across all subgroups and factors (all p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eFor trauma resuscitation and management of polytrauma patients, interprofessional communication and teamwork in the trauma bay are critical factors that largely contribute to sentinel events. Simulation-based team trainings is therefore a plausible approach to practice both technical and non-technical skills under realistic conditions. This is in line with findings from recent systematic reviews and meta-analyses demonstrating that simulation-based training improves team performance and human factor skills across diverse healthcare settings [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. In this context, it improves both technical and non-technical skills [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Whereas the literature strongly supports the benefits of interprofessional CRM trainings in medical teams regarding communication and coordination [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e], there is limited evidence on which CRM dimensions benefit for which subgroups. In this study, we evaluated an individually designed simulation-based interdisciplinary trauma team training at a Level I trauma center in Germany based on ATLS\u0026reg; principles. Our aim was to characterize the structure of learning gains across CRM dimensions and to examine subgroup differences by role, profession, and prior experience to inform instructional design. Recent studies have addressed particularly needs for team training in ad-hoc teams and report performance gains even without stable team constellations [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. In line with Kirkpatrick\u0026rsquo;s framework, our evaluation corresponds to level 2 (\u0026lsquo;Learning\u0026rsquo;) and relies on retrospective self-assessed competence gains [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. While medical education literature suggests a weak correlation between self-assessment and objective performance measures [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], self-reports are pragmatic and minimize testing reactivity[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Due to the course concept involving voluntary participation, implementation of a structured summative assessment was not applicable. Given voluntary participation, summative performance testing was not feasible.\u003c/p\u003e\u003cp\u003eThe EFA revealed a three-factor model comprising personal operational competence, team communication, and decision making. Internal consistency was acceptable, and inter-item correlations indicated related yet distinct. While the first factor (\u003cem\u003epersonal operational competence\u003c/em\u003e) primarily addressed technical aspects within the working environment, the other two factors focused on non-technical team interaction. Within this framework, the largest mean learning gains occurred in items related to operational/ technical knowledge, particularly among less experienced participants (\u0026lsquo;providers\u0026rsquo;). In healthcare training, technical and non-technical skills are typically regarded as two distinct concepts, both of which are crucial in managing and preventing critical or adverse events [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Non-technical skills are generally seen as cognitive and social skills, whereas technical skills involve the use of medical equipment and drugs, along with specific medical expertise [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe factors \u003cem\u003eteam communication\u003c/em\u003e and \u003cem\u003edecision making\u003c/em\u003e showed highly significant gains across participant groups. These aspects touch upon the utilization of all available personnel resources without restriction, for example, due to existing hierarchies. Previous work in context of trauma teams support flatter structures [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e], allowing team members to interact and communicate on an equal footing with a high amount of psychological safety [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Regarding \u003cem\u003eteam communication\u003c/em\u003e, no subgroup differences by department, experience, or profession were observed pre-post, indicating that all groups benefit from the training intervention. Our findings confirm that simulation-based training within trauma teams enhance communication and performance irrespective of prior job-related experience, with particularly pronounced gains in personal operational competence (workplace/ process) among less experienced participants. Therefore, it is reasonable not only to include members at all levels of experience in the training, but also to design scenarios that explicitly address communication-related issues and reinforce flat hierarchies. Finally, the attitude that situations should be dynamically reevaluated and repeated team time-outs are necessary (summarized in \u003cem\u003edecision making\u003c/em\u003e) yielded high pre- and post-test self-evaluated scores across all subgroups without between-group differences. Given the relatively small subgroup sizes, additional data collection may reveal a positive trend in this aspect with repeated training sessions. To date, it remains unclear whether self-reported pre-test values change among participants attending multiple training sessions over time.\u003c/p\u003e\u003cp\u003eIn summary, the iSRST appears to improve collaboration within the specified team structures. The training proves advantageous for all participating subgroups, regardless of their professional background, expertise or prior training experience. This is consistent with previous studies that both surgeons and anesthetists\u0026rsquo; benefit from simulation-based training [\u003cspan additionalcitationids=\"CR29\" citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eNonetheless, there are specific limitations that need to be addressed. Firstly, our evaluation was designed to cover the second level of Kirkpatrick\u0026rsquo;s framework (\u0026lsquo;Learning\u0026rsquo;). However, the levels 3 and 4 (corresponding to \u0026lsquo;Did the intervention result in a change of behavior?\u0026rsquo; and \u0026lsquo;Did the intervention influence performance?\u0026rsquo;), still need to be evaluated in detail. Previous studies have reported longer time spent on trauma patients [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. For this purpose, long-term data collection and statistical evaluation is warranted. Previous studies have addressed Kirkpatrick\u0026rsquo;s level 3 by comparing video-records of preintervention and repeated post-intervention simulations [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. The present analysis was not intended to detect changes in global clinical endpoints (e.g., mortality, morbidity, and length of stay), which refer to level 4 by Kirkpatrick. Interpretation of these outcomes must incorporate additional context information, as they are often the result of a constellation of multiple factors and are less under the team\u0026rsquo;s direct control.\u003c/p\u003e\u003cp\u003eSecondly, the durability of effects after a single short session remains uncertain; mid- and long-term follow-up is needed. Some authors reported retained improvement in non-technical skills following one-day training sessions in short timespans of one or two months [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Comparable findings have also been demonstrated in trauma-focused ATLS\u0026reg;-based trainings [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e] and in prehospital emergency simulation settings [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Thus, the iSRST needs to be mid- and long-term evaluated. In addition, repeated training sessions will likely be necessary to sustain improvement regarding the CRM-concepts. The optimal time frequency and duration require further investigation. Regarding our individual course concept, participants evaluated that a frequency of 1\u0026ndash;2 trainings per year suited their expectations towards the training best. Thirdly, our data fully relied on subjective self-assessment. Evaluating self-assessed competencies and calculating retrospective learning gains may be limited indicators of actual knowledge gain. A meta-analysis on this topic indicates that while self-assessments are commonly used in literature for evaluation purposes, they may be imperfect and unreliable indicators of underlying true learning [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Furthermore, there is a lack of consensus in the interpretation of self-assessments, sometimes treated as a facet of reactions (analogous Kirkpatrick\u0026rsquo;s level 1) and sometimes as an indicator of knowledge levels (analogous Kirkpatrick\u0026rsquo;s level 2) (\u0026lsquo;Is Teacher Immediacy Actually Related to Student Cognitive Learning?\u0026rsquo; [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]). Fourthly, our analysis used a purpose-designed individual questionnaire. Additional training aspects may not have been captured to the full extend. The single questionnaire precludes any conclusion regarding the sustainability of training effects. Finally, this was a single-center study conducted in a specific institutional context, which may limit the generalizability. Future multi-center trials with objective outcome measures and longitudinal follow-up are warranted to strengthen the evidence base.\u003c/p\u003e"},{"header":"CONCLUSIONS","content":"\u003cp\u003eIn this single-center study, an ATLS®-based, interprofessional in-situ trauma team training produced significant pre-post gains in CRM-related competencies across professions, experience and clinical role. Providers showed the largest improvement in personal operational competence, whereas team communication and decision-making were comparable across subgroups. These findings support embedding structured, simulation-based team trainings with structured debriefings as a routine component of quality management in trauma centers and as targeted scaffolding for early-career staff. Future work should determine durability and optimal training dose and evaluate behavioral (Kirkpatrick’s level 3) and patient/ process outcomes (level 4) using objective measures in multi-center, longitudinal designs.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eDATA AVAILABILITY\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors confirm that the data supporting the findings of this study are available within this article. For further inquiries, please contact the corresponding author.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eJFL and MMP are active ATLS\u0026reg;-instructors and receive professional fees from the Akademie der Unfallchirurgie (AUC) GmbH. Moreover, the authors declare no competing financial or non-financial interests related to this manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSH, JFL and MMP designed experiments. SH, JFL, SK, OH and MMP conducted the simulation and data collection. SH, JFL and MMP analyzed the data. SH and MMP drafted the manuscript, SK performed the language editing and all authors commented on and revised the manuscript. JFL and MMP coordinated the study and secured funding. All authors read and approved the final version.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by grants from the IZKF Wuerzburg to MMP (ZZ-30). The authors thank the training organization team, especially C. Hofmann, M. Wunderling, A. Stenzel, H. Huflage, N. Matthes, F. Weber and D. R\u0026ouml;der. We are grateful to all training participants, the hospital board approving the program and the directors of all departments for their ongoing support.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eGeorgiou A, Lockey DJ. The performance and assessment of hospital trauma teams. Scand J Trauma Resusc Emerg Med. 2010;18:66. doi: 10.1186/1757-7241-18-66.\u003c/li\u003e\n\u003cli\u003eCapella J, Smith S, Philp A, Putnam T, Gilbert C, Fry W, et al. Teamwork training improves the clinical care of trauma patients. J Surg Educ. 2010;67(6):439-43. doi: 10.1016/j.jsurg.2010.06.006.\u003c/li\u003e\n\u003cli\u003eBuljac-Samardzic M, Doekhie KD, van Wijngaarden JDH. Interventions to improve team effectiveness within health care: a systematic review of the past decade. Hum Resour Health. 2020;18(1):2. doi: 10.1186/s12960-019-0411-3.\u003c/li\u003e\n\u003cli\u003eBarleycorn D, Lee GA. How effective is trauma simulation as an educational process for healthcare providers within the trauma networks? A systematic review. Int Emerg Nurs. 2018;40:37-45. doi: 10.1016/j.ienj.2018.03.007.\u003c/li\u003e\n\u003cli\u003eMcLaughlin C, Barry W, Barin E, Kysh L, Auerbach MA, Upperman JS, et al. Multidisciplinary Simulation-Based Team Training for Trauma Resuscitation: A Scoping Review. J Surg Educ. 2019;76(6):1669-80. doi: 10.1016/j.jsurg.2019.05.002.\u003c/li\u003e\n\u003cli\u003eZhang C. A Literature Study of Medical Simulations for Non-Technical Skills Training in Emergency Medicine: Twenty Years of Progress, an Integrated Research Framework, and Future Research Avenues. Int J Environ Res Public Health. 2023;20(5). doi: 10.3390/ijerph20054487.\u003c/li\u003e\n\u003cli\u003eSalas E, Burke CS, Bowers CA, Wilson KA. Team training in the skies: does crew resource management (CRM) training work? Hum Factors. 2001;43(4):641-74. doi: 10.1518/001872001775870386.\u003c/li\u003e\n\u003cli\u003ePaul MM, Westphale S, Huflage H, Helf D, Hofmann C, K\u0026ouml;nig S, et al. Etablierung eines interdisziplin\u0026auml;ren Schockraumsimulationstrainings an einem \u0026uuml;berregionalen deutschen Traumazentrum. Notfall + Rettungsmedizin. 2023. doi: 10.1007/s10049-023-01181-6.\u003c/li\u003e\n\u003cli\u003eKirkpatrick DL. Techniques for evaluation training programs. Journal of the American Society of Training Directors. 1959;13:21-6. \u003c/li\u003e\n\u003cli\u003eDavis DA, Mazmanian PE, Fordis M, Van Harrison R, Thorpe KE, Perrier L. Accuracy of physician self-assessment compared with observed measures of competence: a systematic review. Jama. 2006;296(9):1094-102. doi: 10.1001/jama.296.9.1094.\u003c/li\u003e\n\u003cli\u003eSitzmann T, Ely K, Brown KG, Bauer KN. Self-Assessment of Knowledge: A Cognitive Learning or Affective Measure? Academy of Management Learning \u0026amp; Education. 2010;9(2):169-91. doi: 10.5465/amle.2010.51428542.\u003c/li\u003e\n\u003cli\u003eHappel O, Papenfuss T, Kranke P. [Training for real: simulation, team-training and communication to improve trauma management]. Anasthesiol Intensivmed Notfallmed Schmerzther. 2010;45(6):408-15. doi: 10.1055/s-0030-1255348.\u003c/li\u003e\n\u003cli\u003eGaba DM. Crisis resource management and teamwork training in anaesthesia. British journal of anaesthesia. 2010;105(1):3-6. doi: 10.1093/bja/aeq124.\u003c/li\u003e\n\u003cli\u003eAbildgren L, Lebahn-Hadidi M, Mogensen CB, Toft P, Nielsen AB, Frandsen TF, et al. The effectiveness of improving healthcare teams\u0026apos; human factor skills using simulation-based training: a systematic review. Adv Simul (Lond). 2022;7(1):12. doi: 10.1186/s41077-022-00207-2.\u003c/li\u003e\n\u003cli\u003eHauta A, Iacobescu RA, Corlade-Andrei M, Nedelea PL, Cimpoesu CD. Translating training to medical practice in trauma care, a literature review. Eur J Trauma Emerg Surg. 2024;50(5):2017-28. doi: 10.1007/s00068-024-02548-1.\u003c/li\u003e\n\u003cli\u003eSauter TC, Hautz WE, Hostettler S, Brodmann-Maeder M, Martinolli L, Lehmann B, et al. Interprofessional and interdisciplinary simulation-based training leads to safe sedation procedures in the emergency department. Scand J Trauma Resusc Emerg Med. 2016;24:97. doi: 10.1186/s13049-016-0291-7.\u003c/li\u003e\n\u003cli\u003eWayne DB, Butter J, Siddall VJ, Fudala MJ, Wade LD, Feinglass J, et al. Mastery learning of advanced cardiac life support skills by internal medicine residents using simulation technology and deliberate practice. J Gen Intern Med. 2006;21(3):251-6. doi: 10.1111/j.1525-1497.2006.00341.x.\u003c/li\u003e\n\u003cli\u003eDaniels K, Auguste T. Moving forward in patient safety: multidisciplinary team training. Semin Perinatol. 2013;37(3):146-50. doi: 10.1053/j.semperi.2013.02.004.\u003c/li\u003e\n\u003cli\u003eFung L, Boet S, Bould MD, Qosa H, Perrier L, Tricco A, et al. Impact of crisis resource management simulation-based training for interprofessional and interdisciplinary teams: A systematic review. J Interprof Care. 2015;29(5):433-44. doi: 10.3109/13561820.2015.1017555.\u003c/li\u003e\n\u003cli\u003eSteinemann S, Berg B, Skinner A, DiTulio A, Anzelon K, Terada K, et al. In situ, multidisciplinary, simulation-based teamwork training improves early trauma care. J Surg Educ. 2011;68(6):472-7. doi: 10.1016/j.jsurg.2011.05.009.\u003c/li\u003e\n\u003cli\u003eJogerst KM, Cassidy DJ, Coe TM, Monette D, Sell N, Eurboonyanum C, et al. Interprofessional Trauma Team Training: Leveraging Each Specialties\u0026apos; Expertise to Teach Procedural-Based Skills. J Surg Educ. 2022;79(6):e273-e84. doi: 10.1016/j.jsurg.2022.09.010.\u003c/li\u003e\n\u003cli\u003eInnocenti F, Tassinari I, Ralli ML, Bona A, Stefanone VT, Audisio R, et al. Improving technical and non-technical skills of emergency medicine residents through a program based on high-fidelity simulation. Intern Emerg Med. 2022;17(5):1471-80. doi: 10.1007/s11739-022-02940-y.\u003c/li\u003e\n\u003cli\u003eGamborg ML, Salling LB, Rolfing JD, Jensen RD. Training technical or non-technical skills: an arbitrary distinction? A scoping review. BMC Med Educ. 2024;24(1):1451. doi: 10.1186/s12909-024-06419-6.\u003c/li\u003e\n\u003cli\u003eFletcher GC, McGeorge P, Flin RH, Glavin RJ, Maran NJ. The role of non-technical skills in anaesthesia: a review of current literature. British journal of anaesthesia. 2002;88(3):418-29. doi: 10.1093/bja/88.3.418.\u003c/li\u003e\n\u003cli\u003eRuchholtz S, Waydhas C, Aufmkolk M, Tager G, Piepenbrink K, Stolke D, et al. [Interdisciplinary quality management in the treatment of severely injured patients. Validation of a QM system for the diagnostic and therapeutic process in early clinical management]. Unfallchirurg. 2001;104(10):927-37. doi: 10.1007/s001130170033.\u003c/li\u003e\n\u003cli\u003eSchaser KD, Melcher I, Stockle U, Bail HJ, Puhl G, Settmacher U, et al. [Interdisciplinarity in reconstructive surgery of the extremities]. Unfallchirurg. 2004;107(9):732-43. doi: 10.1007/s00113-004-0844-5.\u003c/li\u003e\n\u003cli\u003eKumar S. Psychological Safety: What It Is, Why Teams Need It, and How to Make It Flourish. Chest. 2024;165(4):942-9. doi: 10.1016/j.chest.2023.11.016.\u003c/li\u003e\n\u003cli\u003eFlin R, Patey R, Glavin R, Maran N. Anaesthetists\u0026apos; non-technical skills. British journal of anaesthesia. 2010;105(1):38-44. doi: 10.1093/bja/aeq134.\u003c/li\u003e\n\u003cli\u003eGusgen C, Anger F, Hauer T, Willms A, Buhr HJ, Germer CT, et al. [Advanced training of general and visceral surgeons in life-saving emergency surgery : Results of a survey among participants of a surgery course]. Chirurg. 2020;91(12):1044-52. doi: 10.1007/s00104-020-01170-2.\u003c/li\u003e\n\u003cli\u003eHeaton SR, Little Z, Akhtar K, Ramachandran M, Lee J. Using simulation to train orthopaedic trainees in non-technical skills: A pilot study. World J Orthop. 2016;7(8):475-80. doi: 10.5312/wjo.v7.i8.475.\u003c/li\u003e\n\u003cli\u003eHaerkens M, Kox M, Noe PM, Van Der Hoeven JG, Pickkers P. Crew Resource Management in the trauma room: a prospective 3-year cohort study. Eur J Emerg Med. 2018;25(4):281-7. doi: 10.1097/MEJ.0000000000000458.\u003c/li\u003e\n\u003cli\u003eRoberts NK, Williams RG, Schwind CJ, Sutyak JA, McDowell C, Griffen D, et al. The impact of brief team communication, leadership and team behavior training on ad hoc team performance in trauma care settings. Am J Surg. 2014;207(2):170-8. doi: 10.1016/j.amjsurg.2013.06.016.\u003c/li\u003e\n\u003cli\u003eYee B, Naik VN, Joo HS, Savoldelli GL, Chung DY, Houston PL, et al. Nontechnical skills in anesthesia crisis management with repeated exposure to simulation-based education. Anesthesiology. 2005;103(2):241-8. doi: 10.1097/00000542-200508000-00006.\u003c/li\u003e\n\u003cli\u003eKim MJ, Lee JG, Lee SH. The Effectiveness of Simulation Training in an Advanced Trauma Life Support Program for General Surgery Residents: A Pilot Study. Journal of Trauma and Injury. 2020;33(4):219-26. doi: 10.20408/jti.2020.0015.\u003c/li\u003e\n\u003cli\u003eAbelsson A, Rystedt I, Suserud BO, Lindwall L. Learning by simulation in prehospital emergency care - an integrative literature review. Scand J Caring Sci. 2016;30(2):234-40. doi: 10.1111/scs.12252.\u003c/li\u003e\n\u003cli\u003eRodr\u0026iacute;guez JI, Plax TG, Kearney P. Clarifying the relationship between teacher nonverbal immediacy and student cognitive learning: Affective learning as the central causal mediator. Communication Education. 2009;45(4):293-305. doi: 10.1080/03634529609379059.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Box 1","content":"\u003cp\u003eBox 1 is available in the Supplementary Files section\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"european-journal-of-trauma-and-emergency-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ejot","sideBox":"Learn more about [European Journal of Trauma and Emergency Surgery](http://link.springer.com/journal/68)","snPcode":"68","submissionUrl":"https://submission.nature.com/new-submission/68/3","title":"European Journal of Trauma and Emergency Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"CRM, simulation, team training, polytrauma, ATLS®, factor analysis","lastPublishedDoi":"10.21203/rs.3.rs-8192330/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8192330/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e\u003cp\u003eTeam performance in polytrauma management determines patient outcome and is crucially shaped by Crew Resource Management (CRM). This study aimed to evaluate the effects of an interdisciplinary, interprofessional, in-situ, simulation- and ATLS\u0026reg;-based trauma team training with a focus on CRM principles. We conducted a retrospective analysis based on self-assessed questionnaires. As trauma teams were composed of multiple subspecialties with heterogeneous levels of expertise, we hypothesized that different subgroups might benefit to varying degrees from the training.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eBetween 03/2022 and 11/2023, 36 training sessions including 238 participants took place at a German Level I trauma center. Participants completed post-intervention questionnaires and subgroup analysis including exploratory factor analysis was performed.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eParticipants came from anesthesiology, surgery and radiology in equal proportions and differed in working experience, professional role, and exposure to polytrauma management. Exploratory factor analysis identified the three CRM dimensions: i) personal operational competence, ii) team communication, and iii) decision making. Learning gains were evident across all subgroups, however, providers demonstrated particularly high improvements in personal operational competence compared to experts (p\u0026thinsp;\u0026lt;\u0026thinsp;0.01).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eIn-situ trauma team training enhanced CRM-related competencies in all professions and subspecialties, regardless of prior experience or trauma exposure. Thus, such trainings are well suited to improve team performance in polytrauma care at a high-volume trauma center.\u003c/p\u003e","manuscriptTitle":"Learning gain of an ATLS®-based interprofessional and multidisciplinary in-situ simulation training of trauma resuscitation","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-04 15:21:59","doi":"10.21203/rs.3.rs-8192330/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-01-15T06:39:39+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-14T12:09:12+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-26T21:10:32+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"87345202619418763377893701746827111255","date":"2025-11-26T16:32:48+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"213325396072266214248961158975065127050","date":"2025-11-26T12:06:32+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-11-26T10:26:40+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-11-25T21:48:08+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-11-25T05:21:58+00:00","index":"","fulltext":""},{"type":"submitted","content":"European Journal of Trauma and Emergency Surgery","date":"2025-11-24T10:25:05+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"european-journal-of-trauma-and-emergency-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ejot","sideBox":"Learn more about [European Journal of Trauma and Emergency Surgery](http://link.springer.com/journal/68)","snPcode":"68","submissionUrl":"https://submission.nature.com/new-submission/68/3","title":"European Journal of Trauma and Emergency Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"814d9d67-8ae3-45f3-9e85-c1fc03df6560","owner":[],"postedDate":"December 4th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-03-23T16:15:13+00:00","versionOfRecord":{"articleIdentity":"rs-8192330","link":"https://doi.org/10.1007/s00068-026-03146-z","journal":{"identity":"european-journal-of-trauma-and-emergency-surgery","isVorOnly":false,"title":"European Journal of Trauma and Emergency Surgery"},"publishedOn":"2026-03-17 15:59:02","publishedOnDateReadable":"March 17th, 2026"},"versionCreatedAt":"2025-12-04 15:21:59","video":"","vorDoi":"10.1007/s00068-026-03146-z","vorDoiUrl":"https://doi.org/10.1007/s00068-026-03146-z","workflowStages":[]},"version":"v1","identity":"rs-8192330","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8192330","identity":"rs-8192330","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}