Exploring tools used in the assessment of Trauma Team Leadership using video review: a systematic review

BACKGROUND: Leadership is a key non‑technical determinant of trauma team performance and is associated with adherence to protocols and patient outcomes. Retrospective video review is increasingly used to evaluate trauma resuscitations; However, the structured observational tools used to evaluate trauma team leadership during video review are heterogeneous and inconsistently reported. This systematic review identifies and characterises structured observational tools used during video review to assess trauma team leadership behaviours. METHODS: This systematic review was conducted in accordance with PRISMA 2020 guidelines and prospectively registered on PROSPERO (CRD42025636807). MEDLINE, Embase and CINAHL were searched without date restrictions. Studies were eligible if they used retrospective video review of real or simulated trauma resuscitations and applied a structured observational tool to assess leadership or leadership‑related non‑technical skills. Two reviewers independently screened studies extracted data and performed methodological appraisal using the Mixed Methods Appraisal Tool (MMAT). Due to substantial heterogeneity, results were synthesised narratively. RESULTS: Twenty studies published between 1988 and 2024 were included. Most studies were conducted in the United States (n = 15), with additional studies from Canada (n = 3) and the Netherlands (n = 2). Nineteen distinct structured assessment tools were identified. The Non‑Technical Skills Scale for Trauma (T‑NOTECHS) was the most frequently used instrument (n = 7), followed by the Mayo High Performance Teamwork Scale and the EM Resuscitation Team Leadership Measure. Considerable variation existed in leadership domains assessed, scale structure, rater background and rater training. Communication, decision‑making, task management and situational awareness were the most commonly evaluated leadership attributes. Inter‑rater reliability was inconsistently reported and ranged from poor to excellent, with higher agreement generally observed in simulation‑based assessments. CONCLUSIONS: Multiple tools have been used to assess trauma team leadership using video review, with marked heterogeneity in design, rater approach, and reliability reporting. While T-NOTECHS is the most commonly applied instrument, variation in constructs and scoring limits comparability across studies and trauma centres and complicates evaluation of leadership-focused education and quality-improvement initiatives. Inconsistent reliability evidence also constrains outcome-linked research. Greater consistency in leadership assessment tools, rater training, and psychometric reporting is therefore required to support benchmarking, robust evaluation of improvement programmes, and research linking leadership behaviours to clinical and system outcomes.