Situational Awareness is an Important Part of High Reliability

Editor’s note: The following is an excerpt from the HCPro book, Building a High-Reliability Organization: A Toolkit for Success, coauthored by Gary Sculli, MSN, ATP, and Douglas E. Paull, MD, MS, FACS, FCCP, CHSE. Sculli, a former pilot for a major U.S. airline and a registered nurse for more than three decades, has a unique perspective on high reliability. He will share specifics on how to achieve it at our upcoming High Reliability and Safety in Healthcare Workshop, April 16 at Renaissance Orlando at SeaWorld® in Florida. To register, visit

High-reliability industries and organizations are very familiar with the term situational awareness (SA). In such industries, the term is not a passing fad embraced for a few short years only to be replaced by the next buzzword or catchy movement. SA is a foundational concept, and its importance in operational decision-making at the front line is recognized and categorically supported by leadership. In healthcare, save for pockets of very safe and reliable care delivery, this is generally not the case. SA is not a term that is fluently defined or discussed by frontline clinicians, clinical managers, and healthcare executives. For example, Fore and Sculli (2013) published a concept analysis on the term “situational awareness” in nursing practice. What they discovered was interesting. An overwhelming majority of these articles were unrelated to healthcare and came from other disciplines such as aviation, nuclear power, and military operations. Limiting the search to use of the term in nursing returned almost nothing, so they expanded to healthcare in general. While this increased the number of studies that discussed the definition, use of, or measurement of SA, and while the number has increased over the last decade or so, healthcare continues to be under-represented when it comes to understanding and supporting SA.

What is meant by the phrase “supporting situational awareness”? It’s simple. Healthcare leaders must understand the critical link between situational awareness and clinical decision-making. They need to understand how teams develop situational awareness and be prepared to clear any and all obstacles that impede that process. Executive leaders and service line leaders close to the bedside must scrutinize models of care delivery currently in use and be sure that these models enhance a clinician’s ability to capture patient information, easily communicate that information to other team members, and use an engaged and functional team to manage clinical situations likely to occur. The importance of the previous sentence cannot be underestimated.

If you approached the everyday line pilot for a major airline and asked the question, “What is meant by the term situational awareness, and what are some specific behaviors you and your team practice on a regular basis to maintain it?” you would receive a cogent answer with specifics. Yet, if you approached a nurse or physician or any other healthcare worker and asked the same question, chances are the answer would not come as easily. It can be comfortably asserted that it is exponentially harder for clinicians to maintain adequate levels of SA than it is for an airline pilot. When you consider staffing shortfalls, hostile work environments, distractions, unmanageable task loads, inadequate training, and poor human-centered designs that persist in many patient care environments, the ability to develop and maintain adequate levels of SA can be profoundly compromised (Sculli, Fore, Neily, Mills, & Sine, 2011). I also assert that if healthcare organizations from the top down and bottom up were committed to making it easier for clinicians to develop SA at the front line of care, where hands touch patients, many of the adverse events described above would not happen. There can be no discussion of achieving high reliability in healthcare without a commitment to the development of high levels of situational awareness among clinical teams.

Developing situational awareness

The following is a commonly accepted definition of the term SA used in healthcare: SA is defined as the perception of the elements within a volume of time and space, the comprehension of their meaning, and the projection of their status in the near future (Singh et al., 2012; Endsley, 1995). To further explain, SA is divided into three levels:

Level 1: Perception of elements. A clinician is aware of things, meaning certain elements have reached his or her attention. For example, an emergency room (ER) physician assesses a patient and learns that the patient is 66 and lives with his daughter who is gone most of the day, has a history of congestive heart failure (CHF), recently had the flu, has not been in the hospital recently but was treated as an outpatient for “walking pneumonia” a few months ago, has a productive cough, decreased breath sounds in the left chest, temperature of 99° F, respiratory rate of 22/min, mild pleuritic chest pain, decreased appetite, and occasional confusion but is presently quite lucid. The patient’s lab work is unremarkable. A chest X-ray taken immediately after triage shows a “left lower lobe infiltrate.” These are simply elements or facts of which the physician is aware. By themselves, these pieces of information mean nothing. Again, level 1 is simply the perception of specific elements in the environment, meaning these items have captured one’s attention. That’s all.

Level 2: Comprehension of meaning. The ER physician will now put all of these disjointed elements together, find relationships between them, and assign meaning to the scenario. It’s like taking individual trees and putting them together to create a patch of forest. One can say it’s an ability to see the “big picture.” Using the elements so far, the physician’s big-picture view suggests community-acquired pneumonia (CAP) with a marginal Pneumonia Severity Index (a tool used to numerically calculate the chance of mortality and the need for admission as an inpatient).

Level 3: Projection. Now the physician will project into the very near or immediate future. From this projection, he or she knows that if interventions and therapies are not promptly initiated, the patient may very well continue to deteriorate and develop a profound pneumonia with continued failure to thrive. Serious illness and mortality can occur, especially if the patient is sent home with minimal monitoring and assistance from family throughout the day.

Moving through these levels, the physician can then make decisions and take actions. In this case, sputum cultures, pulse oximetry, oxygen, and prompt antibiotic therapy are ordered, and a plan to admit as an inpatient is formulated (Yealy & Fine, 2014). The physician moves through these levels subconsciously, and it occurs within a circumscribed period of time and space—taking place in the ER during the time the patient is triaged, evaluated, and a decision to treat and admit is made. You can say, then, that the development of SA is the precursor to decision-making.

Situational awareness derailed

In our model of SA, the end points (i.e., decisions) can be compromised by failures at any level. For example, in the case of our ER physician, if he or she is distracted, fatigued, or task saturated due to poor staffing or high patient load, key elements in the patient’s presentation, such as weakness and a recent history of confusion, may not be known. They fail to reach the physician’s attention, which creates a level 1 SA failure. The consequence is that the subsequent “big picture,” short-term projections, and, ultimately, the end-point decision to admit as an inpatient for treatment may not occur even though it may be indicated based on the patient’s true condition.

The same compromise to clinical decision-making can occur at level 2 SA. Consider, for example, the case of a nurse on a medical-surgical unit caring for a middle-aged, female patient with a severe kidney infection. The patient is exhibiting signs and symptoms of sepsis (i.e., infection in the bloodstream), which if not treated promptly can be fatal. The nurse has perceived all of the necessary elements by way of handoff report and patient assessment: hypotension, tachycardia, altered mental status, decreased urine output, low-grade fever, and decreased oxygen saturation. However, if this nurse is unable to put these elements together and form the correct big picture, if the relationships among the individual elements are not processed and recognized, then what is comprehended is not reflective of the patient’s true state. The decisions and actions of this nurse will be less than optimal for the patient. Potential causes for this inability to recognize the patient’s true state may be fatigue or the presence of distractions; however, we can also imagine a lack of continual training on the clinical manifestations of sepsis to allow pattern recognition as causal in this level 2 SA failure. If the nurse thought the patient might be septic but wasn’t sure and failed to confirm with another team member, then the absence of continual training on nontechnical skills such as crew resource management (CRM), which emphasizes vigilance, communication, and using other team members to solve problems, may be causal. Whatever the reason, if the actual state of the patient is not comprehended, the level 2 SA failure can lead to flawed decision-making.

Continuing with the same case, if the nurse perceives all necessary elements (level 1 SA), forms the appropriate relationships between them, and recognizes the big picture as sepsis (level 2 SA), but near-future projections (level 3 SA) fail to paint the very real picture of septic shock, multi-system organ failure, and death, then, again, the appropriate end-point decision may not occur. This patient requires transfer to a higher level of care, vasopressors and intravenous fluids for blood pressure support, and aggressive antibiotic therapy. Perhaps the nurse does not possess the requisite experience to know what the near future can look like for a septic patient. Or the simple human factor issues previously mentioned such as fatigue or high task load might derail the process. As with all levels of SA, a level 3 SA failure can compromise the integrity of the clinical decision that is made, ultimately placing the patient at greater risk.

Environmental threats to situational awareness

SA is dynamic, constantly changing and updating, and is subject to a number of threats from the environment in which healthcare teams work, including fatigue, hierarchy, and distractions. Fatigue has been defined as “an overwhelming sense of tiredness, lack of energy, and feeling of exhaustion associated with impaired physical and cognitive functioning” (Dubeck, 2014). Provider fatigue is a contributing factor to preventable adverse events in healthcare (The Joint Commission, 2011). Fatigue directly threatens SA by causing lapses in attention and memory and decreasing both the speed and accuracy in which the human brain processes information (The Joint Commission, 2011). Nurses working more than 12.5 hours in a shift are three times more likely to make an error. Residents working 24-hour shifts are five times more likely to make a diagnostic error and 61% more likely to suffer a needlestick injury. Despite ample evidence, healthcare leaders are largely unaware of the threat fatigue represents to patient and employee safety.

The culture of an organization, or for that matter the patient care unit, serves as a strong modulator of SA. Nurse-physician interactions—often characterized by poor communication, conflict, and dissatisfaction—can lead to preventable patient-adverse events. It is not so much what is said, but rather what is not said: “Silence kills” in healthcare (Moore & Putman, 2008). Healthcare workers observe important safety violations, errors, incompetence, and/or disrespectful behavior but fail to “speak up” because of the intimidating environment often passively condoned by local supervisors (Moore & Putman, 2008). This lack of information sharing inhibits level 1 SA development.

SA depends on teamwork and communication. A culture that facilitates communication leads to improved SA, better decision-making, and better outcomes for patients. Perhaps Leape et al. (2012) best summarize the relationship between culture, the organization, and leadership: “Without mutual respect and a sense of common purpose, people cannot and will not work effectively together … these characteristics are embodied in so-called ‘high-reliability organizations’ … The responsibility for creating a culture of respect falls on the organization’s leader because only he or she can set the tone and initiate the processes that will lead to change.”



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