Section 2: Explanation of Key Concepts and Tools
This section contains explanations and illustrations to help you better understand and appreciate the importance of situation monitoring and TeamSTEPPS situation monitoring tools. If you teach this content or want additional insights on how the material can be more fully learned, you may find the instructor suggestions in section 3 helpful.
Situation Monitoring
Situation monitoring is one of the four essential skills central to safe, efficient, and patient-centered care.
Situation monitoring is the process of actively scanning behaviors and actions to assess elements of the situation or environment. Situation monitoring is the skill required to create the outcome of situation awareness. When all team members engage in situation monitoring and maintain situation awareness, the end result for the team is a shared mental model that is needed for rapid and successful team decision making and safe and patient-centered care.
The Situation Monitoring Diagram illustrates the relationships among these three concepts.
Situation Monitoring Diagram
The discussion that follows further explains these concepts and provides examples. It then describes situation monitoring tools team members can use to achieve individual situation awareness and the desired team outcome of a shared mental model.
Situation Monitoring: A Key Skill for Individuals
Situation monitoring is the skill of actively scanning and assessing elements of a situation to obtain information or maintain an accurate understanding of the situation in which the team functions. Examples of situation monitoring in important contexts are in the table “Situation Monitoring Examples.”
Situation monitoring is an essential skill for team members for several reasons:
- It enables team members to identify potential issues or deviations early enough to correct and handle them before they become a problem or pose harm to the patient.
- It fosters mutual respect and team accountability and, through the process of cross-monitoring, provides a safety net for both the patient and other team members.
- It ensures team members are supported in stressful or high-pressure situations.
Examples of situation monitoring in common contexts are captured below.
Situation Monitoring Examples
| Context | Example |
|---|---|
| Hospital | A nurse notices that another nurse has several patients needing substantial attention and offers to assist. |
| A nurse assisting a physician in inserting a central line notices the physician inadvertently contaminates their glove and calls out to the physician the break in sterile technique (cross-monitoring). | |
| Ambulatory Care | The receptionist observes that a patient in the waiting room seems deeply distressed and mentions it to the nurse or physician. |
| The front desk patient service rep notices that a patient in the waiting room is slumping in their chair and appears to be lethargic; after checking the patient in, they notify the medical assistant and registered nurse. | |
| Diagnostic Accuracy | A nurse notes that results are lacking for a common diagnostic test. |
| Team members maintain awareness of workload spikes and stress levels among themselves that may lead to diagnostic errors. | |
| Patient and Family Caregiver | A family caregiver checks on a patient and calls their doctor because the patient appears confused and agitated. |
| The spouse of a patient admitted for an acute asthma attack notices that the patient has become unresponsive and calls for the registered nurse or the Rapid Response Team. | |
| Virtual Teams | A physician calls a colleague after a video call in which the colleague arrived late, appeared flustered, and did not speak—all very unusual behaviors. |
| Virtual Care | An electronic intensive care unit (eICU) nurse notices a concerning change in vital signs (heart rate, blood pressure, temperature, oxygen saturation) and lab values. In view of the patient’s admission diagnosis, the eICU nurse notifies the bedside nurse of possible signs of sepsis. |
TeamSTEPPS: Situation Monitoring in Office-Based Care (2:26)
To reflect on the meaning and importance of situation monitoring, watch the video scenario. Afterwards, think about how you would answer these questions:
- Was situation monitoring demonstrated in this video?
- Was this strategy effective? Why or why not?
- Did you see any other opportunities for situation monitoring to be demonstrated in this video?
- Have you encountered crises like this in your teams? If so, how did you overcome them?
Consider another scenario involving situation monitoring in a nonclinical situation encountered by a care team:
Susan was due for a mammogram and the provider ordered it. Upon arrival at the mammography service, Susan was told that she would have to pay for the mammogram, since her insurance company did not cover it. Confused, Susan returned to the clinic and told the administrative assistant that she did not have the money to pay for this. She was especially upset because her mother was a breast cancer survivor.
The administrative assistant assessed (1) the status of the situation (that a billing specialist was needed); (2) the environment (the patient was upset); and (3) the progress, or lack of it, toward the goal (the patient was being denied access). The billing specialist then called the insurer and clarified that the insurer had the wrong dates and Susan’s mammogram was due. The insurer realized their error and covered the mammogram.
Use these questions to reflect on the scenario:
- Whose responsibility was it to assist the patient? It is very common for multiple team members to be aware of a problem but assume that someone else is handling it.
- Can you think of situations where multiple team members were aware of an issue but everyone assumed someone else was addressing it? Checking with other team members to ensure that ownership of challenges is clearly defined is vital to effective situation monitoring and strong teamwork.
Evaluate your own personal experiences using the following questions:
- When have you used situation monitoring in your work?
- How did the information you obtained from the environment affect how you approached or responded to the situation?
- Think about your own office team and daily routines in terms of situation monitoring. Have you encountered barriers to proper situation monitoring? What proactive steps can you take to overcome these barriers and effectively monitor the situation even when it is challenging?
Situation Awareness: A Key Outcome for Individuals
Situation awareness is knowing the current conditions that affect your work. It includes the continuous awareness of the status of the patient, team, and environment and progress toward defined treatment goals.
Situation awareness is critical because the healthcare environment is continuously changing. Team members change each shift or day; patients’ conditions evolve; staff workloads change in response to the changing needs of their patients. Situation awareness allows team members to support each other to manage stress levels and to support patients and family caregivers.
Situation awareness can prevent ambiguity, confusion, and inefficient communication. This awareness can be achieved when team members, including the patient and family caregiver:
- Share information with the team.
- Request information from others.
- Direct information to specific team members.
- Include the patient or family caregivers in relevant discussions.
- Use resources fully (e.g., status board, automation).
- Maintain documentation that is adequate, complete, and timely.
- Know and understand where to focus attention.
- Know and understand the treatment plan.
- Inform team members when the plan or team composition has changed.
Situation awareness plays a central role in ensuring diagnostic accuracy. During the diagnostic process, situation awareness provides an important way to prevent diagnostic errors.
Ideally, patients and providers have the same set of facts, understand each other’s values (e.g., risk tolerance, quality vs. quantity of life, discomfort tolerance, importance of independence) and goals, and agree on “where things are” in the diagnostic process. Many malpractice suits illustrate the problems that arise when understanding and expectations are misaligned.
Fostering continuous situation awareness should begin by assessing your own situation awareness. Reflect on how consistently you perform the nine activities noted in the bullet list above to promote situation awareness. Can you improve in one or more of these areas? Pick one area where you think you can improve the most and look for opportunities to improve in it daily.
If you are in a leadership position, you may want to ask your team members to try this exercise as well and to share what they're working on in a team meeting. But by starting with yourself, you’ll make it clear that you view situation awareness as an area in which everyone, including you, should try to continuously improve.
Shared Mental Model: A Key Team Outcome
A shared mental model is a mental picture or sketch of the relevant facts and relationships defining an event, situation, or problem.
Shared mental models:
- Consist of the relevant facts and interrelationships among tasks and situations the team is dealing with in their care of a patient or response to a defined issue.
- Provide team members with a common understanding of who is responsible for which task and what the information requirements are for each task.
- Enable the team to anticipate and predict each other's needs; identify changes in the team, task, or teammates; and adjust the course of action or strategies as needed.
Shared mental models support teams by:
- Leading to a mutual understanding of problems, goals, team strategies, patients’ condition, and plan of care.
- Leading to more effective communication to ensure that team members have the necessary information to do their tasks.
- Enabling team members to back up and fill in for each other.
- Helping team members understand each other’s roles and how they relate to each other.
- Improving individual team members’ ability to provide mutual support by predicting and anticipating the team’s needs.
- Creating commonality of effort and purpose.
- Helping avoid errors that put patients at risk.
Each team member has a background, set of experiences, and awareness of the situation that may or may not match those of other team members. These unique perspectives can benefit the team as a whole if they are recognized and accounted for. However, without sharing and communication, diverse perspectives may impede the team’s creation of shared mental models.
Even simple images can be perceived differently. Look at these images—can you see two distinctly different objects? Do you see different images if you look left to right or right to left? How do these different perspectives influence your ability to see the whole picture?
What did you see? A vase, or two people? A duck, or a rabbit? A young woman, or an older woman?
As you reflect on your own experiences, can you identify a specific time a team worked flawlessly based on a shared mental model? What did that team do to preserve a shared mental model during rapidly changing circumstances?
Creating and sustaining shared mental models within teams requires supporting each team member’s efforts to engage in situation monitoring and awareness.
A shared mental model requires information sharing among team members, including the patient. When each team member shares their unique information, the team will have a more accurate assessment of the situation. It is imperative that every team member feel empowered to speak up, even if they seem to be stating the obvious. One piece of information can affect how the team moves forward.
If someone holds back information or is ignored by other team members, patient care can be compromised. Mutual support among all team members helps give everyone on the team a voice. Information can be shared during team events such as briefs, debriefs, and huddles (discussed in Module 2), as well as through in-person or virtual conversations. Tools that can be used to share information include SBAR (Situation-Background-Assessment-Recommendation), call-outs, and check-backs (see Module 1).
Teams should communicate whenever a need arises or when the environment or patient status changes substantially. This communication can ensure everyone agrees and has a comprehensive view of the situation. Teams work more efficiently and effectively when all members are "on the same page." If teams can better predict and anticipate, the team will know what is supposed to happen and will have a better understanding of how the patient is progressing.
Situation Monitoring Tools
Situation monitoring tools provide the specific skills needed to help individual team members achieve situation awareness and help teams maintain the shared mental models needed to function effectively. TeamSTEPPS now includes five situation monitoring tools. Each tool helps maintain the collective awareness of the situation required to support effective team functioning. This table can help you select the tool or tools most relevant for specific needs.
Situation Monitoring Tools
| Tool | Primary Use |
|---|---|
| STEP | Patient status |
| I'M SAFE | Team member status |
| Cross-Monitoring | Status of environment and other team members |
| STAR | Status of specific activities or tasks |
| Five Whats: Know, Alternatives, Information, Consequences, Steps (KAICS) | Accurate diagnosis |
