Measuring situation awareness and team effectiveness in pediatric acute care by using the situation global assessment technique

Improving Situation Awareness to Advance Patient Outcomes: A Systematic Literature Review

Improving nurses' situation awareness skills would likely improve patient status recognition and prevent adverse events. Technologies such as electronic health record dashboards can be a promising approach to support nurses' situation awareness. However, the effect of these dashboards on this skill is unknown. This systematic literature review explores the evidence around interventions to improve nurses' situation awareness at the point of care. Current research on this subject is limited. Studies that examined the use of electronic health record dashboards as an intervention had weak evidence to support their effectiveness. Other interventions, including communication interventions and structured nursing assessments, may also improve situation awareness, but more research is needed to confirm this. It is important to carefully consider the design and content of situation awareness interventions, as well as the specific outcomes being measured, when designing situation awareness interventions. Overall, there is a need for higher-quality research in this area to determine the most effective interventions for improving nurse situation awareness. Future studies should focus on developing dashboards that follow a theoretical situation awareness model information and represent all situation awareness levels.

Structured Callouts, the Shared Mental Model, and Teamwork: A Video-Based Study in a Pediatric Emergency Department

OBJECTIVES

The shared mental model is essential to high-quality resuscitations. A structured callout (SCO) is often performed to establish the shared mental model, but the literature on SCOs is limited. The objectives of this study are to describe performance of SCOs during pediatric medical emergencies and to determine whether a SCO is associated with better teamwork.

METHODS

This was a retrospective study in the resuscitation area of an academic pediatric emergency department, where performance of a SCO is a standard expectation. Only medical or nontrauma patients were eligible for inclusion. Data collection was performed by structured video review by 2 observers and verified by a third blinded observer. A SCO was defined as team leader (Pediatric Emergency Medicine fellow or faculty physician) verbalization of at least 1 element of the patient history/examination or an assessment of patient physiology and 1 element of the diagnostic or therapeutic plan. We independently measured teamwork using the Teamwork Emergency Assessment Measure (TEAM) tool.

RESULTS

We reviewed 60 patient encounters from the pediatric emergency department resuscitation area between April 2018 and June 2020. Median patient age was 6 years; the team leader was a Pediatric Emergency Medicine fellow in 55% of encounters. The physician team leader performed a SCO in 38 (63%) of patient encounters. The TEAM scores were collected for 46 encounters. Mean TEAM score (SD) was 42.3 (1.7) in patients with a SCO compared with 40.0 (3.0) in those without a SCO ( P = 0.007).

CONCLUSIONS

Performance of a SCO was associated with better teamwork, but the difference was of unclear clinical significance.

Guidelines on human factors in critical situations 2023

OBJECTIVE

To provide guidelines to define the place of human factors in the management of critical situations in anaesthesia and critical care.

DESIGN

A committee of nineteen experts from the SFAR and GFHS learned societies was set up. A policy of declaration of links of interest was applied and respected throughout the guideline-producing process. Likewise, the committee did not benefit from any funding from a company marketing a health product (drug or medical device). The committee followed the GRADE® method (Grading of Recommendations Assessment, Development and Evaluation) to assess the quality of the evidence on which the recommendations were based.

METHODS

We aimed to formulate recommendations according to the GRADE® methodology for four different fields: 1/ communication, 2/ organisation, 3/ working environment and 4/ training. Each question was formulated according to the PICO format (Patients, Intervention, Comparison, Outcome). The literature review and recommendations were formulated according to the GRADE® methodology.

RESULTS

The experts' synthesis work and application of the GRADE® method resulted in 21 recommendations. Since the GRADE® method could not be applied in its entirety to all the questions, the guidelines used the SFAR "Recommendations for Professional Practice" A means of secured communication (RPP) format and the recommendations were formulated as expert opinions.

CONCLUSION

Based on strong agreement between experts, we were able to produce 21 recommendations to guide human factors in critical situations.

Team situational awareness in the context of hospital emergency: A concept analysis

BACKGROUND

Successful management of in-hospital life threatening and emergency conditions require a well working, collaborative team. One of the vital skills that enhance team coordination of information and actions is team situational awareness (TSA). Although the concept of TSA has been long known in military and aviation settings, the concept has not been well investigated in the hospital emergency context.

OBJECTIVE

This analysis was to explore the concept of "TSA" in the context of hospital emergency to explain its meaning for optimum understanding and use in clinical practice and future research.

RESULTS

TSA encompasses two types of situational awareness, each equally important: complementary (individual) and shared situational awareness (SA). The three defining attributes of complementary SA are the perception, comprehension, and projection, meanwhile, the three defining attributes of shared SA include: (1) information is clearly shared; (2) interpreted in the same way; and (3) the same projection of actions formed to guide expectation. Although, TSA is related to other terms in literature, there is increasing acknowledgment that the concept has an impact on team performance. Finally, the two types of TSA should be considered when assessing team performance CONCLUSION: TSA is acknowledged in different fields requiring human control as a significant construct for team performance. Yet it needs to be examined in the emergency hospital context, systematically investigated and agreeably recognized as a fundamental factor in team performance.

Development of trauma team cognition can be explained by "split vision": A grounded theory study

The aim of this study was to explore interaction of interprofessional hospital trauma teams. A theory about how team cognition is developed through a dynamical process was established using grounded theory methodology. Video recordings of in-real-life resuscitations performed in the emergency ward of a Scandinavian mid-size urban hospital were collected and eligible for inclusion using theoretical sampling. By analyzing interactions during seven trauma resuscitations, the theory that trauma teams perform patient assessment and resuscitation by alternating between two process modes, the two main categories "team positioning" and "sensitivity to the patient," was generated. The core category "working with split vision" explicates how the teams interplay between the two modes to coordinate team focus with an emergent mental model of the specific situation. Split vision ensures that deeper aspects of the team, such as culture, knowledge, empathy, and patient needs are absorbed to continuously adapt team positioning and create precision in care for the specific patient.

Exploring the Study of Simulation as a Continuing Professional Development Strategy for Physicians

INTRODUCTION

Practicing physicians have the responsibility to engage in lifelong learning. Although simulation is an effective experiential educational strategy, physicians seldom select it for continuing professional development (CPD) for reasons that are poorly understood. The objective of this study was to explore existing evidence on simulation-based CPD and the factors influencing physicians' engagement in simulation-based CPD.

METHODS

A scoping review of the literature on simulation-based CPD included MEDLINE, Embase, and CINAHL databases. Studies involving the use of simulation for practicing physicians' CPD were included. Information related to motivations for participating in simulation-based CPD, study objectives, research question(s), rationale(s), reasons for using simulation, and simulation features was abstracted.

RESULTS

The search yielded 8609 articles, with 6906 articles undergoing title and abstract screening after duplicate removal. Six hundred sixty-one articles underwent full-text screening. Two hundred twenty-five studies (1993-2021) were reviewed for data abstraction. Only four studies explored physicians' motivations directly, while 31 studies described incentives or strategies used to enroll physicians in studies on simulation-based CPD. Most studies focused on leveraging or demonstrating the utility of simulation for CPD. Limited evidence suggests that psychological safety, direct relevance to clinical practice, and familiarity with simulation may promote future engagement.

DISCUSSION

Although simulation is an effective experiential educational method, factors explaining its uptake by physicians as a CPD strategy are unclear. Additional evidence of simulation effectiveness may fail to convince physicians to participate in simulation-based CPD unless personal, social, educational, or contextual factors that shape physicians' motivations and choices to engage in simulation-based CPD are explored.

Shared Situational Awareness within the Hospital Emergency Context: A Scoping Review

Background. Shared Situation Awareness (SSA) has been applied in many fields such as sport, the military and aviation with promising outcomes on team performance. The application of SSA within the hospital emergency healthcare context has not been explored yet. The aim of this scoping review is to explore and map literature related to shared situational awareness within the hospital emergency healthcare context. Methods. The Arksey and O’Malley (2005) framework was used in which three electronic databases were searched for evidence investigating SSA within a hospital emergency healthcare context. Results. A review of the literature showed a clear lack of evidence that directly investigates SSA within the context of hospital emergency care. In the emergency medical field, the term SSA is seldom used and ‘team situation awareness’ is the most frequently used term. The most common framework was the three-level framework. Two techniques were reported in the selected studies to investigate SSA (1) freeze probe technique and (2) observer-based rating technique. The freeze probe technique mandates a simulation or artificial environment, while the observer-based rating technique could be applied in an ecological as well as an artificial environment. There is no standardized technique to calculate the score of the SSA. Finally, there was a significant impact of SSA on clinical team performance as well as some related skills such as leadership, task management, mindfulness and task prioritization. Conclusions. Reviewing the literature revealed a lack of studies investigating the use of SSA within the context of hospital emergency care. There is also a lack of agreement on how a SSA score should be calculated. Further studies are required to overcome these issues.

Can a targeted educational approach improve situational awareness in paramedicine during 911 emergency calls?

BACKGROUND

Paramedics must be situationally aware in order to avoid human error and protect themselves, their partner, their patient, and the public. Previous research has suggested that paramedics lack situational awareness (SA), possibly due to a lack of an organized approach, distraction, and a poor understanding of SA. There is no educational approach provided to paramedics that is known to improve their levels of SA. If such an approach were provided, it could possibly reduce human error and lead to improved outcomes.

OBJECTIVE

The aim of this study is to determine whether providing paramedics with a targeted educational approach, including aspects from crew resource management (CRM) such as sterile cockpit and Endsley's model for SA, can improve overall SA during emergency calls.

METHODS

A prospective, quasi-experimental before-and-after study was used, in which out-of hospital paramedics were observed during 911 emergency calls. Baseline SA was measured using the situational awareness global assessment technique (SAGAT). Paramedics were then given a targeted educational lesson focusing on elements of SA and CRM as well as a novel quick reference tool to utilize during 911 calls. Post intervention SA was then measured again, and before-and-after results were compared for difference of mean scores.

RESULTS

The overall baseline SA was 62% increasing to 86% following the educational intervention. The Wilcoxon Ranked Sum was used to assess for statistically significant differences between mean SA performance in the same group of paramedics before and after the intervention. The increase in SA was found to be statistically significant where p = 0.011.

CONCLUSIONS

A targeted educational approach focusing on CRM and a novel quick reference tool may increase SA levels of paramedics during 911 emergency calls. Further studies are needed with bigger cohorts. Paramedicine educational institutions and out-of-hospital agencies should consider implementing this targeted approach with their students and currently practicing providers.

Taking the Pulse on Pediatric Simulation: A National Survey of Pediatric Residency Programs' Simulation Practices and Challenges

OBJECTIVES

There is abundant literature on simulation use in individual pediatric residency programs but limited overall data on simulation in US pediatric residency programs. This study sought to determine how US pediatric residency programs use simulation for teaching and assessment and the challenges programs face in their use of simulation.

METHODS

The Association of Pediatric Program Director's Healthcare Simulation in Pediatrics Learning Community members developed a 15-multipart question survey on the use of simulation in US pediatric residency programs using best practices in survey design. The survey was distributed electronically to US pediatric residency program directors. Qualitative questions were analyzed by content analysis and quantitative questions using descriptive statistics.

RESULTS

The survey response rate was 21%; respondents were disproportionately from large academic medical centers. Qualitative analysis found that respondents use simulation to teach pediatric residents in the areas of urgent/emergent situations, procedures, and communication, and common challenges to simulation implementation are time, physical resources, expertise, competing priorities, logistics, and buy-in. Quantitative analysis demonstrated that, although respondents are largely confident that their simulation programs improve resident preparedness and competence, few objectively evaluate their simulation programs.

CONCLUSIONS

Pediatric residency programs use simulation for similar purposes and face similar challenges. By collaborating, the resources of the national pediatric simulation community can be leveraged to collect evidence for best practices for simulation use in pediatric residency training.

Situation awareness and the mitigation of risk associated with patient deterioration: A meta-narrative review of theories and models and their relevance to nursing practice

BACKGROUND

Accurate situation awareness has been identified as a critical component of effective deteriorating patient response systems and an essential patient safety skill for nursing practice. However, situation awareness has been defined and theorised from multiple perspectives to explain how individuals, teams and systems maintain awareness in dynamic task environments.

AIM

Our aim was to critically analyse the different approaches taken to the study of situation awareness in healthcare and explore the implications for nursing practice and research as it relates to clinical deterioration in ward contexts.

METHODS

We undertook a meta-narrative review of the healthcare literature to capture how situation awareness has been defined, theorised and studied in healthcare. Following an initial scoping review, we conducted an extensive search of ten electronic databases and included any theoretical, empirical or critical papers with a primary focus on situation awareness in an inpatient hospital setting. Included papers were collaboratively categorised in accordance with their theoretical framing, research tradition and paradigm with a narrative review presented.

RESULTS

A total of 120 papers were included in this review. Three overarching narratives reflecting philosophical, patient safety and solution focussed framings of situation awareness and seven meta-narratives were identified as follows: individual, team and systems perspectives of situation awareness (meta-narratives 1-3), situation awareness and patient safety (meta-narrative 4), communication tools, technologies and education to support situation awareness (meta-narratives 5-7). We identified a concentration of literature from anaesthesia and operating rooms and a body of research largely located within a cognitive engineering tradition and a positivist research paradigm. Endsley's situation awareness model was applied in over 80% of the papers reviewed. A minority of papers drew on alternative situation awareness theories including constructivist, collaborative and distributed perspectives.

CONCLUSIONS

Nurses have a critical role in identifying and escalating the care of deteriorating patients. There is a need to build on prior studies and reflect on the reality of nurse's work and the constraints imposed on situation awareness by the demands of busy inpatient wards. We suggest that this will require an analysis that complements but goes beyond the dominant cognitive engineering tradition to reflect the complex socio-cultural reality of ward-based teams and to explore how situation awareness emerges in increasingly complex, technologically enabled distributed healthcare systems.

Do team and task performance improve after training situation awareness? A randomized controlled study of interprofessional intensive care teams

Background

When working in complex environments with critically ill patients, team performance is influenced by situation awareness in teams. Moreover, improved situation awareness in the teams will probably improve team and task performance. The aim of this study is to evaluate an educational programme on situation awareness for interprofessional teams at the intensive care units using team and task performance as outcomes.

Method

Twenty interprofessional teams from the northern part of Sweden participated in this randomized controlled intervention study conducted in situ in two intensive care units. The study was based on three cases (cases 0, 1 and 2) with patients in a critical situation. The intervention group (n = 11) participated in a two-hour educational programme in situation awareness, including theory, practice, and reflection, while the control group (n = 9) performed the training without education in situation awareness. The outcomes were team performance (TEAM instrument), task performance (ABCDE checklist) and situation awareness (Situation Awareness Global Assessment Technique (SAGAT)). Generalized estimating equation were used to analyse the changes from case 0 to case 2, and from case 1 to case 2.

Results

Education in situation awareness in the intervention group improved TEAM leadership (p = 0.003), TEAM task management (p = 0.018) and TEAM total (p = 0.030) when comparing cases 1 and 2; these significant improvements were not found in the control group. No significant differences were observed in the SAGAT or the ABCDE checklist.

Conclusions

This intervention study shows that a 2-h education in situation awareness improved parts of team performance in an acute care situation. Team leadership and task management improved in the intervention group, which may indicate that the one or several of the components in situation awareness (perception, comprehension and projection) were improved. However, in the present study this potential increase in situation awareness was not detected with SAGAT. Further research is needed to evaluate how educational programs can be used to increase situation awareness in interprofessional ICU teams and to establish which components that are essential in these programs.

Trial registration

This randomized controlled trial was not registered as it does not report the results of health outcomes after a health care intervention on human participants.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13049-021-00878-2.

[Paediatric Life Support]

The European Resuscitation Council (ERC) Paediatric Life Support (PLS) guidelines are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations of the International Liaison Committee on Resuscitation (ILCOR). This section provides guidelines on the management of critically ill or injured infants, children and adolescents before, during and after respiratory/cardiac arrest.

Mindfulness Is Related to the Situational Awareness of Medical Students Confronted with Life-Threatening Emergency Situations

BACKGROUND

Emergency medicine can impose a heavy psychological burden on healthcare workers. Stress experienced during life-threatening situations may disrupt situational awareness (SA), i.e., the perception of environmental elements with respect to time and space, the comprehension of their meaning, and the projection of their state into the near future. We aimed to investigate whether mindfulness (a special way of paying attention: conscious, non-judgmental, and oriented to the present moment) can be related to the SA levels among final-year medical students confronted with life-threatening situations during medical simulations.

METHODS

The simulations were constructed as high-fidelity scenarios in children and adults (ClinicalTrials.gov ID: NCT03761355). The components of mindfulness were assessed using the Five Facet Mindfulness Questionnaire. SA among students was assessed using The Situation Awareness Global Assessment Technique at three levels: (1) data, (2) comprehension, and (3) projection.

RESULTS

In total, 117 students were included. Level 1 SA positively correlated with the overall mindfulness score and its components, i.e., nonreactivity, conscious presence, and nonjudgment. Moreover, level 3 SA significantly correlated with the description, but not with the overall mindfulness score. A regression model showed that nonreactivity explained 34% of Level 1 of SA variability. The addition of conscious presence and nonjudgment into this model did not change its predictive value.

CONCLUSIONS

nonreactivity a component of mindfulness of final-year medical students is related to the meticulous data collection of patients in life-threatening situations.

Relationship between mindfulness, stress, and performance in medical students in pediatric emergency simulations

Objectives: Pediatric teams of emergency departments work under extreme stress, which affects high-level cognitive functions, specifically attention and memory. Therefore, the methods of stress management are being sought. Mindfulness as a process of intentionally paying attention to each moment with acceptance of each experience without judgment can potentially contribute to improving the performance of medical teams. Medical simulation is a technique that creates a situation to allow persons to experience a representation of a real event for the purpose of education. It has been shown that emergency medicine simulation may create a high physiological fidelity environment similarly to what is observed in a real emergency room. The aim of our study was to determine whether the technical and non-technical skills of medical students in the course of pediatric high fidelity simulations are related to their mindfulness and stress. Participants and methods: A total of 166 standardized simulations were conducted among students of medicine in three simulation centers of medical universities, assessing: stress sensation (subjectively and heart rate/blood pressure), technical (checklists) and non-technical skills (Ottawa scale) and mindfulness (five facet mindfulness questionnaire): ClinicalTrials.gov ID: NCT03761355. Results: The perception of stress among students was lower and more motivating if they were more mindful. Mindfulness of students correlated positively with avoiding fixation error. In the consecutive simulations the leaders' non-technical skills improved, although no change was noted in their technical skills. Conclusion: The results of our research indicate that mindfulness influence the non-technical skills and the perception of stress of medical students during pediatric emergency simulations. Further research is needed to show whether mindfulness training leads to improvement in this field.

Impact of a shared decision-making mHealth tool on caregivers' team situational awareness, communication effectiveness, and performance during pediatric cardiopulmonary resuscitation: study protocol of a cluster randomized controlled trial

Background

Effective team communication, coordination, and situational awareness (SA) by team members are critical components to deliver optimal cardiopulmonary resuscitation (CPR). Complexity of care during CPR, involvement of numerous providers, miscommunication, and other exogenous factors can all contribute to negatively influencing patient care, thus jeopardizing survival. We aim to investigate whether an mHealth supportive tool (the Interconnected and Focused Mobile Apps on patient Care Environment [InterFACE]) developed as a collaborative platform to support CPR providers in real-time and share patient-centered information would increase SA during pediatric CPR.

Methods

We will conduct a prospective, cluster randomized controlled trial by groups of 6 participants in a tertiary pediatric emergency department (33,000 consultations/year) with pediatric physicians and nurses. We will compare the impact of the InterFACE tool with conventional communication methods on SA and effective team communication during a standardized pediatric in-hospital cardiac arrest and a polytrauma high-fidelity simulations. Forty-eight participants will be randomized (1:1) to consecutively perform two 20-min video-recorded scenarios using either the mHealth tool or conventional methods. The primary endpoint is the SA score, measured with the Situation Awareness Global Assessment Technique (SAGAT) instrument. Enrollment will start in late 2020 and data analysis in early 2021. We anticipate that the intervention will be completed by early 2021 and study results will be submitted in mid 2021 for publication.

Discussion

This clinical trial will assess the impact of a collaborative mHealth tool on increasing situational awareness and effective team communication during in-hospital pediatric resuscitation. As research in this area is scarce, the results generated by this study may become of paramount importance in improving the care of children receiving in-hospital CPR, in the era of increasing communication technology.

Trial registration

ClinicalTrials.gov NCT04464603. Registered on 9 July 2020.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-021-05170-3.

European Resuscitation Council Guidelines 2021: Paediatric Life Support

These European Resuscitation Council Paediatric Life Support (PLS) guidelines, are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the management of critically ill infants and children, before, during and after cardiac arrest.

A Systematic Review and Meta-Analysis of Direct Objective Measures of Situation Awareness: A Comparison of SAGAT and SPAM

OBJECTIVE

To examine evidence of sensitivity, predictiveness, and methodological concerns regarding direct, objective measures of situation awareness (SA).

BACKGROUND

The ability to objectively measure SA is important to the evaluation of user interfaces and displays, training programs, and automation initiatives, as well as for studies that seek to better understand SA in both individuals and teams. A number of methodological criticisms have been raised creating significant confusion in the research field.

METHOD

A meta-analysis of 243 studies was conducted to examine evidence of sensitivity and predictiveness, and to address methodological questions regarding Situation Awareness Global Assessment Technique (SAGAT), Situation Present Assessment Technique (SPAM), and their variants.

RESULTS

SAGAT and SPAM were found to be equally predictive of performance. SPAM (64%) and real-time probes (73%) were found to have significantly lower sensitivity in comparison to SAGAT (94%). While SAGAT was found not to be overly memory reliant nor intrusive into operator performance, SPAM resulted in problems with intrusiveness in 40% of the studies examined, as well as problems with speed-accuracy tradeoffs, sampling bias, and confounds with workload. Concerns about memory reliance, the utility of these measures for assessing Team SA, and other issues are also addressed.

CONCLUSION

SAGAT was found to be a highly sensitive, reliable, and predictive measure of SA that is useful across a wide variety of domains and experimental settings.

APPLICATION

Direct, objective SA measurement provides useful and diagnostic insights for research and design in a wide variety of domains and study objectives.

Relationship between Executive Functions, Mindfulness, Stress, and Performance in Pediatric Emergency Simulations

Over the past decade, high-fidelity medical simulation has become an accepted and widely used teaching method in pediatrics. Both simulation and work in the real conditions of emergency departments are accompanied by stress that affects the executive functions of participants. One of the methods for reducing stress among medical students and healthcare professionals is the practice of mindfulness. The aim of this study was to examine whether executive functions, mindfulness, and stress are related to the technical and non-technical skills of medical students participating in medical simulations in pediatrics. The study included 153 final-year medical students. A total of 306 high-fidelity simulations of life-threatening situations involving children were conducted. Results: Stress and the coping mechanism of the participants were correlated to their skills during pediatric simulations. Some components of mindfulness, such as non-judgment and conscious action, were positively related to the skills of medical team leaders. Executive functions correlated with the non-technical skills and mindfulness of the medical students. Conclusions: Stress, mindfulness, and executive functions modeled the behavior and skills of medical students during pediatric simulations of life-threatening events. Further research in this area may prove whether mindfulness training will improve learning outcomes in pediatric emergency medicine.