TeamSTEPPS Fundamentals Course: Module 5. Situation Monitoring

Instructor's Guide

TeamSTEPPS is a teamwork system developed jointly by the Department of Defense (DoD)and the Agency for Healthcare Research and Quality (AHRQ) to improve institutional collaboration and communication relating to patient safety.

Image: A seal is trying to catch a penguin using fish as bait. The seal is thinking about eating the penguin, and the penguin is thinking about eating the fish.

Instructor Outline: Situation Monitoring

Note icon Instructor Note: In this module, you will present information about situation monitoring. Participants will learn how to identify relevant information that will inform situation awareness and create shared mental models.

The Situation Monitoring module includes the content provided in the outline below. More content is available than can be covered in the time provided; therefore, optional content and activities are noted. It is strongly recommended that instruction not focus solely on lecture, but also include exercises, videos, and other activities. As such, instructors should use the information below to plan how the module will be taught within the time available. 

# Content Page # Approx. Time
1. Teamwork Exercise #2 5 - 6 10 mins*
2. Introduction 7 - 9 4 mins
3. The STEP Process 10 - 15 10 mins
4. Situation Monitoring Exercise 16 5 mins
5. Situation Awareness 17- 18 4 mins*
6. Shared Mental Models; When and How To Share 19 - 21 10 mins
7. Practical Exercise 22 -23 10 mins*
8. What Do You See?; How Shared Mental Models Help Teams 24 - 25 5 mins
9. Tools and Strategies Summary 26 2 mins
10. Applying TeamSTEPPS Exercise 27 5 mins
*Although all instructional content and activities are recommended to ensure that participants achieve the learning objectives, these activities may be considered “optional” if time is constrained.

 

Additional Resources: Below are sources of additional information and videos you may wish to use to customize this module to your participants.

 

Icon: Document Subsections:
  • Teamwork Exercise #2
  • STEP
  • Situation Awareness
  • Shared Mental Models
Time icon. Time: 45 minutes
Materials icon

Materials:

  • Construction Paper
  • Tape
  • Scissors
  • Flipchart or Whiteboard (Optional)
  • Markers (Optional)
  • STEP Video (STEP_INPTMED.mpg)
  • Cross Monitoring Video (Intern to Resident; Cross_Monitoring_LandD.mpg)
  • Copies of Information Set A
  • Copies of Information Set B
  • Status Board Slide
  • TeamSTEPPS Implementation Worksheet

 

Contents


(Optional) Teamwork Exercise #2

Teamwork Exercise #2

 

Note icon Instructor Note: This is the second iteration of the teamwork exercise conducted at the beginning of the course.

Say:

You'll recall our paper chain exercise from earlier. Please get back into your teams, and this time, identify a team leader.

Do:

Take the leaders out of the room and brief them on the exercise, using the information below.

Say (Only to team leaders):

When we return to the room, you will direct your team to make the longest paper chain possible. This time, however, team members may only use their non-dominant hand, and there will be no talking. You will have 30 seconds to brief your team. At the end of the 30 seconds, the talking must stop. You will have 2 minutes to work after I say "Begin."

Ask:

  • Does anyone have any questions?

Do:

Provide the team leaders with the materials and return to the room.

Say:

You now have 30 seconds to brief your team. After this briefing period, I will say "Begin" and you will then have 2 minutes to work.

Do:

After 30 seconds, say "Begin."

At the end of the 2 minutes, tell the teams to "Stop" and identify the longest chains. To conclude the exercise, conduct a debrief using the discussion questions that follow. You may wish to list any key points identified during the discussion on a flipchart or whiteboard.

Discussion icon. Discussion: 

  • What did the leader do before the exercise began?
  • Was there a clear plan? What was the plan?
  • Did you have a clear understanding of your role and responsibilities? If not, what information would have been helpful?
  • Did you know the roles and responsibilities of others on your team?
  • Did your role change during the exercise?
  • How did the lack of communication during the task affect your work on the task?
  • Were other communication techniques used? If so, what were they?
  • Given the information your leader shared at the start of the exercise, what were you monitoring throughout the task?
  • What would you do differently if you performed this exercise again?
Time icon. Time: 10 minutes
Materials icon Materials:
  • Construction Paper
  • Tape
  • Scissors
  • Flipchart or Whiteboard (Optional)
  • Markers (Optional)

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Objectives

Objectives

Say:

Following this module, you will be able to:

  • Discuss how situation monitoring affects team processes and outcomes.
  • List components of the STEP mnemonic.
  • Explain situation awareness and identify undermining conditions.
  • Define a shared mental model and how it is cultivated within a team.

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TeamSTEPPS Teamwork Skills

Situation Monitoring. TeamSTEPPS logo. For details, go to [D] Text Description.

[D] Select for Text Description

Say:

So far, we have covered the following in the TeamSTEPPS framework:

  • Team Structure, which facilitates teamwork by identifying the individuals among which information must be communicated, a leader must be clearly designated, and mutual support must occur.
  • Communication, which facilitates teamwork by enabling team members to effectively relay relevant information in a manner that is known and understood by all.
  • Leadership, which facilitates teamwork through leaders' effective communication with their team members to ensure that a plan is conveyed, reviewed, and updated; continuous monitoring of the situation to better anticipate team members' needs and effectively manage resources; and fostering of an environment of mutual support through role modeling and reinforcement.

In this module, we will cover Situation Monitoring.

Situation Monitoring is a way for team members to be aware of what is going on around them. This awareness will enable individuals to adapt to changes in the situation and will also create opportunities to support other team members when needed. Situation monitoring is moderated by communication, which allows for the sharing of new and emerging information with other team members, to develop and maintain a shared mental model.

Because situation monitoring concerns the willingness and ability to continually monitor situations and share this awareness with fellow team members, it is enhanced by team leadership, given that team leaders encourage and role model supportive behaviors.

Situation monitoring also allows for mutual support through the ability to anticipate other team members' needs with accurate knowledge of their responsibilities.

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A Continuous Process

A Continuous Process

Say:

Situation monitoring is a continuous process because of the dynamic situations in which teams function. This process consists of three components:

  • Situation monitoring (an individual skill) is the process of actively scanning and assessing elements of the situation to gain information or maintain an accurate understanding of the situation in which the team functions. Situation monitoring is a skill, which implies that it can be taught, developed, and improved. It enables team members to identify potential issues or minor deviations early enough to correct and handle them before they become a problem or pose harm to the patient.
  • Situation awareness (an individual outcome) is the state of knowing the conditions that affect one's work. It is a detailed picture of the situation. Note that situation awareness is not a static "thing" or concept. Because the situation and context in which the situation exists are dynamic and ever changing, team members must continually assess relevant components of the situation and update their individual situational awareness.
  • Shared mental models (a team outcome) are the result of each team member maintaining his or her situation awareness and sharing relevant facts with the entire team. Doing so helps ensure that everyone on the team is "on the same page."

Ask:

  • When have you used situation monitoring in your work?
  • How did the information that you obtained from the environment affect how you approached or responded to the situation?

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STEP

STEP: Components of Situation Monitoring

Say:

In a busy health care environment, knowing which elements you need to monitor, and being able to keep track of each element, can feel overwhelming. Yet knowing the relevant components of the situation that provide clues about impending complications or contingencies is critical for patient safety. STEP is a mnemonic tool that can help you monitor critical elements of the situation and the overall environment.

The STEP mnemonic stands for:

  • Status of the patient.
  • Team members.
  • Environment.
  • Progress toward the goal.

It is not only the responsibility of the direct care team to monitor these elements—anyone involved in the care of patients or the environment should be expected to monitor the situation.

Examples:

  • The respiratory therapist notes that a ventilated patient is showing a marked increase in respiratory rate that might indicate an increased level of pain that cannot be communicated (STATUS).
  • The patient's nurse is busy helping another patient (TEAM MEMBERS).
  • It is a shift change, and everyone is busy, so you check the medication record and note that the patient is overdue for his morphine (ENVIRONMENT).
  • You notify the oncoming nurse of your concern (PROGRESS).

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Status of the Patient

Status of the Patient

Say:

In a health care setting, the most obvious element of the situation requiring constant monitoring is the patient's status. Even minor changes in the patient's vital signs may require dramatic changes in the team's actions and the urgency of its response. When assessing patient status, consider the following:

  • Patient history.
  • Vital signs.
  • Medications.
  • Physical exam.
  • Plan of care.
  • Psychosocial condition (e.g., patient's stress level).

Let's view a video example.

Do:

Play video icon Play the video by clicking the director icon on the slide.

Discussion icon. Discussion:

  • Even though the patient's vital signs were normal, why did Greg have reason for concern?
    • Patient was not lucid.
    • Patient did not "seem" herself.
    • Patient's stress level was elevated.
Video time (duration) icon Video Time: 0:37 seconds
Materials icon Materials:
  • STEP Video (STEP_INPTMED.mpg)

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Team Members

Team Members

You should also be aware of team members' status, to include the following:

  • Fatigue level.
  • Workload.
  • Task performance.
  • Skill level.
  • Stress level.

Health care providers are just as prone to human error as the general population. Teams that recognize and maintain an awareness of their individual team members' functioning are more likely to provide constructive feedback, have a shared understanding of the situation, and lend support or assistance when needed.

Observing the actions of fellow team members—or cross-monitoring—is a safety mechanism that can be used to mitigate error before the patient is harmed. Commonly referred to as "watching each other's back," monitoring other team members by keeping track of their behavior and providing feedback ensures that procedures are being followed appropriately. It allows team members to self-correct their actions if necessary.

Staff members need to constantly be aware of the situation, anticipate next steps, "watch each other's back," and take appropriate corrective action to prevent errors from reaching the patient.

In the next video, let's watch how Dr. Pham prevents a possible medication error.

Do:

Play video icon Play the video by clicking the director icon on the slide.

Discussion icon. Discussion:

  • What did Dr. Pham do in this scenario?
    • Actively listened and participated in the care plan.
    • Detected and corrected an error.
    • Offered support in the form of clarification and correction.
Video time (duration) icon Video Time: 0:18 seconds
Materials icon

Materials:

  • Cross-Monitoring Video (Intern to Resident; Cross_Monitoring_LandD.mpg)

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I'm Safe Checklist

I’M SAFE Checklist

Say:

Being aware of, and honest about, your own current state is also a vital component of a safe environment. We will now discuss how to assess your own condition, as well as the condition of your team members.

"I'M SAFE" is a simple checklist that can be used to determine your ability to perform safely. I'M SAFE stands for:

  • Illness. Am I feeling so bad that I cannot perform my duties?
  • Medication. Is the medication I am taking affecting my ability to maintain situation awareness and perform my duties?
  • Stress. Is there something—such as a life event or situation at work—that is detracting from my ability to focus and perform my duties?
  • Alcohol/Drugs. Is my use of alcohol or illicit drugs affecting me so that I cannot focus on the performance of my duties?
  • Fatigue. Am I tired? The effects of fatigue should not be ignored. Team members should alert the team regarding their state of fatigue. For example, saying "Watch me a little closer today. I only had 3 hours of sleep last night."
  • Eating and Elimination. Has it been 6 hours since I have eaten or used the restroom? Many times we are so focused on ensuring our patient's basic needs that we forget to take care of our own. Not taking care of our elimination needs affects our ability to concentrate and stresses us physiologically.

Ask:

  • In your current situation, would you feel able to express that you're not safe?
  • What are the factors that inhibit you from doing so or that contribute to your inability to do so?
  • If you feel inhibited, what can you and your team do to change the culture?

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Environment

Environment

Say:

The environment directly affects the quality of care delivered. Is the needed equipment present? Are there enough staff to tend to all the patients? The environment can change quickly and dramatically, and teams must be able to adapt to the dynamic nature of the situation. When assessing the environment, consider the following:

  • Facility information.
  • Administrative information.
  • Human resources.
  • Triage acuity.
  • Equipment status.

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Progress Toward Goal

Progress Toward Goal

Say:

By monitoring progress toward the team's established goals, team members will be able to alert the team when strategies or the plan of care may need to be reconsidered or revised, or when additional resources are needed. When assessing progress, team members need to consider the following:

  • Status of the team's patients.
  • Goal of the team.
  • Tasks/actions completed or that need to be completed.
  • Continued appropriateness of the plan.

Goals were established and agreed on at the team briefing. If something has changed, a huddle should be called to discuss how the plan needs to be modified.

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Exercise: Situation Monitoring

Situation Monitoring Exercise

Say:

A patient in the ICU has coded, and CPR is in progress. The Resuscitation Team is busy ensuring that intravenous access is available and the ET tube is inserted correctly. Dr. Matthews, the Team Leader, is calling out orders for drugs, X-rays, and labs. Judy, a nurse at the bedside, is inserting an IV. Nancy, another nurse, is drawing up meds. Judy can tell by Nancy's expression that she didn't get the last order called out by Dr. Matthews. Judy calls out while continuing to place the IV, "Nancy, he wants the high-dose epinephrine from the vial in the top drawer."

Discussion icon. Discussion:

  • What TeamSTEPPS tools and strategies were exhibited in this scenario?
  • Identify each component of the STEP framework in this scenario. How was the STEP framework useful?
Time icon. Time: 5 minutes
Materials icon

Materials:

  • Flipchart or Whiteboard (Optional)
  • Markers (Optional)

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Situation Awareness Is...

Situation Awareness is…

Say:

Situation awareness is the state of knowing the conditions that affect one's work. This awareness is achieved by constantly monitoring the ever-changing situation. Situation awareness is the extent to which team members are aware of the following:

  • Status of the patient.
  • Status of other team members.
  • Status of the environment.
  • Status of the progress toward the goal.

The health care environment is dynamic, requiring team members to continually reassess situations to update their situation awareness. What results is a sense of "knowing what's going on around them" and the ability to support each other where needed.

A loss of situation awareness results in:

  • Ambiguity.
  • Confusion.
  • Decreased communication.

Note icon Instructor Note: (Time Permitting): The question below is intended to prompt discussion prior to showing the next slide.

Ask:

  • What are the factors that undermine situation awareness?

Do:

As participants respond to the question, you may wish to use a flipchart or whiteboard to list their responses and then compare them with the information you will present on the following page.

Time icon. Time: 5 minutes
Materials icon

Materials:

  • Flipchart or Whiteboard (Optional)
  • Markers (Optional)

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Conditions That Undermine Situation Awareness

Conditions That Undermine Situation Awareness

Say:

There are numerous barriers to maintaining situation awareness. They are the result of team members' 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 that is adequate, complete, and timely.
  • Know and understand where to focus attention.
  • Know and understand the plan.
  • Inform team members the plan has changed.

Here are some examples of where failure can occur in the STEP process:

  • Status of the Patient: Failure to take a patient's vital signs.
  • Team: Failure to assist a team member who you know is overloaded.
  • Environment: Failure to know where the necessary equipment is stored.
  • Progress Toward Goal: Failure to call a huddle and update the team when the plan has changed.

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A Shared Mental Model Is...

A Shared Mental Model is…

Say:

A mental model is a mental picture or sketch of the relevant facts and relationships defining an event, situation, or problem. When all members of a team share the same mental model, this is referred to as a "shared mental model." Sharing your situation awareness with fellow team members results in a shared mental model, or in "everyone being on the same page." This is a continuous process requiring relevant input from all team members.

Similar to the way situation awareness is the result of an individual team member's situation monitoring, a shared mental model is the result of each team member maintaining his or her situation awareness and sharing relevant facts with the entire team. In isolation, it is possible for an individual team member to misinterpret cues or to place too much emphasis on one piece of information. Shared mental models are knowledge structures of the relevant facts and relationships about tasks or situations that the team is engaged in and about the way the team members interact. Shared mental models 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 are sustained by:

  • Huddles.
  • Briefings.
  • Monitoring.
  • Communication.

Shared mental models provide team members with a common understanding of who is responsible for which task and what the information requirements are. In turn, this allows them to anticipate each other's needs so that they can work (i.e., provide patient care) in synchronicity.

Ask:

  • What is an example from your own experiences of being "on the same page" with others on your team?
  • How was a shared understanding maintained?

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Shared Mental Model?

Shared Mental Model?

Say:

On our continuum of situation monitoring, situation awareness, and shared mental model, where are these two groups? How can lack of a shared mental model affect safety?

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When And How To Share?

When and How to Share?

Say:

Sharing information with other team members is necessary to establish and maintain a shared mental model. When each team member shares his or her unique information, the team will have a more accurate assessment of the situation.

There are both ad hoc and structured opportunities to share vital information with team members.

Some examples of when information can be shared include team events such as:

  • Briefs.
  • Huddles.
  • Debriefs.

It is important to establish the expectation that these team events will occur and that all team members are empowered to speak up.

Some examples of how to share information include:

  • SBAR.
  • Call-outs.
  • Check-backs.

Teams should communicate often and at the right time to ensure that everyone is on the same page and has a comprehensive view of the situation.

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(Optional) Practical Exercise

Practical Exercise


 

Room # Patient Orders VS
1 Jackson EKG, O2, Cardiac Enzymes HR 115 R 24 B/P 174/98
2 Simmons CBC, UA, HCG, IV HR 132 R 22 B/P 92/76
3 Bailey CXR, neb Rx, CBC, UA, O2 HR 120 R 32 B/P 132/86

 

Note icon Instructor Note: Prepare two sets of information, and place them each separately on an index card or sheet of paper.

Information Set A should include a list of three to four patients by name, sex, and age.

Example of Information Set A:

  1. Patient Jackson is a 23-year-old male.
  2. Patient Simmons is a 19-year-old female.
  3. Patient Bailey is a 76-year-old male.

Information Set B should include some details of past medical history, presenting symptoms, or scheduled procedure for each patient listed in Information set A.

Example of Information Set B:

  1. Patient Jackson is a known cocaine user with chest pain, and you are concerned about a possible MI.
  2. Patient Simmons is hypotensive and experiencing tachycardia, and you are concerned about a ruptured ectopic pregnancy.
  3. Patient Bailey has tachypnea, tachycardia, and fever, and you are concerned about pneumonia.

A Status Board slide should be prepared for display that includes the standard information used on a specific unit for patients listed in the information sets. An example Status Board is found in the slides. You should modify as needed for your audience, based on the units they work on.

This exercise can be conducted in small groups or with the entire participant group. Facilitation instructions for each can be found on the following page.

Do (Small Group Exercise):

  • Divide the class into an even number of teams.
  • Provide half the teams with Information Set A and the other half with Information Set B.
  • Display the Status Board slide.
  • Ask each team to independently discuss and prioritize the patients using only the information provided.
  • After 5 minutes, ask a representative from each team to report his or her team's conclusions.
  • Focus discussion on the relationship between the communication of information and the development of a shared mental model.

Or

Do (Whole Group Exercise):

  • Display the Status Board slide.
  • Ask the class to prioritize the patients using only the information provided on the slide.
  • After they discuss their conclusions, provide the class with Information Set A.
  • Discuss how the additional information alters the group's initial plan.
  • Provide Information Set B. Discuss how this additional information changes the group's revised plan.
  • Focus discussion on the relationship between the communication of information and the development of a shared mental model.

 

Time icon. Time: 10 minutes
Materials icon

Materials:

  • Copies of Information Set A
  • Copies of Information Set B
  • Status Board Slide

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What Do You See?

What Do You See?

Say:

Each team member has a unique perspective and information that benefits the team as a whole when shared. Different people may view the same situation differently, but without sharing and communicating, each team member may have a different understanding.

Discussion icon. Discussion:

  • When looking at these images, what do you see?
  • Do you see different images if you look right to left versus left to right?
  • How did discussing these different perspectives increase your ability to see the whole picture?

Answers:

  • Left image: American Indian and Alaska Native.
  • Center image: Duck and rabbit.
  • Right image: Old lady and young woman.

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How Shared Mental Models Help Teams

How Shared Mental Models Help Teams

Say:

Teams will work more efficiently and effectively if all members of the team are "on the same page." If teams are better able to predict and anticipate, the team will know what is supposed to happen and will have a better understanding of how the case is progressing.

Shared mental models can help 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 for task performance.
  • Enabling team members to back up and fill in for each other.
  • Helping team members understand each other's roles and how they interplay.
  • Improving the ability of individual team members to provide mutual support by predicting and anticipating the needs of the team.
  • Creating commonality of effort and purpose.

Most important, shared mental models help teams avoid errors that put patients at risk.

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Tools and Strategies Summary

Tools & Strategies Summary

Say:

Situation monitoring is an integral piece of the TeamSTEPPS framework and directly links to communication, leadership, and mutual support. Engaging in effective communication techniques will enable team members to relay relevant and timely information.

Leadership's role in continually monitoring and updating the team when changes to the plan are necessary helps to maintain a shared mental model. Likewise, when team members are aware of the situation, they are better able to support each other, either when asked or when they see a need.

The tools and strategies introduced in this module include STEP and the I'M SAFE checklist. Use of these tools will aid in awareness of the situation and development of a shared mental model, which will enable team members to anticipate, prevent, and correct potential errors in care.

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Exercise: Applying TeamSTEPPS

Applying TeamSTEPPS Exercise

Note icon Instructor Note: This slide is intended for the Master Training course only. The previous slide should be the last one shown to staff participants at your organization.

Say:

Now return to your TeamSTEPPS Implementation Worksheet. Think about whether any aspect of your teamwork issue is related to situation monitoring and answer the questions for this module.

Think about:

  • Whether the team or individuals targeted for your TeamSTEPPS implementation have an issue related to their ability to monitor the situation?
  • If so, which of the Situation Monitoring tools or strategies might you use to address the issue?

Do:

Ask a few individuals to report on issues they have identified as related to Situation Monitoring and which TeamSTEPPS tools or strategies they might use to address the issue in their implementation plan.

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Return to Index

Page last reviewed March 2014
Internet Citation: TeamSTEPPS Fundamentals Course: Module 5. Situation Monitoring : Instructor's Guide. March 2014. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/education/curriculum-tools/teamstepps/instructor/fundamentals/module5/igsitmonitor.html