Situation Awareness

“the perception of the elements in the environment within a volume of time and space, the comprehension of their meaning and the projection of their status in the near future.” Endsley (1995)

‘knowing what is going on around you’

Endsley, 2005

Situation Awareness

Perception• Getting / Gathering Information

Comprehension• Understand / Interpret

Projection• Think Ahead / Anticipate Future

Retrospectively

• Comments from system operators where failures in situation awareness occur include:– “I didn’t realize that…”– “I didn’t notice that…”– “I wasn’t aware that…”– “We were very surprised when…”– “I was so busy attending to…”– “We were convinced that…”

Flin et al., 2008

Non-technical skills

Category Role Rate Example

Teamwork & Cooperation

A1 1 S1 asks if the ABG was done, A1 answers yes, and does not volunteer the result. S1 then asks for the result, and at this point, A1 addresses At and admits to looking for the result, having forgotten to do the ABG. He then asks At to do an ABG. Does not provide any explanation to S1 for the oversight.

Teamwork & Cooperation

S1 4 Asks A1 if he would mind ‘sharing’ the ABG result. S1 did not make any comments about it when he realizes that it was not done at all. Conflict resolution: concentrates on what is right.

Leadership & Management

S1 3 Authority and assertiveness. Persistent when asking for the ABG report (which was a long time in coming).

Getting/Gathering Information(Perception)

• Information is not available• Data is difficult to detect/perceive• Failure to scan or observe • Misperception of data

Endsley, 2005

Understand/Interpret Information(Comprehension)

• Lack of poor mental models• Use of incorrect mental models• Over-reliance on default values– Incorrect assumptions

• Memory failure

Endsley, 2005

Thinking Ahead / Anticipating Future (Projections)

• Ambiguity• Fixation• Confusion• Lack of required information• Failure to maintain critical tasks• Failure to meet expected target or checkpoint• Difficulty resolving discrepancies

CAA, 2006; Okray and Lubnau, 2004

Category Role Rate Example

Teamwork & Cooperation

A1 1 S1 asks if the ABG was done, A1 answers yes, and does not volunteer the result. S1 then asks for the result, and at this point, A1 addresses At and admits to looking for the result, having forgotten to do the ABG. He then asks At to do an ABG. Does not provide any explanation to S1 for the oversight.

Teamwork & Cooperation

S1 4 Asks A1 if he would mind ‘sharing’ the ABG result. S1 did not make any comments about it when he realizes that it was not done at all. Conflict resolution: concentrates on what is right.

Leadership & Management

S1 3 Authority and assertiveness. Persistent when asking for the ABG report (which was a long time in coming).

What can we do to improve situation awareness?

What can we do to improve situation awareness?

• Good briefings• Fitness for work• Minimizing distraction and interruption during

critical tasks• “Sterile cockpit”• Updating• Monitoring (“zoning out”)• Speaking up• Time management (“hurry up syndrome”)

What can we do to improve situation awareness?

• Good briefings• Fitness for work• Minimizing distraction and interruption during

critical tasks• “Sterile cockpit”• Updating• Monitoring (“zoning out”)• Speaking up• Time management (“hurry up syndrome”)

Examples of situation awareness

Proceeding only with agreement from everyone

“Are we ready to start the procedure?”

Your turn

• Find someone in the room who you have never met before

• Together, come up with two questions that have/would improve situation awareness in your teams.

What is your immediate goal?

What are you doing to support that goal?

What are you worried about?

What is the current problem, size, and intention?

What do you think this situation will look like in ____minutes, and why?

Communication failures related most frequently to equipment and keeping team members updated as to the progress of an operation.

Teaching Situation Awareness

• Easiest to work with is data exchange– Better form, better printout, better handover,

better briefing• Teach tricks and clues to identify projection

errors • Most difficult is building ‘better’ mental

models– Experience, competence

Decision Making

Decision-making is the process of reaching a judgement, choosing an option, or making a diagnosis about a situation in both normal or time-pressured situations.

Flin et al., 2008

Non-technical Elements of Decision-making

Situation Assessment• D

efining problem

Generating Options• C

onsidering response

Selecting Option(s)• I

mplementing

Outcome• R

eview

Recognition-primed

(Intuition)Rule-based

Choice

Creative

Increase cognitive effort and stress

Decrease cognitive effort and stress

Decision Traps

• Jumping to solutions• Not communicating• Unwilling to challenge the experts• Complacency (worry too much)• Assuming no time• Failure to consult• Failure to review

Walters, 2002: p 15

Training decision-making

• Tactile decision games • Storytelling

A Storytelling Example

How can we teach non-technical skills through this example?

Delay in patient awakening:

At the end of the case, when informed about the changes in the MEP recording, S2 decided to clinically assess motor power in the lower limbs before shifting. This request was conveyed to A1 and A2. The team ends up waiting for almost one and half hours, but the patient is still not awake enough to follow commands. S2 blames Clonidine for the delay and is very vocal about how he disapproves of the drug. A1 explains to him that it is the synergy between Gabapentin and Clonidine and not the latter alone. A1 gives no explanation to S2 about why the latter was given if this synergy was known to occur. A1 also says that for a patient on clonidine, the anaesthesia requirement would only be 2/3 rd of the normal, but its unclear if the maintenance anaesthetic was toned down as recommended in this case. S2 is getting frustrated at the delay and conveys it non-verbally by crossing arms and shaking head.

At one point while A1 was away from the room, A2 says out loud that he was not party to the clonidine being given. The surgical and nursing team seem to be unhappy with the delayed wake up scenario – not explicitly conveyed, but very evident in body language. A1 comes back to the surgical suite and gives titrated doses of Naloxone to the patient to help her wake up – S2 was not very happy with this, since an overshoot of the dose of naloxone would cause the patient to wake up in severe pain.

Eventually after 1 hour and 45 minutes, the team decides to shift her anyway, and A1 offers to give her some neostigmine just in case there is some residual muscle paralysis from the relaxant that can be reversed (technical observer suggests that residual paralysis – not likely and Neostigmine at this point – quite unnecessary). To this suggestion, S2 says – ‘No, I don’t want her given any more drugs’ in a curt manner. This process took 2 hours before the patient left the OR.

Teaching Decision Making

Good• Gathers information

and identifies problem• Reviews causal factors

with other members• Considers and shares

risks of alternative course of action

Poor• Fails to diagnose

problem• Does not search for

information• Fails to inform team of

changes in decision path