Shared Situational Awareness

How situational awareness can help elucidate the path to shared clinical decision making.

A policeman sees a drunk man searching for something under a streetlight and asks what the drunk has lost. He says he lost his keys and they both look under the streetlight together. After a few minutes the policeman asks if he is sure he lost them here, and the drunk replies, no, and that he lost them in the park. The policeman asks why he is searching here, and the drunk replies, "this is where the light is". (1)

Methods to promote shared decision making in clinical practice have been based on multiple conceptual frameworks. In a 2011 review, Glyn Elwyn and colleagues reviewed eight frameworks – expected utility theory, the conflict model of decision making, prospect theory, fuzzy-trace theory, differentiation and consolidation theory, the ecological rationality theory, the rational–emotional model of decision avoidance, and the Attend, React, Explain, Adapt model of affective forecasting – and concluded that none of them could effectively serve as the basis for decision support interventions. (2) An important limitation of this review is that the authors only reviewed theories they considered “major theoretical developments” and that had been used to develop decision support interventions for patients.

The results of this study, along with the continuing difficulties implementing shared decision making in practice settings, suggest a need to identify effective conceptual frameworks for shared clinical decision making. Aside from a paper published in 2014 by Elwyn and colleagues that was devoted to developing an entirely new theory (3), it appears that the 2011 review sparked little interest in closing the shared decision making theory-practice gap. (If anyone knows of any substantial developments in this area, please let me know.)

In recent blog posts I’ve discussed a couple of decision making frameworks that could be used to advance the practice of clinical shared decision making: the OODA loop on October 7, 2022 and best practices for successfully implementing decision support interventions in real world settings on October 2, 2022. Today I’d like to introduce another: Situational Awareness.

Situational Awareness is:

“… the perception of the elements in the environment within a volume of time and space, the comprehension of their meaning, and the projection of their status into the near future”. (4)

Situational awareness (also sometimes called Situation Awareness) has been most commonly used to understand and guide decisions in rapidly changing aviation and military environments. However, it is fundamentally a framework for understanding factors that affect decisions to identify ways to improve them. Thus concept applies equally well to many situations and could serve as a useful model for shared clinical decision making.

A basic situational awareness model adapted from Endsley and Jones (4) is shown in figure below.

Street and Politi have defined the ultimate goal of shared decision making as the achievement of a “shared mind” between patient and clinician. (5) In terms of Situational Awareness, a shared mind is equivalent to shared situational awareness. Achievement of shared situational awareness depends on both the factors that impact individual situational awareness and the effectiveness of the clinician/patient interaction. An adapted shared situational awareness model is shown in the following figure:

In this model, both the clinician and the patient develop an awareness of the situation and what could happen after following different courses of action. This awareness is influenced by individual characteristics including each person’s goals and objectives, preconceptions, baseline knowledge and ability to process new information, as well as extrinsic factors including their current level of stress, time pressure, and access to needed information. The nature of the clinician/patient interaction then determines the extent to which their individual situational awarenesses are shared and mutually understood. The resulting shared situational awareness then guides the decision making process which, in turn, results in subsequent actions and outcomes.

For example, consider how this model would apply to decisions about colorectal cancer screening. Both the clinician and the patient develop an individual awareness of the risks and benefits associated with colorectal cancer screening and the advantages and disadvantages of the different screening options available. They then seek to merge their individual situational awarenesses into a single shared awareness to decide what is best for this particular patient.

Musings

Looking at shared decision making through the situational-awareness lens makes it clear how complicated the process is. In addition to the decision itself, factors associated with the people involved and the environment they are acting in can all effect the final outcome, in both good and bad ways.

Based on my recent review of the shared decision making literature - described in the recent series of posts - it appears that most proposals for implementing shared decision making in clinical practice focus primarily or exclusively on the clinician/patient interaction. To date, none has been very successful in fostering adoption of shared decision making in practice.

The situational awareness model suggests that the conversational approach is too limited to effectively address the complexity involved. If so, we need to develop new ways of thinking about clinical shared decision making that are appropriate for the level of complexity involved. I propose that situational awareness is one that merits further consideration.

References

1. Streetlight effect. In: Wikipedia [Internet]. 2020 [cited 2021 May 12]. Available from: https://en.wikipedia.org/w/index.php?title=Streetlight_effect&oldid=994601415

2. Elwyn G, Stiel M, Durand M-A, Boivin J. The design of patient decision support interventions: addressing the theory-practice gap. J Eval Clin Pract. 2011 Aug;17(4):565–74.

3. Elwyn G, Lloyd A, May C, van der Weijden T, Stiggelbout A, Edwards A, et al. Collaborative deliberation: A model for patient care. Patient Educ Couns. 2014 Nov;97(2):158–64.

4. Endsley MR, Jones DG. Designing for Situation Awareness: An Approach to User-Centered Design, Second Edition. 2nd ed. 2012;396.

5. Politi MC, Street RL. The importance of communication in collaborative decision making: facilitating shared mind and the management of uncertainty. J Eval Clin Pract. 2011;17(4):579–84.