Situation awareness is critical to the functioning of a clinical team, especially in theatre. I asked Trevor Dale, a retired BA Captain and trainer to offer his thoughts on situation awareness. It is not something that is taught or explained until recently through the advent of the Non-Technical Skills for Surgeons (NOTSS) course. The experienced surgeon can walk into a theatre and will be able to pick up all the verbal and nonverbal cues that will inform the observer how the operation is progressing. The sound of the ECG, the smell of the diathermy, the rhythm of the machines (ventilator, intra-aortic balloon pump, bypass machine) and the warning bells all add to the assimilation of the situation.
However, it is difficult to appreciate the nuances of all these elements when trying to master the technical skill of surgery. The real beginner needs to be encouraged to breathe but as the these skills become unconsciously competent, the trainee may feel confident to have a more relaxed conversation. It is at this stage in learning that situation awareness can be appreciated. Even then it will regress under stress – more so for the trainee than the expert. The problem is we can all lose situation awareness. Perhaps an alternative way of putting it might be that our cognitive functions become attenuated under stress and our attention mechanism becomes affected. Our senses are impacted - hearing is affected first, which is why often colleagues simply do not respond and even become unaware of alarm bells and beeps. Tunnel vision is the second effect and under stress we lose our peripheral vision. The last sense to be affected is sense of smell and why smelling salts can help in some instances.
Sadly, experience can play a factor, but it is crucial that everyone accepts that we can all lose situation awareness, no matter how experienced. It is the single most important aspect of Human Fallibility.
I know of one cardiac trainer who has a ‘wipe down’ couch in theatre that enables him to sit in theatre to maintain situation awareness while the trainee is learning to practice solo. This a crucial skill for the surgical trainer who should be there for briefing and debriefing to explain and plan the trainees’ involvement.
How could you teach what to many is an abstract concept, such as situation awareness? They said it could not be done – I strongly disagree.
Firstly, I believe it is the single most crucial aspect of everyday life, both personal and professional. It is like the God Particle – ever-present. Simple things in daily life; What time do I need to get out of bed? What shall I wear today - what do I need to wear today? What time do I need to be at my destination? Who am I meeting? and in the clinical day; What is on the clinical list today? Does the order of the list need to change? Are there any challenging cases? Is the patient Diabetic? Do I have patients with learning difficulties? Is the skill mix of the team suitable? Do I have any trainees?
I won’t go on but the most vital aspect is simply this – does everyone else know? Are we all on the same page?
Perhaps, an analogy with driving could help. Imagine heading along the motorway in the right-hand lane with plenty of traffic to your left. You need to exit at the next junction; when do you start to weave your way between the traffic? The traffic is moving out in front of you and cars are streaming behind you blocking your ability to join the correct lane. ‘If only I’d thought ahead and moved out early.’
In aviation, when ab-initio training, the instructor will teach the basic handling of the aircraft. First flying straight and level, then level turns, then climbing and descending, all in a controlled manner of course. The instructor takes care of the situational awareness with regards to location, conflicting traffic, weather and essential safety. As the training progresses, the student is firstly instructed on what to think about, for example, the actions in the event of an engine failure or system malfunction. But as progress builds, so the role of the instructor changes to facilitator by asking what the student is thinking rather than telling.
The form of communication is paramount. Start with open questions “what are you thinking about now?”, “where would you head if the engine failed?” But the questions should be phrased according to the student’s level of progress. Firstly, you simply cannot facilitate out of ignorance. If the student doesn’t know, then no amount of questioning can get the answer. They may have forgotten, or may not have been taught. Or it could be that the phrasing of the question is inappropriate. Equally telling them things that they already know induces disrespect and learning paralysis. A look at the antics of Sir Lancelot Spratt in the old Carry-On films can be helpful here.
Some people struggle to think clearly if they feel under threat. This is not Mastermind, it is about helping the student get further, faster that they could by trial and error. When it comes to enhancing situation awareness it can be helped by bringing those subtle clues that the experienced trainer knows almost intuitively to the conscious brain.
Situation awareness in action. Have you ever turned up at a social function at the wrong time, wearing the wrong clothing? I had a friend arrive at a black-tie dinner dance in open-necked shirt and jeans - mind you they were ironed! My wife has a gluten intolerance, so we always check restaurant menus before booking. This is situation awareness in action again.
I had the pleasure of meeting Mica Endsley when she visited British Airways in the early days of Crew Resource Management in about 1991. Her definition of situation awareness is “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". Essentially, it is a knowledge state but it is highly dynamic and changing constantly. It is a constant effort to keep up with reality, which fits with driving and also with surgery. We translated that to Notice, Understand and Think Ahead.
How do you build situation awareness in your team? Briefings, huddles - that’s what they are for. How do you know if it was effective? Debrief and discuss it. When coaching surgical teams, I ask post-hoc – “how did it go? Was it as planned? As you expected? Any surprises?” If there was anything you could have done with knowing, then could it have been briefed?
Consider the team function between surgeon, scrub and runner. When it all goes swimmingly then they all share high level situational awareness. The scrub nurse gives the surgeon what they need, not necessarily what they ask for. They know which ‘thingy’ or ‘wotsit’ you need. Now compare a dysfunctional team. Wrong clamp, missing prosthetic, wrong suture! Aagh. Would a better huddle have avoided this? PDSA – Plan – (briefing), Do (surgery) Study (debrief), Act – do it again.
Many of us will be familiar with the film depicting the tragic circumstances around the death of Martin Bromiley’s wife Elaine, ‘Just a Routine Operation’. While the rerun of the failed intubation is very much a best guess, the behaviour of the team can be very useful instruction in situation awareness. When the nurses arrive in the anaesthetic prep room, they see a blue patient, their eyes are drawn to the vital signs on the monitor and they see a saturation level of 40%. They also realise the passage of time. How do they react? Please be assured I am not criticising here, but, what they say is interesting. One states that she has ordered a critical care bed, the other produces a cricothyroidotomy kit. They have noticed, understood and thought ahead.
The bad news is that they are apparently met with blank looks. The clinicians and Operating Department Practitioner are sub-notice level. When training our advice is simple. If you see something you’re concerned about then ‘state the obvious’.
There are a set of ‘classic’ clues to the loss of situation awareness.
When it comes to human factors, I believe we should all aim to be consciously competent. By that I mean understanding ourselves – self-awareness, such that we can self-debrief. When we make a mistake, we can work out how it happened, interrupted, distracted, not thinking, assumptions etc. Equally we can do the same when all has gone well.
It doesn’t make you immune from error but it does help you learn. It also helps move away from the insidious desire to blame, others and ourselves.
That has been my aim for years, to help others become consciously competent.
Trevor Dale
Managing Director, Atrainability
Specialist trainers working across the healthcare spectrum in NHS and the private sector to bring aviation-based training skills to enhance patient safety.
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