We have all been there, conversing with colleagues and undoubtedly broached the ‘time-served’ concept as though it is a metaphorical trophy, a marker of capability and skill.
Some may see it as one year repeated many times, or years of progressive professional development. But in practice, what does that mean for situation management and situational awareness (SA)? Can we teach situational awareness? Is it a natural skill or something that is attained over time? To understand this, we need to understand it.
The following scenario uses a unique operating environment to illustrate the complexities of situational awareness in practice, some of the theory and fundamentally how, through time and development of the Paramedic profession, situational awareness is an example of non-technical skills being part-characteristic of the clinician and part attained skill through formal education.
You are on shift at the busiest airport in Europe (working solo). It is midway through the 12-hour shift, and you have already attended 4 calls. The radio comes to life again…
“All terminal and Searcher Stations, be advised of an ambulance request. Terminal 3 on the inbound British Airways BA853 with an ETA of 14:10 to stand 320 for a male unconscious and fitting”
Just some thoughts now crossing your mind are:
1. The information is limited, and there is no age given; is it adult or paediatric?
2. How long has this patient been fitting? What equipment will you take?
3. The ETA is 10 minutes away; you need to navigate from one side of the airport to the other and get to the stand. There is no Satnav for this.
4. Is there a lift up to the gate level? Is there a jet bridge with stairs from the apron to the aircraft door?
5. For the airport ambulance, it is shift changeover, and you know the cycle response paramedic for Terminal 3 is already on another call. Are there resources assigned from outside the airport?
6. This is a Category 1 call; usually, the Airport Fire Service (AFS) will deploy to these, but you have not heard they will be attending.
7. You think about where on the aircraft the patient is; if they are near the front, do you get them off into a bigger space to work in? But then passengers are possibly held on the aircraft. If they are in the rear, do you move them to the galley?
Situational awareness is inextricably linked to control of complex systems in any safety-critical environment.
The world of clinical practice is a system, and patient safety learning responses hinge on this system concept, although not always explicitly citing situational awareness as a whole.
Stanton et al. highlight that the separation between actual ‘system statuses’ and the operator’s understanding of ‘system status’ is fundamental to the definition of situational awareness. In practice, they are saying that the difference between the objective truth of holistic system factors in any moment and how they will play out is the nub of what SA is about.
Endsley’s seminal work on situational awareness defines it as
“The perception of the elements in the environment within a volume of time and space, the comprehension of their meaning and a projection of their status in the near future”.
Amongst much of the literature, there is perception, comprehension and projection in some form. The figure below illustrates their central role in the broader picture of system influences.
When you think about it, much of situational awareness theory applies to many clinical aspects of our practice.
We often need to obtain an impression of what is happening with the patient, form a differential diagnosis and then predict the patient’s clinical trajectory. Some guidelines encompass these concepts, such as using the anticipated clinical course as an indication for rapid-sequence induction or using NEWS2 scores as an ‘early warning’ of what might happen.
However, a lot happens here that relies on dual-process thinking, a.k.a. System 1 and System 2 thinking. Clinicians will rely on heuristics, experience, and intuition for rapid decision-making (system 1) or slow-paced, reasoned, analytical, and conscious assessment of a situation (system 2) to reach a diagnostic conclusion.
Herein lies the potential for diagnostic error, largely observed as the burden of cognitive bias within system 1 thinking.
Norman et al. challenge this by arguing that errors arise equally in system 1 and system 2 thinking, and that errors can boil down to a lack of access to appropriate knowledge. i.e., layering both systems leads to processing conflict and potential for disruption of awareness.
More layers increase complexity and cognitive burden. For this reason, in emergency care, clinicians are encouraged to make a conscious sense-check effort. However, this doesn’t always account for the bigger picture.
What about everything else in the system? What about other stakeholders? What about the geography, what about the logistics, how does this all play out? How good are clinicians at the non-clinical, non-technical work we inevitably get embroiled in?
You arrive at stand 320, and the aircraft is just shutting down its engines, with chocks being applied. You go up the jetty stairs as it is loaded onto the aircraft.
The doors open, and you are greeted by the cabin crew who direct you to the rear of the aircraft.
You are greeted by a patient lying in the rear galley, accompanied by an emergency department doctor from Spain who just happened to be on the flight. The handover they provide you is structured and helpful:
Situation – 15-year-old male who has presented with a first seizure approximately 30 minutes before landing.
Background – Witnessed bilateral tonic-clonic seizures (BTCS) for 10minutes and has been unconscious since.
Started having another BTCS just before landing with less intensity. Patient has been on O2 for approx. 45mins.
Father states no previous medical history, no seizures, unlikely to have taken any recreational drugs, no other complaints (E.g. headaches, visual disturbance, viral/bacterial illness) recently
Currently, the patient is U/AVPU,
Airway – patent,
Breathing – tachypnoeic, self-ventilating, SpO2 93% on O2,
Circulation – pulse 128 regular, palpable radial pulse,
Disability – GCS 3, Pupils equal and reactive,
Expose/examine – no injuries, no rash, no acute concerns. (
Further examination by you reveals normal temperature and blood glucose, and due to the initial priorities, no blood gas /electrolyte analysis is done yet).
Assessment – Patient in Convulsive Status Epilepticus (CSE).
Recommendation – Rapid conveyance to hospital!Also alongside you are Border Force officers and a Passenger Experience Manager (PEM) from the airport who are trained first aiders and attend all ambulance calls.
The Doctor present is happy to remain and assist.
The evidence base on situational awareness in emergency medical services (EMS), and healthcare in general is a broad mix of literature reviews and reasonable attempts at primary research, but the nature of it is measured using the Situation Awareness Global Assessment Technique (SAGAT) and needing tailored timepoint measurements doesn’t lend itself to anything beyond simulation, Delphi studies or semi-structured interviews.
Most studies involve small sample sizes, making it difficult to ascertain statistical significance. Thus, in the hierarchy of evidence, the literature doesn’t rank well, but it remains a reasonable basis for deriving quality consensus.
Research themes
Sedlár’s literature review highlights that very few predictors of cognitive skills were identified among pre-hospital clinicians, but commonality across the studies was found in specific acts or verbalisations that positively influenced the progression of a scenario.
One such example of this expertise was termed ‘paramedic kairotope’, meaning having good knowledge of when/where to act, acting at the right time and place, and being situationally aware. Experience has a role.
Andersson et al. consider team and individual experience vital to outcomes, and emphasise the importance of holistic assessment that considers a broad range of cues informing decisions. The discussion here notes the importance of being prepared without committing to specific courses of action.
Contrary to Sedlár’s findings, Ozkaynak et al. claim that EMS clinicians lack situational awareness, with a core cause being poor closed-loop communication.
Hunter et al. provide what could be considered a run-through of research on SA in paramedicine, i.e., what is taught, the current quality of situational awareness, and what targeted interventions provide.
Their 2019 literature review scoping what is known in paramedicine identifies a real challenge in establishing the presence of literature. The review’s findings align with what we have previously said about research limitations: it is not conducted in actual clinical practice. Consequently, there is no robust evidence to validate the presence of situational awareness in paramedicine, indicating that knowledge in this domain is limited.
Building on this gap, Hunter et al. conducted a high-fidelity simulation study to measure situational awareness. It demonstrated that student paramedics had poor awareness in time-critical patients. As students were quizzed on progressively refined clinical details, perception dropped, as did comprehension and projection of patients’ clinical trajectories, with a total SAGAT SA score of 38%.
Hunter et al. then undertook a cross-sectional study assessing 10 paramedics across 67 real emergency calls. SAGAT assessments yielded an overall SA score of 34% across 387 queries. Both studies claim that paramedics are not situationally aware, citing high stress, tunnel vision, and a lack of structured approaches.
This is a small study from a single EMS setting with very limited data and no clarity on patient acuity. It signals a real issue and the concept that SA is not innate yet can be measured, as demonstrated by Dishman et al.’s validation of SAGAT among anaesthesia nurses.
With knowledge and some objective data on SA competence, Hunter et al. advanced the research by conducting a quasi-experimental before-and-after study to assess the effect of targeted education on SA and crew resource management. They concluded that SA increased from 62% to 86% (p=0.011) post-intervention, a statistically significant increase.
Good, right? Yes, and arguably each participant is their own control, regardless of background, but the limitation of this study was the sample size (10 paramedics).
The authors account for this through the Wilcoxon Signed-Rank test, which allows non-paired data (e.g., before/after ranking) to be used for effect estimation and limits the effect of individual variability. The pre-post design also protects against this. However, the lack of confidence intervals limits precision calculations, and one suspects they would be wide due to factors such as the Hawthorne effect (knowing you are being watched) and sample size. The generalisability of this study is poor, but it is a nod to the education impact.
The patient remains in CSE and requires airway and pharmacological interventions.
Time is ticking, and you are aware that this reduces the chances of terminating seizures.
You task the doctor with managing the airway, provide the equipment, and commence pharmacotherapy with Midazolam and Oxygen. This assessment and decision-making occurs within the first 2 minutes of arriving.
You have permitted staff to de-board passengers as you will not be going anywhere for a few minutes.
An update is passed to ambulance control, upgrading the call and requesting an ambulance ASAP, providing them with an access location in the airport.
While preparing the medication, you update the father on your findings and your plan.
Liaising with the PEM, you ask for the Hi-lift vehicle to facilitate extraction on a stretcher when the ambulance arrives. The PEM advises that the Hi-lift is 30 minutes away, just as you administer your first dose of Midazolam intramuscularly.
This leads you to request AFS’s domestic appliances and air stairs. Between you and the PEM, you liaise with the flight crew on this information, ensuring crew will be available to open the aircraft door.
Concurrently, you obtain intravenous access and continue monitoring the patient.
The seizure doesn’t stop.
The ambulance crew arrive, and you provide a handover.
There is still no means of extrication. You task one of the crew with obtaining extrication equipment and the other with taking over airway management and patient monitoring.
Eventually, you extricated the patient who required further intravenous doses of Midazolam, which temporised the seizure but not completely. A team debrief follows.
Contemporary Healthcare SA
Pelaccia et al. recognise that deliberate effort is required to improve situational awareness, but the educational approach is not fully explored in the literature and offers strategies to address this.
As such, the educational model and curriculum are changing. Healthcare and education systems are acutely aware of the role and importance of non-technical skills, as evidenced by the drive to improve the strategic approach to education.
The most recent Royal College of Paramedics (RCPara) Paramedic Curriculum, 6th Ed. emphasises the need for such knowledge and skills, with a core requirement for Leadership and Non-Technical Skills. Similarly, the RCEM curriculum includes human factors and non-technical skills as fundamental to patient safety competencies.
The bottom line
Situational awareness is predominantly an acquired skill, augmented by innate personal traits.
It relies on the interplay of clinical knowledge, experience, and trained, deliberate, cognitively effortful practice to fully understand the system surrounding an event at a given time.
References
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Stanton NA, Chambers PRG, Piggott J. Situational awareness and safety. Saf Sci 2001;39(3):189–204.
Endsley MR. Design and Evaluation for Situation Awareness Enhancement. Proceedings of the Human Factors Society Annual Meeting 1988 Oct;32(2):97–101.
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Pelaccia T, Sherbino J, Wyer P, Norman G. Diagnostic reasoning and cognitive error in emergency medicine: Implications for teaching and learning. Academic emergency medicine 2025 Mar;32(3):320–326.
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Hunter J, Porter M, Phillips A, Evans-Brave M, Williams B. Do paramedic students have situational awareness during high-fidelity simulation? A mixed-methods pilot study. International emergency nursing 2021 May 1;56:100983.
Hunter J, Porter M, Cody P, Williams B. Are paramedics situationally aware? A cross-sectional study during emergency calls for service. BMJ Open 2022 May 1;12(Suppl 1):A5.
Dishman D, Fallacaro MD, Damico N, Wright MC. Adaptation and Validation of the Situation Awareness Global Assessment Technique for Nurse Anesthesia Graduate Students. Clinical Simulation in Nursing 2020;43:35–43
Hunter J, Porter M, Cody P, Williams B. Can a targeted educational approach improve situational awareness in paramedicine during 911 emergency calls? International emergency nursing 2022 Jul 1;63:101174.
Pelaccia T, Sherbino J, Wyer P, Norman G. Diagnostic reasoning and cognitive error in emergency medicine: Implications for teaching and learning. Academic Emergency Medicine 2025 Mar;32(3):320–326.
Royal College of Paramedics. Paramedic Curriculum (6th Edition). 2024.
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