Author: Charlotte Davies / Editor: Nikki Abela / Reviewer: Charlotte Davies / Codes: / Published: 19/06/2018 / Reviewed: 24/08/2025
Do you know what is going on with you and around you? Have you been in a situation where there are nine poorly patients in the resuscitation room, and you are the only Clinician looking after them? A new patient for another team comes in, and a new Clinician arrives and demands your help and doesn’t understand why you can’t be with them. Why don’t they understand? Almost certainly, they have no situational awareness. How we think and how we make decisions is a fascinating and very important subject, and this brief blog post only really touches the surface of it. We make thousands of decisions every day without thinking about them.
Outside of work, do you walk into people whilst you’re head down reading RCEMLearning blogs? Did you walk into the riots because you didn’t notice them? Situational awareness is important in every situation.
We will look at the three levels of situational awareness: how we prioritise, think and how we make some decisions.
What is situational awareness?
“The perception of 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)
“One’s ability to remain aware of everything that is happening at the same time and to integrate that sense of awareness into what one is doing at the moment” (Haines & Flateau, 1992).
Level One: Awareness
Level one of situational awareness is looking at the elements in the environment — collecting the basic data about the patient and situation. This includes things like basic observations, blood test results and knowing other members of the team are present, but also knowing that a fifth patient is due into your four bed resus room.
This will help prevent you becoming biased or blinkered in what you see. I see a lot of blinkering in the Emergency Department (ED). The easiest ED-based example is you have a patient with atrial fibrillation that started an hour ago (!! Speedy triage). They need electrical cardioversion, and have consented to that. Is that the right thing to do? If resus is empty and there’s no patients waiting then yes, it is. If resus is already doubled up, we’re 5 Nurses short, and have a four hour wait maybe not. It’s a case of being aware of everything, and balancing the needs of the patient with the needs of the department.
Another common ED example is everyone ignoring the crash buzzer because they need to get those ’emergency antibiotics’ in.
To make sure you get all the information you need to make an excellent decision, it might be useful to ‘scan & search’, pay attention, expect the unexpected and share the mental model considering:
Patient: Right patient, right time. What are the patient’s symptoms and observations?
Environment:
Physical: Is it too noisy for me to do this? Can I control that? Are there too many distractions?
Human: Am I “HALT”? Hungry, Angry, Late or Lonely, Tired. What else is happening in the department? Did the “team huddle” earlier revealed we are 5 Nurses short tonight. Pilots use “I’m Safe” to identify any potential decision making problems before crunch point
Task: What is my goal? Is it to diagnose the patient, or to treat the numbers?
Time: Is now the right time to be doing this? How much time have I got?
Some of this information will be delivered or “pushed” to you, like the patient’s general appearance and the noise levels around you. Some information you will have to request or “pull”, like the observations. If you don’t push and pull all of the information, you run the risk of being biased in your information gathering approach.
When do errors happen at work? HALT – Hungry, Angry, Late or Tired. #humanfactors
ED Doc (@4hrEmergencyDoc) April 10, 2014
Level Two: Comprehension
For level two awareness you begin to use the separate level 1 elements to understand what is happening. This might be:
Realising the monitor shows asystole because the leads have become unstuck.
Realising the respiratory rate has dropped because the fascia iliac block caused the pain stimulus to disappear, and the morphine has just kicked in.
Understanding the information requires a lot more cognitive (brain) function than just knowing the information. It is harder to learn this from textbooks alone. It needs people to recognise and interpret patterns, and see whether their patient fits.
It is during level two situational awareness that we might become cognitively biased, and need to employ strategies to stop this. Have you noticed that you suddenly see lots of cases of prostatitis after you’ve just had a teaching session on prostatitis? Or that the stroke team diagnose patients with strokes that you don’t think have had a stroke? These are all biases that we need to be aware of.
How do you avoid being biased?
- RCEMLearning blog – Thinking Situational Awareness Part 2
- ASME – Innovative teaching in situational awareness
- We often use ‘sharing the mental model’ when talking about human factors. By this we mean tell the team what you think might be happening. If you list your differentials, it shows to them you have been thinking and helps avoid bias. A time-out or cognitive stop point can give you more time, and enable you to:
– Consider alternatives
– List your differential diagnoses
– Look to see if anything does not fit - Minimise interruptions.
- Make sure your system is set up for you to succeed, without the holes of the Swiss cheese lining up. If you don’t encourage change, things will never improve. Marginal gains make big differences small steps at a time.
– Encourage accountability
– Change systematic factors
– Encourage improvement - Training
– Practice high risk moments
– Simulation - Cognitive Unloading
