Generating SA and maintaining it at a high
level can reduce the probability of patient injury,
because the healthcare provider can respond
more quickly to an emerging problem and it can
allow proactive management of human and
material resources during a crisis. 3,4
Team SA (TSA)
TSA is ‘the degree to which every team member
possesses the SA required for his or her
responsibilities’. 5 Teamwork is characteristic
to the OR, where an interdisciplinary team of
individuals is engaged in the common project
of ‘patient treatment’. 2 In a highly effective
team approach, decisions should be based on
information derived from all team members. This
allows for an efficient plan of action; otherwise,
a breakdown of performance would occur when
team members are not able to anticipate what
help is needed by the others. 6,7 However, not all
members of the team should be aware of the
same thing at the same time and nor does all
the information need to be shared with every
individual involved. Rather, it is necessary that
each person be aware of circumstances that are
relevant to their respective roles and responsibilities
and to create a system where the right
information reaches the right person at the right
time, and this involves team coordination. 3,8,9
Team processes and behaviours that can improve
TSA include closed-loop communication, group
prioritisation, contingency planning and actively
sharing SA about the patient, planned procedure
and potential critical events. 6,10
Patient
simulation
and debriefing
techniques
can enhance
individual
and team
performance
despite all the relevant information being
detected. This is due to an inappropriate or
absent mental model; with time pressure and
high cognitive workload we may get drawn
into bias by selecting a mental model that we
prefer based on our experience. 3 In the third
level (projection), the future is not correctly
anticipated, although the situation is understood.
As errors on SA levels II and III necessarily involve
long-term memory content for the processing of
basic data, this may be due to a lack of training
and experience. 3,4
Schulz et al reviewed 200 reports from the
German anaesthesia critical incident reporting
system and found that SA errors were involved
in 81.5% of the cases; in addition, more errors on
the levels of perception (38%) and comprehension
(31.5%) were identified. 4 With a similar
methodology, we reviewed 100 incidents reported
to the Spanish anaesthesia and intensive care
incident reporting system (SENSAR; Safety
Reporting System in Anaesthesia and
Rescuscitation) and found comparable results.
SA errors were identified in 65% of the cases and
the majority were on the levels of perception
(51%) and comprehension (8%).
Distributed SA (DSA)
DSA is a concept that recognises the contribution
of technical systems. The entire system including
human and non-human subsystems, and the
interactions between them, is considered to
develop SA. Hence, cognitive processes occur
at a system level rather than an individual
level. 11 The DSA approach allows a better
overall understanding of the operating theatre
interactions where a group of people
(anaesthetist, surgeon, nurse, patient) interact
with external objects (for example, equipment,
monitors, charts) in a dynamic explicit and
implicit way, and it is only when the interactions
between all the individual components are
compiled that a coherent picture emerges. 12 The role of expertise and training
Important cognitive mechanisms for the
development of SA as well as knowledge
bases and task skills are gained with experience.
Many studies have shown that experienced
subjects develop SA in a shorter time and with
less effort than novices. These differences may
be attributable to several factors that determine
the achievement of good SA, such as correct
distribution of attention, prioritising information,
dynamic switching between goal-driven
processing and data-driven processing,
automaticity, which can provide good
performance with very low level of attention
demand, learned skills, pattern-matching with
prototypical situations, and development of
mental models that help in the integration of
information and projection of future states. 2
Patient simulation and related debriefing
techniques can enhance individual and team
performance by focusing on skills and behaviours
related to good SA, such as prioritisation, and
coordination and communication that are essential
for the effective treatment of critical incidents. 3–10
SA errors
There can be failures at each level of SA,
leading to low performance. 13 In the first level
(perception), relevant information may not
be correctly detected or if too much data are
perceived at a time, we become overloaded,
focusing on just part of the information (‘tunnel
vision’) and missing parts that matter. It is widely
recognised that more data does not equal more
information. Today’s systems’ problems are not
the lack of information but finding what is
needed when it is needed; therefore, a critical
part of SA level I is learning the cues to watch
for (proper distribution of attention). 2 An outside
view sometimes helps to reveal what we cannot
see or give additional information that might
help highlight that something has been missed.
In the second level (comprehension), the
situation might not be understood correctly, Assessment of SA
Several direct and indirect methods have been
developed to assess SA and can be summarised as
query-, rating- and performance-based techniques.
In query techniques, the subjects are asked
directly about their perception of certain aspects
of the situation. The Situation Awareness Global
Assessment Technique (SAGAT) has been validated
as an objective and direct method to evaluate
different levels of SA during a simulated scenario,
and consists of stopping at random points to ask
the participants to complete a questionnaire
regarding what is occurring at that specific time.
This technique can be perceived as intrusive due
to freezes in a simulation but many studies have
shown it does not affect performance. 3,14 In rating
techniques, the subjects or observers are asked
to rate SA directly along a few dimensions
(SA Rating Technique) or indirectly through
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