With Laurel Messer PhD, Assistant Professor at the Barbara Davis Center for Juvenile Diabetes
We all want to be effective decision-makers, but success in this area depends on having an accurate understanding of the decision we are facing. This concept is sometimes known by the term "situational awareness." The UK construction industry defines situational awareness as "being aware of what is happening around you in terms of where you are, where you are supposed to be, and whether anyone or anything around you is a threat to your health and safety." For pilots, situational awareness has been described as an "integrated understanding of factors that will contribute to the safe flying of the aircraft under normal or non-normal conditions." Situational awareness has been discussed in fields as diverse as air traffic control, manufacturing, refinery operations, and nuclear power safety. And the term situational awareness has been used in the nursing literature to describe a nurse's ability to respond to a patient's needs by understanding "what's going on, why it's happening, and what's likely to happen next." In one of Dr. Messer's current grants, we are also using the concept of situational awareness to describe patients' ability to self-manage type 1 diabetes.
Although the term situational awareness has been used by the military as far back as World War I, the first widespread use in other fields began in the 1990s. Endsley (1995) identified three components of situational awareness: (a) perception of the current environment, (b) comprehension of what current conditions mean, and (c) projection of the most likely future states. Endsley's three components are the same ones identified in a 2013 concept analysis of how the term situational awareness has been used in the nursing literature. For nursing, the authors propose a definition that includes "perception of the elements of the environment in a volume of space and time, the comprehension of their meaning, and the projection of their status in the near future." The expected result of situational awareness is effective decision-making and performance of some action. All three steps of situational awareness incorporate a person's goals and expectations -- in other words, you are not just aware of what's going on but also using that information to more effectively move toward some objective. In fact, some experts have argued that situational awareness without a goal is not situational awareness at all, just self-reflection or mindfulness. A person's consciousness has to be directed outward toward the environment, with an integration of prior knowledge and capabilities, in order for their mental state to be considered situational awareness.
Part of the widespread interest in situational awareness has come out of people's increased reliance on technology in many everyday processes. For pilots, aviation has become progressively "less hands-on and eyes-on," with greater reliance on instruments instead of direct observation out the window of the plane. As information is increasingly mediated through electronic interfaces, there is greater need for operators who understand the meaning of the data rather than just the raw data points. Pilots with greater situational awareness are able to selectively attend to instrument readings that offer the greatest diagnostic value in predicting future events; they also respond based on correlations across multiple instruments rather than just noticing abnormal readings on a single indicator. These abilities let them respond earlier and more accurately based on smaller deviations from the norm. Similarly, naval experts with greater situational awareness were found to pay significantly more attention to context in planning their tactics, compared to novice officers.
All of these findings suggest that situational awareness describes something important about a person's ability to perceive, comprehend, and respond effectively to challenging conditions. It's an open question whether that "comprehension" has to be something the person can put into words. In fact, much of the literature on situational awareness seems to fit with Klein's Naturalistic Decision Making theory that describes expertise as a state of "just knowing" what to do, without necessarily being able to say why. The best measures of situational awareness seem to focus on performance of actual tasks, or else a "freeze-probe" technique where someone is interrupted in the middle of performing a task and asked to explain what they are doing. These measures create a conceptual problem: "situational awareness" might just be another word for expertise. If we measure the concept mainly by its outcomes (successful task performance), then it might not describe an internal "capability" at all -- situational awareness is a word that we use to describe successful problem-solving. "Success" is another word for the same result. One of these can't logically be an explanation for the other, because they mean the same thing.
Whether it represents an internal state or simply describes a successful pattern of behavior, situational awareness is something to strive for when you are working to achieve a challenging goal. Situational awareness has been most often studied in health care as a characteristic of nurses, for example based on their ability to recognize when a hospitalized patient’s condition is taking a turn for the worse. In our latest study, however, the research team is looking at whether this concept can also be used to predict patients’ self-management behavior. We faced some of the same definitional issues in measuring situational awareness; we eventually decided on asking patients to predict their own blood sugar level (without looking at their glucose monitoring device), both now and one hour from now. When a patient was better at these predictive tasks, we considered them to be more situationally aware. We could then test whether successful predictions were associated with better actual blood sugar control.
The application of situational awareness to patient behavior is timely because patients have access to more and more data about their own health -- e.g., from smartwatches, sleep sensors, meditation aids, or personal genetic analysis services like 23andMe. Like pilots, patients must make decisions in real time using information from an array of different sources, sometimes based on conditions that cannot be directly observed. Several recent papers have used situational awareness as a framework for mobile health (mHealth) interventions to support patients' self-management of arthritis, high blood pressure, type 2 diabetes, and chronic pain. In each case the goal of the mHealth application was to collect and integrate data, present it to the user in an understandable way, and help them to take appropriate action. In these cases, it might be argued that the application, not the user, is what is situationally aware!
Our current study takes a different approach to situational awareness, based on the idea that it is an ability connected to the development of expertise. Rather than getting patients to look at a monitoring app more often, this might actually mean getting them to use the device less often for support, because they don't need it in order to have an accurate understanding of what's going on in their body. In an older study of type 2 diabetes, patients who had greater expertise (and success) in managing their condition had this type of expertise: They said, for instance, that sometime they "just know" their glucose is abnormal. These patients also said that their greater knowledge enabled them to sometimes have a "calculated cheat" in terms of diet or exercise -- they knew what they could get away with and still stay in good control. In this paradigm, data from an app might help a patient to develop the type of deep understanding that is seen as a key component of situational awareness. Eventually, an Intuitive-level understanding might mean that they no longer need to refer back to the app. We are currently looking at some specific behaviors that might be particularly important for self-management of type 1 diabetes, and how these are connected to patients' level of situational awareness.
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