Situation Awareness Innate or teachable?

1. Situation AwarenessInnate or teachable? Dr. Rob Brown Associate Head for Education, Dept of Anesthesia Mindermar Professor of Health Care Simulation University of Manitoba

2. Goals of this talk • By the end of this talk, the listener will • Describe the benefits of simulation in education • Explain the constrict of situation awareness and its importance to medical care • Discuss potential applications of simulation to enhancing trainees’ situation awareness ability

3. Simulation in Health Care Education • Simulation has a long history outside of health care • Introduction into health care began with SimOne • Interest resurrected by David Gaba • Largely driven by patient safety movement

4. Simulation and Patient Safety • Focus on larger issues of safety • Use in examining team and individual dynamics • Discovery of impediments to safety • Better training = safer patients

5. Benefits of Simulation • Patient benefit • “see one, do one, teach one” • “simulate several, see one, do one” • Resource utliization • Increasing training numbers with fewer inpatients • Exposure of trainees • Rare events • Autonomous practice • Repetition- deliberate practice

6. Simulation: a different way to teach • Plus –delta debriefing • This is what you did • This is the ideal • This is what to do differently next time • Focus on WHAT was done • Debriefing for Discovery • Identify the gap • Discover the reasons for the gap The ASA difficult airway algorithm states that you should attempt once call for help attempt to ventilate if you cannot ventilate, you should perform an emergency airway Now that you know where you went wrong, go review the algorithm and try to remember it for next time At this point, what is going through your mind From what I can see, you are in a “can’t intubate, can’t ventilate” position The airway algorithm would suggest an emergency airway at this point What got in the way of your being able to proceed? What could you differently in the future to prevent that?

7. Goals of simulation training • Reinforcement of knowledge • Identification of obstacles to performance • Mindsets • Preconceived ideas • What about the trainee him/herself?

8. What is SA? • Perception of elements in the environment within a volume of time and space, the comprehension of their meaning and the projection of their status in the near future” Endsley, M. “Situation analysis and measurement”, Lawrence Earlbaum, 2000, New Jersey, p.5

9. Endsley’s Information Processing Model • SA comprised of three levels • Level 1- Perception • Level 2- Comprehension • Level 3- Projection

10. Evidence of learning of SA • SA increases with experience • Carretta-171 F15 pilots • Correlated psychometric measures with SA • Experience predicted SA better than any metric • Sohn- 52 active fighter pilots • Experience vs memory as a predictor of SA

11. Individual characteristics and SA • General cognitive ability • Working memory • Visual processing • Temporal processing • Time-sharing/ attention management ability

12. Time Sharing Group 1 Group 2 Group 3 • Complex tasks require attention management • Rapid switching between subtasks • Parallel processing • Response strategies • Damos and Wickens • Transfer of time-sharing between unrelated tasks Dual-training Single-training No training Day 1 STM/Cl task Dual-training Dual-training Dual-training Day 2 Tracking Task Damos and Wickens, The identification and transfer of time-sharing skills, Acta Psychologica, 46;15-39, 1980

13. Attention Control Training • Part-Task Training • Conventional • Segmentation • Fractionation • Simplification • Dyadic Shebilske, D, A Dyadic Protocol for Training of Complex Skills, Human Factors 34(3); 369-74

14. Attention Control- Emphasis Change Both Session Control SC MH 5 x 5 min games 7 x 5 min games 8 x 5 min “ “ “ “ “ 8 x 5 min 5 x 5 min games 7 x 5 min games 8 x 5 min “ “ 5 x 5 min games 7 x 5 min games 8 x 5 min “ “ “ 3 min games 5 min final game MH manipulation SC • Complex Task learning • Space Fortress Game • Full-task practice • Manipulation of attention to subtasks • Ship control • Mine Handling 1 2 3 4 5 6 7 8 9 10 SC manipulation 3 min games 5 min final game MH No emphasis No emphasis No emphasis 8 x 5 min games 8 x 5 min games 3 min games 5 min final game 8 x 5 min games Gopher, D. Practice Under Changing Priorities: an Interactionist Perspective, Acta Psychologica; 71: 147-78, 1989

15. Transfer of attention training to life Group 1 Group 2 GroupControl • Better performancew in space fortress in FT vs EC • No difference betweestudy groups in flight • Both study groups better flight performance • Israeli Air Force pilot training • Computer game training vs flight performance • Compared 2 training regimens to control • Looked at ultimate flight performance • Training techniques • Emphasis change technique • Hierarchical part-task training 1 hour session 10-14 3 min games Feedback in between 18% part-task 82% full-task with EC I hour session 10-14 3 min games All full-task with EC No feedback No Space Fortress Training 10 Hours light aircraft training 5 sessions 3 months Basic Training 5 sessions 8 flights JetTraining Gopher, D. Transfer of Skill from a Computer Game Trainer to Flight, Human Factors, 36(3); 387-405 : 1994

16. Addressing SA in athletes • Improved SA in senior tennis players • Compared three training approaches • PCST consisted of SA specific plus technique • Measured • Response speeds • Response accuracy • Decision-making • Better performance with PCST Caserta, Old dogs New Tricks:Training the Perceptual Skills of Senior Tennis Players, J of Sport and Exercise Psychology, 29;479-97,2007

17. Teaching for Situation Awareness WOMBAT TASK SKILL MEASURED Dual tracking psychomotor 3D rotation spatial perecptual Quadrant location skilled perception 2-back digit cancelling working memory TRACON Terminal Radar approach and control simulator • Obrien et al • Air Traffic control model • Used WOMBAT to assess SA ability • Used TRACON to assess and train • Examined effect of training method • correlated with pre-existing SA ablity Obrien, Situational awareness ability and cognitive skills training in a complex real-world task, Ergonomics 50(7), 1064,91, 2007

18. Teaching SA- O ‘Brien • Experiment 1- • Two groups- both baseline TRACON training (2 sessions) • Advanced training session • Group 1 TRACON with CMG 5 pauses over 20 min then 10 min • Group 2 30 min TRACON exposure without CMG • CMG training • Prompting with attentkon management advice on first pasue • Subsequent pauses focusing questions • Trainees with low WOMBAT scores did better with CMG • Trainees with higher WOMBAT scores benefit less

19. Teaching SA- O Brien • Experiment 3 • Similar to experiment 1 • Planning training in place of CMG • Similar benefit • All Trainees with low WOMBAT benefited from training

20. Applying this to Health Care Sim EMPHASIS CHANGE Focus on fluid management respiratory management cardiovascular manegement Would need a way of scoring or rewarding the focus CMG Guiding questions describe the physiologic state Describe your resources Describe your challenges What are the 3 greatest risks in next minute next 5 minutes What are your goals now next 5 min next 10 min? • SA can be improved by teaching • specific attributes • SA as a global construct • No work in healthcare environment on teaching of SA • Simulation would adapt easily

21. Conclusions • SA is an important determinant of performance • SA improves through experience • SA improvement can be enhanced through specific teaching • Research is needed on how to apply in healthcare simulation –based training