1. 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)
From University of Aberdeen
The term was developed from the military in the First World War when the concept of “gaining an awareness of the enemy before the enemy gained a similar awareness” first appeared.
Developed by the operator having a good mental model “picture in their head” representing the status of current task and the surrounding work environment.

2. ‘knowing what is going on around you’

3. We don’t have to look very far to find accidents where problems in situation awareness were implicated. Chernobyl in 1986, Three Mile Island in 1979, 175 aviation accidents, pilots who land aircrafts at the wrong airport, and surgeons who operate on the wrong side.
Endsley, 2005

4. Situation Awareness Perception Comprehension Projection
Getting / Gathering Information
Comprehension
Understand / Interpret
Projection
Think Ahead / Anticipate Future

5. 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…”
Understanding the human brain’s information system presented (sensory, working, and long-term memory requirements.
Flin et al., 2008

6. Non-technical skills
When looking at non-technical skills, it can include the skill of gathering information, recognising and understanding the situation, and anticipating future events.

7. Teamwork & Cooperation A1 1
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. 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 3
Authority and assertiveness. Persistent when asking for the ABG report (which was a long time in coming).

8. Getting/Gathering Information (Perception)
Information is not available
Data is difficult to detect/perceive
Failure to scan or observe
Misperception of data
“Fixation errors or tunnel vision”
I can teach you how to help with perception and projection, but comprehension is much more complex.
Mental model is “wisdom”
Endsley, 2005

9. 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

10. 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
Clues when the team is losing the correct situational awareness
CAA, 2006; Okray and Lubnau, 2004

11. Teamwork & Cooperation A1 1
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. 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 3
Authority and assertiveness. Persistent when asking for the ABG report (which was a long time in coming).

12. What can we do to improve situation awareness?

13. 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”)

14. 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”)

15. Examples of situation awareness
Proceeding only with agreement from everyone
“Are we ready to start the procedure?”
From University of Aberdeen
Good briefings = good questions
What is your immediate goal
What

16. 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.

17. What is your immediate goal. What are you doing to support that goal
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?
You’re not asking “God” questions, you are focusing on questions related to the task at hand.
Funny (or not so funny story), as I was reviewing my slides with my husband last night he mentioned a coworker at a previous job.
He asked the owner of the company “Why am I here” and the owner said “well if you don’t know why you are here then you don’t need to be here” he was fired on the spot.

18. Communication failures related most frequently to equipment and keeping team members updated as to the progress of an operation.
Better understand vulnerabilities of intraoperative communication
150 hrs of observation
Type of error, subject of error and effect of error

20. 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

21. 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

22. Non-technical Elements of Decision-making
Situation Assessment
Defining problem
Generating Options
Considering response
Selecting Option(s)
Implementing
Outcome
Review
SBAR,

23. Recognition-primed (Intuition)
Decrease cognitive effort and stress
Recognition-primed (Intuition)
Rule-based
Choice
Creative
Increase cognitive effort and stress

24. 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

25. Training decision-making
Tactile decision games
Storytelling

26. A Storytelling Example How can we teach non-technical skills through this example?

27. 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 2/3rd 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.

28. 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