Measuring situation awareness in health care providers: a systematic review of measurement properties using COSMIN methodology
Systematic Reviews volume 12, Article number: 60 (2023)
Situation awareness (SA) is a key factor in accountability and ensuring patient safety in health care. SA is an essential element to research on human factors in healthcare. It is essential to identify valid instruments for measuring this concept and assessing how it is affected by interventions and educational methods.
This systematic review aimed to assess the measurement properties of situation awareness instruments in health care providers’ (HCPS) using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) methodology. Four databases (Medline (through PubMed), Embase, Scopus, and Web of Science) were systematically searched. A manual search was also conducted on Google Scholar and the reference list of the included primary studies to supplement the electronic search. Studies aiming to determine the measurement properties of SA instruments or non-technical skills in HCPS were included. The overall results for each measurement property were reported as sufficient, insufficient, inconsistent, or indeterminate, and the quality of evidence was reported as high, moderate, low, or very low.
A total of 25 studies and 15 instruments were included in the study. More than one measurement property was reported in some of the studies, and none of the studies presented all measurement properties. The most common measurement properties were content validity (12/25) and internal consistency (12/25). Cross‐cultural validity and responsiveness were not investigated in any study. Evidence quality for the measurement properties was not high in any of the 15 instruments.
None of the instruments can be recommended as the most suitable instrument, and all instruments were classified as promising instruments in need of further psychometric assessment. This systematic review proves the dire need for the development and psychometric evaluation of instruments to measure SA in HCPs in clinical settings.
Systematic review registration
In health care, situation awareness (SA) is one of the most prominent non-technical skills and a basis for appropriate clinical decision-making implicated in optimal health care providers’ (HCPs) performance, patient safety, and positive outcomes . SA is an essential element to research human factors in healthcare . Endsley  defines SA 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".
In recent years, the number of studies on SA in nurses , anesthesiologists , surgeons , and students of nursing and medical majors has remarkably increased . The main challenge is for HCPs with the most efficient SA education and SA assessment. Between the two, SA assessment is the more challenging [8, 9].
To improve the quality of care, decrease complications resulting from medical errors, increase patient safety, and investigate the effects of interventions on SA, researchers need to identify the most suitable way to assess SA in HCPS.
Instruments for SA measurement in health care are limited and mostly appropriated from other disciplines . The previous review indicates that the Situation Awareness Global Assessment Technique (SAGAT) and the behavioral rating system-based instruments are the most common instruments for SA measurement in HCPs [4, 11], but a comprehensive appraisal of their measurement properties is not available. Research for current situation identification or outcome evaluation purposes using low quality or unknown quality measurement instruments causes a waste of resources and misdirection of further investigating and training.
This systematic review is the first study using the COSMIN methodology and an up-to-date review of instruments for SA measurement in HCPs. This study aimed to provide a comprehensive view of this instrument’s measurement properties, support evidence-based recommendations in selecting the most suitable instrument, and identify potential improvements in this field from a psychometric point of view.
This study aimed to critically evaluate and summarize the quality of measurement properties in instruments used for measuring SA in HCPs using the COSMIN methodology. Moreover, we aimed to classify the instruments into three groups of 1- instruments that are the most suitable, 2- instruments that need further studies and development, and 3- instruments that are unsuitable, and to provide explanations and reasons for this classification.
In this systematic review, the COSMIN methodology for systematic reviews of Patient‐Reported Outcome Measures (PROMS) and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) were used as methodological guides [12,13,14,15]. The protocol of this systematic review has been registered in PROSPERO (CRD42020147349). The PRISMA checklist completed for the present study is presented in the (Additional file 1). This study was conducted in three steps (Fig. 1), explained below.
Step 1: systematic literature search
Step 1–1: formulating eligibility criteria
The inclusion criteria were as follows: 1- articles aiming to develop and determine measurement properties of instruments for measurement of SA or measuring non-technical skills (assessing SA as one of the dimensions of them: according to the guidelines of COSMIN methodology for systematic reviews of Patient‐Reported Outcome Measures; subscales of instruments can also be assessed using the COSMIN Risk of Bias checklist) in HCPs in clinical or simulated settings, and 2- articles published and instruments developed in English.
Studies on other non-technical skills or in populations different from that of the present study, as well as studies whose full texts were not accessible or were in the form of unpublished manuscripts, conference proceedings, and dissertations, were excluded.
Step 1–2: conducting the literature search
Four databases (Medline (through PubMed), Embase, Scopus, and Web of Science) were systematically searched from inception to December 2020 for peer-reviewed articles. A manual search on Google Scholar and the reference list of the included primary studies were also conducted to supplement the electronic search. The search strategy was developed with the assistance of a health sciences librarian and conducted using a combination of keywords and database-specific subject headings related to SA and psychometric properties (Additional file 2).
Step 1–3: selecting abstracts and full texts of the articles
The duplicates were omitted after transferring the search results to EndNote X7 (Thomson Reuters, Philadelphia, PA). The results were analyzed by two researchers independently based on titles and abstracts to identify the eligible articles. Then, the full text of the articles whose abstracts were screened in the previous step were investigated to determine if they met the inclusion criteria.
All the above steps were conducted independently by two researchers to reduce bias, and in the case of different opinions on an article, disagreements were resolved through discussion and consensus.
Step 2: assessment of measurement properties
Assessment of the instruments' measurement properties was done in 4 steps: 1) Assessment of the methodological quality of the studies based on the COSMIN Risk of Bias checklist, 2) rating results for single studies using the updated criteria for good measurement properties, 3) summing up the results of all studies for each instrument, and 4) grading the evidence quality for each measurement property using the GRADE approach.
In this step, all assessments were made by two reviewers independently, and disagreements were resolved through discussion or consulting a third person.
Step 2–1: assessment of the methodological quality of studies
The COSMIN Risk of Bias checklist was used for assessing the methodological quality of the study measurement properties. The COSMIN Risk of Bias Checklist has 10 boxes (see Fig. 1) for assessment. To assess the methodological quality of each study, first, the measurement properties were specified, and then, relevant boxes were selected. Each measurement standard was scored using a 4-point scale consisting of "very good," "adequate," "doubtful," and "inadequate"; moreover, the overall score of each box was determined by the lowest score of each item based on "the worst score counts" principle.
Step 2–2: rating the results of single studies
Rating of the results for single studies for the instrument development and content validity boxes was done separately based on 10 criteria (5 criteria for relevance, 1 for comprehensiveness, and 4 for comprehensibility). This method is thoroughly explained in the COSMIN Methodology for Assessing the Content Validity of PROMs. Rating of the studies for other measurement properties was done separately using the updated criteria for good measurement properties, and the results were rated sufficient (+), insufficient (-), or indeterminate (?) (Additional file 3).
Step 2–3: summing up the results of all studies for each instrument
All of the results of the studies were qualitatively summed up regarding each measurement property for each instrument, and using the 75% agreement rule; the results were rated sufficient (+), insufficient (-), inconsistent (±), or indeterminate (?). In this step, the focus is on the instrument, while the previous step focuses on the results of the single studies.
In this step, all the results regarding instrument development, content validity, and reviewers’ rating were qualitatively summed up for the overall rating of the relevance, comprehensiveness, and comprehensibility of the instrument. The results were rated sufficient (+), insufficient (-), or inconsistent (±). Since the reviewers' qualitative rating, as + , -, or ± , was possible in this step, the indeterminate (?) rating can be ignored for content validity.
Step 2–4: grading the evidence quality for each measurement property
In the final step, the summarized evidence was graded using Grading of Recommendations Assessment, Development and Evaluation (GRADE). This was done to determine the overall quality of the instrument, and evidence quality is graded as high, moderate, low, or very low.
This method is thoroughly explained in the COSMIN methodology for systematic reviews. In summary, 4 factors are considered in this rating: a) risk of bias (limitations in methodological quality of studies), b) inconsistency (unjustifiable heterogeneity in the results of studies), c) indirectness (evidence from populations different from the target population in the review), and d) imprecision (small number of samples). (Additional file 4).
Step 3: selecting the instrument
Selecting suitable instruments was done based on a combination of the results of steps 2–3 and step 2–4 in the assessment of content validity and other measurement properties. The recommendations were categorized into three groups: a) the most suitable instrument (high-quality evidence for sufficient content validity in terms of relevance, grading the evidence quality for each measurement property, and at least low-quality evidence of a sufficient internal consistency), b) promising instruments needing more psychometric studies (instruments not classified in a and c), c) not recommended (instruments with high-quality evidence of insufficient psychometric properties).
This study did not assess interpretability and feasibility since they are not considered measurement properties.
The systematic literature search
After removing duplicates, a total of 4367 abstracts were recovered from 4 databases. After checking the titles and abstracts, 4247 articles were excluded due to irrelevance and ineligibility. After the assessment of 120 full-text artic eligible articles, 25 eligible articles, and 15 eligible instruments were included in the study. The flow diagram of identifying and assessing the articles is presented in Fig. 2.
The inter-rater reliability was acceptable based on Altman . The weighted kappa coefficient for the primary screening was 0.76 (95% confidence interval [CI] = 0.62–0.95) and 0.77 for the secondary screening (95% CI = 0.67–0.85).
Four instruments had assessed SA, and 11 had assessed non-technical skills, of which SA was a dimension of the instrument in different HCPS. Moreover, 9 studies were conducted in clinical and 14 in simulated settings. One study was conducted in both clinical and simulated settings, and in one study research setting was not reported. More than half of the studies (16 studies) had assessed SA and non-technical skills in HCPs in operating rooms, and others had been conducted in clinical settings or in simulated trauma, acute and intensive care units. Fourteen instruments were observational checklists, and only SAGAT was the pen-and-paper version of the instrument; regarding one of the instruments, it was not determined if it was observational or self-report. A summary of the information on the studies and instruments is presented in Table 1.
Measurement properties assessment
The methodologic quality of the 25 included studies (Step 2–1) was assessed using the COSMIN Risk of Bias checklist. In some studies, more than one psychometric property was measured. Also, more than one psychometric study was conducted on four instruments in various research settings and conditions. The studies' most frequently measured psychometric properties were content validity (12 studies) and internal consistency (12 studies). A small number of the studies had investigated hypothesis testing for construct validity (6 studies), criterion validity and reliability (4 studies), and structural validity (2 studies), and only one study had assessed measurement error. Cross‐cultural validity and responsiveness were not investigated in any study.
The results of the methodological quality assessment (step 2–1) and the rating of the results of the single studies for each measurement property (step 2–2) are presented in Additional files 5 and 6, respectively.
Table 2 presents the results of all the studies for each instrument (2–3) and the grading of the evidence quality for each measurement property (steps 2–4). According to evidence on the content validity of the 15 instruments, only SAGAT (Dishman, 2020) had high-quality evidence of the sufficiency of its relevance; however, the evidence quality in this study was low and very low for the sufficiency of its comprehensiveness and comprehensibility, respectively. Other than this instrument, the evidence quality was not high for the sufficiency or insufficiency of measurement properties of any of the 15 instruments. In cases where the sum of the results for one measurement property was indeterminate (?), the evidence quality was reported as not evaluable (NE) due to insufficient evidence. In some studies, due to the lack of assessment or report of measurement properties, the sum of results and evidence quality was reported as NR (not reported).
The inter-rater reliability in quality assessment was acceptable: The kappa coefficient was 0.67 (95% CI = 0.55–0.8) for step 2–1, 0.62 (95% CI = 0.42–0.75) for step 2–2, 0.74 (95% CI = 0.63–0.83) for step 2–3, and 0.74 (95% CI = 0.65–0.87) for step 2–4.
Quality of psychometric properties
Four included instruments were assessed in numerous studies, as identified in this systematic review, and other instruments were in only one. The measurement properties of these instruments were summarized and evaluated on the basis of criteria for good measurement properties, and the quality of evidence was graded using a modified GRADE approach. The results of the evidence synthesis are presented in Table 3.
Non-technical skills for surgeons tool
Moderate quality of evidence (due to imprecision) was found for sufficient content validity. The NOTSS scale results showed moderate quality of evidence for inconsistent structural validity. Cronbach’s alpha for each of the subscales was not reported in the five studies in which internal consistency was evaluated, resulting in moderate quality of evidence for inconsistent internal consistency. Three of the four hypotheses were confirmed, resulting in moderate-quality of evidence for sufficient construct validity. The quality of evidence for the indeterminate criterion validity was not graded, because the results of the study on criterion validity were missing.
Anesthetists' non-technical skills system
Moderate quality of evidence was found for sufficient content validity. Low evidence for sufficient internal consistency was shown in ANTS. Cronbach’s alpha for the situation awareness subscale was reported in one of two studies.
Trauma non-technical skills tool
Very low-quality evidence for inconsistent content validity was found. T-NOTECHS showed a very low quality of evidence for sufficient reliability, due to the low sample size in the study and methodological flaws.
Scrub practitioners’ list of intraoperative non-technical skills
Very low-quality evidence for inconsistent content validity was found. Very low-quality evidence was found for sufficient reliability and sufficient construct validity. Low evidence for sufficient internal consistency was shown in SPLINTS. Cronbach’s alpha for the situation awareness subscale was reported in one of two studies.
Also, the evidence of measurement properties for SAGAT as tools for direct assessment of SA is highlighted below.
Situation awareness global assessment technique
Moderate quality of evidence for sufficient content validity was found in the studies by Dishman 2020 and Lavoie 2016. Very low-quality evidence for inconsistent content validity was found in the studies by Gardner 2017 and Hogan 2006. Very low quality of evidence was determined for sufficient criterion validity, insufficient and indeterminate internal consistency, and indeterminate hypothesis testing.
Table 3 provides an overview of the findings and all instruments above and others that were tested in only one study, as identified in this systematic review.
Due to a lack of high-quality evidence of sufficient content validity in all three aspects, none of the instruments are recommended as the most suitable; however, no high-quality evidence existed proving insufficient psychometric properties. All instruments were classified as promising and more psychometric studies should be conducted on them.
This systematic review was a comprehensive measurement property review of instruments for SA measurement in HCPs, and it provides evidence-based recommendations for selecting suitable, reliable, and valid instruments. Twenty-five studies were identified for assessing the measurement properties of 15 instruments based on study objectives.
Five psychometric studies were conducted on SAGAT; SAGAT provides the possibility of collecting data on the three SA levels through observation or direct questions in simulation, and the content of the questions is different based on the situation . Due to the difference in the content of the questions, these 5 studies were evaluated separately, and we could not sum up the results of all the studies for each instrument (step 2–3) for SAGAT. TSAGAT and team resuscitation situation awareness tool measured team SA [20, 21], but they were included since each person's SA was measured separately, and team SA was reported as the sum of individual scores in these studies.
In 18 studies, psychometric properties of instruments based on the behavioral rating system were assessed, and SA was introduced as a dimension of these instruments. In the assessment of measurement property quality, the SA subscale was assessed, and evidence quality for this instrument is only applicable to the SA subscale; the overall rating of the instrument for all subscales might be different from the present study results. These instruments were mainly based on the behavioral method, and one potential concern for behavioral rating systems is that subjective rating is susceptible to error; however, the objectivity of the instrument and inter-rater reliability can be improved through education [8, 20].
Psychometric assessment of the instruments in more than half of the studies was done in simulated environments (14 studies), and 14 instruments were observational checklists. The results of direct measurement of performance in a simulated environment and quantifying them to measure SA levels are essential but not sufficient and may not apply to clinical settings due to the existing complications .
Most of the studies were conducted in anesthesiology and operating room settings. Anesthesiology is a dynamic medical specialty with rapid and significant changes; moreover, operating rooms are complex settings with many specialties and different fields and instruments, necessitating a high level of SA. In fact, all medical specialties and HCPs need SA [5, 41, 42]. None of the studies had assessed all the measurement properties highlighted in the COSMIN methodology; also, there was only one psychometric study available for many instruments; therefore, the results on the instrument are indeterminate without a thorough evaluation of psychometric properties, validity, and reliability.
Some studies investigated content validity. In the present review, only Dishman (2020) had assessed content validity from both viewpoints, while the other studies had assessed it only from experts' and professionals' viewpoints. Content validity is the most prominent measurement property that must be considered and, when the contents of an instrument are good representatives of a construct, that instrument is more likely to achieve its assessment goals [43, 44].
Structural validity was only assessed for NOTSS in two studies [23, 24]. In the methodological quality assessment of structural validity, both studies were rated as very good since the COSMIN risk of bias checklist states that exploratory factor analysis (EFA) or confirmatory factor analysis (CFA) should be used; however, since no psychometric data were provided in the next steps, the overall rating of this validity for NOTSS, with moderate evidence quality, was reported as inconsistent. Structural validity is best assessed using the CFA method. Structural validity concerns which dimensions of the construct are assessed using the instrument and if these dimensions are in line with the theory [43, 45]. SA was defined according to Endsley's theory in the included studies, but structural validity was not reported using CFA in these two studies, or no correct reports of this method were reported.
The most frequently assessed measurement property in the studies regarding reliability was internal consistency, and most authors had used it as the only reliability index, which is not enough . Internal consistency is not suitable for assessing the internal consistency of formative measures [46, 47]. Fourteen instruments were checklists, classified as formative measures, and their inter-rater reliability is a more suitable method for assessing their reliability [43, 47]. However, this reliability assessment method cannot be evaluated using the COSMIN Risk of Bias Checklist. Due to its importance in the reliability assessment of formative instruments, it can be considered in developing the COSMIN Risk of Bias Checklist.
Four studies had reported a psychometric evaluation of criterion validity; however, due to the lack of a gold standard, evidence quality was very low or not evaluable for 3 of these studies. Evidence quality for being sufficient was moderate only for NoTSUS, whose gold standard was NOTSS . A gold standard instrument of a similar construct and comparing its scores with the instrument being evaluated is necessary to investigate criterion validity .
Hypothesis testing for the instruments was done in 6 studies; the evidence quality for the sufficiency of the overall rating of this measurement property was not high in these studies, and evidence quality was moderate for hypothesis testing of NOTECHS II and ICARS. There are various methods for hypothesis testing, but only convergent validity and known-groups validity can be assessed for hypothesis testing in the COSMIN risk of bias checklist, and the methodological quality of other methods of hypothesis testing is not evaluable [43, 49]. However, known-group validity is the best method for formative instruments , and 3/6 of studies had used this method for hypothesis testing.
Some of the COSMIN measurement properties might not apply to all studies; for instance, cross-cultural validity was not assessed in any of the included studies since all the instruments were developed in English and not translated from other languages, and this index did not need evaluation [13, 14].
Properties such as measurement error were assessed in only one study . Understanding indices such as minimal important change (MIC) or smallest detectable change (SDC) is important in measuring scores. With this information, we can realize if a change in scores in people's performance represents valid and real change and if the change is insignificant or significant. In the present review, none of the studies reported the values of SDC and MIC. Responsiveness of an instrument refers to its ability to detect a change over time in the construct being measured, and none of the studies had assessed this issue in the present review [43, 50].
In health care, SA is an abstract concept requiring valid and reliable instruments to ensure research quality. The results of this review do not indicate that the present instruments are inefficient, but suggest that investigations of high methodological quality are required to suitably assess their measurement properties.
SAGAT is an objective instrument that develops based on Goal-Directed Task Analysis. One disadvantage of SAGAT is that it cannot easily be used in other conditions. The development of context-general measures of SA can help data collection and generalizability and more measurement properties research can be accomplished on them.
Strengths and limitations
To our knowledge, no systematic review has provided a thorough and precise assessment of the methodological quality of existing studies on SA in HCPs or their results based on the measurement properties recommended in the COSMIN guideline. There is still a lack of information on the measurement properties of the instruments assessed in this study, and none of the instruments were recommended as the most suitable. This systematic review highlights the dire need for precise SA measurement instruments.
The gaps highlighted in this systematic review regarding measurement property assessment can be used in designing new studies on the development or psychometric assessment of this instrument. Moreover, qualitative studies are needed to assess content validity in three aspects of relevance, comprehensiveness, and comprehensibility of an instrument from the viewpoint of the target population and experts. Interventional studies can assess the responsiveness and predictive validity of measures. Authors of measurement studies should provide more precise reports on the methods used to assess validity and reliability, hypothesis testing, measurement error, and relevant details [13,14,15].
One of the limitations of our study was reviewing only English articles and excluding gray literature. Although after the systematic search of the databases, the reference lists of the included articles were also manually searched, some of the studies may have been missed due to publication bias. Also, since 10 properties were assessed according to the COSMIN methodology, other measurement properties might have been missed due to selective reporting bias.
This systematic review assessed the measurement properties of 15 SA measurement instruments using the COSMIN methodology. According to the results, evidence on these instruments is limited, and most of them have insufficient evidence quality. It seems that research on measures of SA in health care is growing.
Endsley's model is the most commonly used in health care. More importantly, it emphasizes the possibility of abstraction at all three levels. To further identify and clarify the concept of SA in the HCPS as the basic step for instrument development, it is necessary that more studies on the concept of SA be conducted on HCPS.
We hope that major shortcomings will be addressed using this systematic review. More studies are needed to develop new instruments specific to SA and not SA as a subscale of non-technical skills. Further assessment of measurement properties of the current instruments based on the COSMIN methodology and precise reports on measurement properties and methods used in the studies is necessary.
Availability of data and materials
COnsensus-based Standards for the selection of health Measurement Instruments
Health care providers
Situation Awareness Global Assessment Technique
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This study has been financially supported by the Vice-Chancellor for Research of Shahid Beheshti University of Medical Sciences.
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This study was conducted under the ethics code IR.SBMU.PHARMACY.REC.1399.308 Issued by the Ethics Committee of Shahid Beheshti University of Medical Sciences.
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Guidance of rating the results of single studies based on COSMIN methodology.
Guidance of grading the evidence quality for each measurement property based on COSMIN methodology.
Methodological quality assessment 0f studies on psychometric properties of the included instruments.
Quality of content validity (per PROM development and Content validity study, and Rating of reviewers) and other psychometric properties per study.
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Ghaderi, C., Esmaeili, R., Ebadi, A. et al. Measuring situation awareness in health care providers: a systematic review of measurement properties using COSMIN methodology. Syst Rev 12, 60 (2023). https://doi.org/10.1186/s13643-023-02220-6