Situation Monitoring Know the plan, share the plan, review the risks

Objectives Discuss how situation monitoring affects team processes and outcomes List components of the STEP mnemonic Explain situation awareness and identify conditions that may undermine situation awareness Define a shared mental model and how a team can develop shared mental models

Situation Monitoring Ensures new or changing information is identified for communication and decision-making Leads to effective support of fellow team members

The Theory Effectiveness Team Leadership Orientation Mutual Performance Monitoring Back-up Behavior Adaptability Shared Mental Models Trust Effectiveness Closed Loop Communication Salas, Sims, Burke. Is there a “Big Five” in teamwork? Small Group Research. 2005; 36:555-599. Big 5 Coord. Mechanism We just learned that during briefs, huddles, and debriefs team members communicate what they have learned by monitoring others, a new shared mental model of how to reach a goal emerges, and team members offer back up behavior or mutual support to achieve that goal. When team members trust each other, use closed loop communication, and value team goals above individual goals; that is they are oriented toward the team; they have the ability to adapt, manage complex systems & patients and learn from experience.

A Continuous Process Situation Monitoring (Individual Skill) Situation Awareness (Individual Outcome) Shared Mental Model (Team Outcome) The ability of a team to hold a shared understanding/model of what is happening in any given situation relies on a continuous process that begins with each individual monitoring what is going on in their environment.

Remember, engage the patient whenever possible! Situation Monitoring Process of actively scanning behaviors and actions to assess elements of the situation or environment Enables team members to identify the potential issues or minor deviations Benefits: Fosters mutual respect and team accountability Provides safety net for team and patient Includes cross-monitoring Remember, engage the patient whenever possible!

Cross-Monitoring A process of ongoing monitoring to recognize risk or unfolding error An opportunity to interrupt or correct an action or event before there is harm or injury to the patient “Watching each other’s backs” Providing feedback to ensure the procedures are being performed appropriately “Mutual performance monitoring has been shown to be an important team competency.” McIntyre RM, Salas E. Measuring and managing for team performance: emerging principles from complex environments. In: Guzzo RA, Salas E, eds. Team effectiveness and decision making in organizations. San Francisco: Jossey-Bass; 1995. p. 9-45.

Steps to monitor the situation

or Project PROJECT PATIENT Resources Patient History Information Tools Timeline PATIENT Patient History Vital Signs Medications Function Plan of Care Safety Concerns or Project TEAM MEMBERS Fatigue Workload Task Performance Skill Level Stress Level

Are Team Members Safe? I’M SAFE Checklist I = Illness M = Medication S = Stress A = Alcohol and Drugs F = Fatigue E = Eating and Elimination

or Project Facility Information Administrative Information Human Resources Triage Acuity Equipment Goal of Team? Call a Huddle? Tasks/Actions Need To Be Completed? Plan Still Appropriate?

Situation Awareness is… The state of knowing the current conditions affecting one’s work. Is this patient at high risk for falls? Do other team members know he is at high risk? Is the environment set up to maximize safety? (NO! walker is folded up and outside his reach.) Are we progressing toward the goal of keeping this patient safe from falling? Includes knowing… Status of the patient Status of other team members Environmental conditions Current progress toward the goal

Conditions That Undermine Situation Awareness Failure to— Share information with the team Request information from others Direct information to specific team members Include patient or family in communication Utilize resources fully (e.g., status board, automation) Maintain documentation Know and understand where to focus attention Know and understand the plan Inform team members the plan has changed

Situation Awareness… Easy to teach? Difficult to teach? Are some people more aware of their surroundings? Can we change behavior?

A Shared Mental Model is… The perception of, understanding of, or knowledge about a situation or process that is shared among team members through communication Team effectiveness will improve if team members have a shared understanding of the situation. In health care, if the wrong plan is developed, potentially all actions that follow are wrong, and the patient and caregiver are at risk.

Shared Mental Model? Do all members of this team have a shared mental model?

The Theory Effectiveness Team Leadership Orientation Mutual Performance Monitoring Back-up Behavior Adaptability Shared Mental Models Trust Effectiveness Closed Loop Communication Salas, Sims, Burke. Is there a “Big Five” in teamwork? Small Group Research. 2005; 36:555-599. Big 5 Coord. Mechanism If we value a shared mental model of how teamwork improves our effectiveness, we will monitor what is going on around us, offer back up behavior to others and improve our ability to adapt to changing circumstances. During briefs, huddles, and debriefs in which information is shared, a new shared mental model of how to reach a goal emerges, and team members offer back up behavior or mutual support to achieve that goal. When team members trust each other, use closed loop communication, and value team goals above individual goals; that is they are oriented toward the team; they have the ability to adapt, manage complex systems & patients and learn from experience.

When and How to Share? When: Briefs Huddles Debriefs Transitions in Care How: SBAR Call-outs Check-backs

What Do You See? In each figure, you should be able to see two images: Figure 1. an Eskimo entering an igloo or an Indian chief in profile Figure 2. an old woman and a young woman Figure 3. a duck and a bunny Remember that many people can look at the same situation but interpret it differently. We must share our individual perceptions during briefs, huddles and debriefs to ensure a shared mental model.

How Shared Mental Models Help Teams Lead to mutual understanding of situation Lead to more effective communication Enable back-up behaviors Help ensure understanding of each other’s roles and how they interplay Enable better prediction and anticipation of team needs Create commonality of effort and purpose

Tools & Strategies Summary BARRIERS Inconsistency in Team Membership Lack of Time Lack of Information Sharing Hierarchy Defensiveness Conventional Thinking Complacency Varying Communication Styles Conflict Lack of Coordination and Followup With Coworkers Distractions Fatigue Workload Misinterpretation of Cues Lack of Role Clarity TOOLS and STRATEGIES Communication SBAR Call-Out Check-Back Handoff Leading Teams Brief Huddle Debrief Situation Monitoring STEP I’M SAFE OUTCOMES Shared Mental Model Adaptability Team Orientation Mutual Trust Team Performance Patient Safety!!