■ Physician-team:

Leveraging the power of collaboration to foster safe care

Situational awareness

Surgeons working in operating room.
Published: April 2021
10 minutes


Situational awareness is a cognitive skill that involves:

  1. gathering information
  2. understanding the information, including its significance in the context of the situation
  3. applying that understanding in order to think ahead and anticipate potential complications

In the simplest terms, situational awareness is knowing what is going on around you1 and keeping an eye on the “big picture” while managing individual issues. Situational awareness is critical for effective decision-making and is one of the most important non-technical skills for physicians and teams.

Team situational awareness refers to the collective understanding of the evolving situation. It involves knowledge of tasks as well as team roles and responsibilities.2 When individuals on the team share their knowledge and analysis of a situation with other team members, team situational awareness can be created.

It is easy to lose situational awareness. The loss of situational awareness is often an unconscious process that may result from a variety of issues, such as cognitive overload or unconscious drift away from safe practices. Unfortunately, as individuals, we often cannot recognize that we are about to commit an error until it is too late. While individuals may be blind to their risk of error, their co-workers might see and hear things differently and thus identify an otherwise unappreciated risk.

Fostering a culture of support

To create highly reliable teams focused on learning and identifying problems before they occur, it is important to foster a culture of support. In such a setting, each member of a healthcare team realizes they are prone to the loss of situational awareness and welcomes the input of others. To “have each other’s back” means not hesitating to speak up about concerns, while also inviting and integrating input from other team members.

Good practice guidance

Situational awareness is a key component of human factors science.

What is meant by human factors science?

Human factors science studies the human characteristics, capabilities, and limitations that influence how people interact with their environments. The goal of human factors science for healthcare is to support the cognitive, physical, and technological work of healthcare providers, thereby enabling safe patient care.3 In healthcare, the consideration of human factors science in the genesis of patient safety incidents (accidents in Québec) helps us design safer systems.

Human factors science comprises the following elements:

  • individuals
  • teams
  • environment
    • human: includes culture, leadership, and teams
    • physical: includes tasks, equipment, and technology

According to human factors science, the factors discussed below influence situational awareness. All of these factors may play a role in any given situation and can impact performance and patient outcomes.

The patient

The patient is the most important element. Each patient has unchanging information, such as name, age and past history. The patient also has dynamic information such as vital signs and evolving medical conditions.


The patient presents in a specific environment which will have both physical and human aspects. The physical environment includes the design and layout of the space and aspects such as noise, lighting, and temperature. The human aspects include the individuals involved as well as organizational aspects (such as handovers, staffing, protocols, training and supervision).

Individual provider factors play an important role in situational awareness. These individual factors include knowledge, experience, training, technical skills, memory, and communication skills, as well as performance modifying factors such as stress, fatigue, hunger, and emotional distress.


Tasks are often complex, dynamic and depend on the clinical situation. The individual’s tasks will depend on the roles and responsibilities of each team member.

Tasks involved in the diagnostic process include:

  • gathering information from the history, physical exam, and results of investigations
  • interpreting the information when formulating the differential diagnoses and final diagnosis
  • determining the therapeutic plan with the involvement of the patient
  • monitoring the care process
  • continuously monitoring dynamic information
  • judiciously utilizing available resources


Refers to the actual time, the elapsed time and the projected time. We often underestimate the time it will take to complete a specific task and easily lose perspective during clinical emergencies.

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We can promote situational awareness by consciously and continuously:

  • being alert to the evolving condition of the patient, particularly if the urgency of the situation is changing
  • switching to more analytical and critical thinking, when warranted
  • thinking ahead and anticipating problems
  • leveraging the team’s situational awareness to complement our own
  1. Acquiring information

    Staying attuned to the wealth of information sources we have can be difficult, especially in times of stress. Valuable information may come from:

    • patients and family members
    • medical records
      • notes written by allied health professionals often contain key pieces of information and may be overlooked
    • team members
      • scheduled huddles, handovers
      • review of checklists
      • structured communication tools (like SBAR)
      • concerns raised and questions asked
      • informal conversations
    • monitors
    • laboratory, pathology and imaging reports
  2. Understanding or interpreting information

    The information must be processed and analyzed in order to lead to clinical decisions. At this stage, providers interpret the implications of the information for the patient and the clinical situation.

    Generally, understanding the information involves:

    • pattern recognition allowing for rapid assessment and diagnosing based on previous experience
    • an analytic approach which is slower, more deliberate, and more common in unfamiliar situations
    • interpretation of the significance of perceived information based on goals and expectations

    Experts purposefully use a slowing down technique to switch from the “autopilot” pattern recognition mode to a slower, purposeful, effortful, analytic approach when they need to manage different scenarios or particularly challenging situations. Creating a differential diagnosis encourages one to shift cognitive abilities, slow down, and actively consider other diagnostic possibilities. Slowing down can be anticipated (for example, preoperatively) or spontaneous (for example, as a result of situational awareness of an emergent intraoperative challenge).4

    Cognitive biases (distortions of thinking) and affective biases (intrusions of prejudices and emotions) may interfere with reasoning and decision-making.5 Awareness of biases can decrease the risks of them interfering with an accurate diagnosis and management plan.

  3. Thinking ahead or projecting

    With an understanding of key information, the clinician can anticipate what their perceptions mean for the future of the patient and the care goals. The components of perception, interpretation, and projection are not linear or static. Situational awareness is highly dynamic; providers continually perceive, interpret, and project their individual and collective (team) knowledge of the patient and their situation.

    Novices may have more difficulty projecting ahead as they have not had sufficient clinical experience or gained sufficient knowledge to anticipate potential outcomes. Effective coaching by supervisors should include teaching situational awareness through the use of personal reflections, briefings and debriefings.6

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Team situational awareness is “… the degree to which each team member possesses the situational awareness required for his or her responsibilities”.7

Teamwork is a joint cognitive endeavour. While each member of a team contributes to the overall care received by the patient, an over reliance on individual competence instead of collective competence can lead to missed opportunities to promote the reliability and safety of care.8

  • A team may be underperforming even when each member of the team is individually competent, if the team does not function well as a whole.
  • A team can be highly competent even if one member of the team is underperforming if there a system redundancies designed to mitigate that effect.
  • A team can be competent in one situation and not in another, depending on the culture and environment it relies on to function.

Psychological safety is a shared belief that anyone on the care team can speak up and share their opinion respectfully without fear of retribution.9 Team behaviours around information sharing help foster the creation and maintenance of situational awareness, which is a key driver of safe care and clinical excellence. Within a psychologically safe culture, team members are able to enhance situational awareness, rather than focusing on self-protection.

Teams can suffer from loss of situational awareness in a number of different ways:

  • the needed information may not be shared clearly
  • the required information may not be available to all team members
  • individual team members may interpret the information differently, based on different perspectives

Studies suggest that team members tend to relay information and assume everyone will interpret it in the same way. Even with the same understanding of the clinical situation, different team members may anticipate or project different outcomes for the patient.

Improved team collective competence can be achieved by:

  • improving technology so that members of the team have equal access to patient health information
  • encouraging the use of checklists to engage all members of the team in providing input
  • creating policies and procedures that build-in redundancies such as double checking medication administration
  • using simulation to focus teaching of high performing team-based behaviours
  • involving patients as active participants in their team and encouraging speaking up

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Preparation is the first step in creating adequate situational awareness. The information required to build situational awareness can and should be obtained through huddles, briefings such as a surgical safety checklist, handovers, ward rounds, or reviewing a medical record.

Preparation for good situational awareness includes:

  • knowing your team members’ names
  • knowing their roles
  • reducing distractions
  • anticipating complications
  • using structured communication tools

Building and maintaining situational awareness

Maintaining situational awareness can be challenging in any situation. Each context has its own unique challenges that can test the maintenance of situational awareness. To remain situationally aware, it is important to be proactive and build systems that promote ongoing situational awareness by:

  • remaining watchful and prepared for the unexpected
  • being alert to the evolving condition of the patient
  • being alert to our own condition and that of co-workers
  • building processes to force structured team communication
  • empowering others to speak up
  • continually being on the lookout for biases
  • thinking ahead

It is possible to improve self-awareness by:

  • fostering a psychologically safe environment – one where healthcare providers are not afraid to speak up about their personal performance concerns
  • recognizing our own fatigue
  • recognizing that stress may interfere with our reasoning
  • examining our thinking for cognitive biases
  • assessing our own mental and physical health

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Checklist: Situational awareness

Situational awareness is critical for effective decision-making

Situational awareness includes obtaining information, interpreting the information to understand the clinical situation, and thinking ahead.

Have you:

  • Empowered your team to speak up about any concern?
  • Gathered pertinent information from all available sources?
    • patients
    • family members (with patient consent or where permitted by law)
    • medical records
    • team members
    • monitors
    • laboratory and imaging reports
  • Minimized distractions?
  • Considered cognitive biases that may impact your interpretation of the clinical situation?
  • Used a pause, time-out, briefing or huddle to prepare for the task?
  • Confirmed the names, roles, and responsibilities of your team members?
  • Used structured communication tools to convey information to each team member?
  • Confirmed each individual’s understanding of the information using read back or teach back?
  • Developed an action plan?
  • Anticipated complications and possible outcomes?
  • Debriefed post event/procedure to extract lessons learned?

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  1. Endsley MR. Toward a Theory of Situation Awareness in Dynamic Systems. Human Factors.1995; 37(1):32–64. Available from: https://journals.sagepub.com/doi/abs/10.1518/001872095779049543
  2. Parush A, Campbell C, Hunter A, et al. Situational Awareness and Patient Safety. Royal College of Physicians and Surgeons of Canada, 2011. Available from: http://www.royalcollege.ca/rcsite/documents/canmeds/situational-awareness-patient-safety-preview-e.pdf
  3. Russ AL, Fairbanks RJ, Karsh B, et al. The science of human factors: separating fact from fiction. BMJ Qual Saf. 2013; 22:802-808 Available from: https://qualitysafety.bmj.com/content/qhc/22/10/802.full.pdf
  4. Moulton CA, Regehr G, Mylopoulos M, et al. Slowing down when you should: a new model of expert judgement. Acad Med. 2007; 82 (10):109–16
  5. Lingard L. Paradoxical Truths and Persistent Myths: Reframing the Team Competence Conversation. Journal of Continuing Education in the Health Professions. 2016; 36:S19-S21. doi: 10.1097/CEH.0000000000000078. Available from: https://journals.lww.com/jcehp/Abstract/2016/03631/Paradoxical_Truths_and_Persistent_Myths__Reframing.6.aspx
  6. Pradarelli J, Yule S, Panda N, et al. Surgeons’ Coaching Techniques in the Surgical Coaching for Operative Performance Enhancement (SCOPE) Program. Annals of Surgery. 2020 Jul. doi: 10.1097/SLA.0000000000004323. Available from: https://journals.lww.com/annalsofsurgery/Abstract/9000/Surgeons__Coaching_Techniques_in_the_Surgical.94294.aspx
  7. Endsley MR. Toward a Theory of Situation Awareness in Dynamic Systems. Human Factors.1995; 37(1): 32–64. Available from: https://journals.sagepub.com/doi/abs/10.1518/001872095779049543
  8. Lingard L, Espin S, Rubin B, et al. Getting teams to talk: Development and pilot implementation of a checklist to promote interprofessional communication in the OR. Qual Saf Health Care. 2005;14(5):340-346. doi:10.1136/qshc.2004.012377
  9. Edmondson A. Psychological Safety and Learning Behavior in Work Teams. Administrative Science Quarterly.1999;44(2):350-83
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DISCLAIMER: The information contained in this learning material is for general educational purposes only and is not intended to provide specific professional medical or legal advice, nor to constitute a "standard of care" for Canadian healthcare professionals. The use of CMPA learning resources is subject to the foregoing as well as the CMPA's Terms of Use.