Seeing the bigger picture

By Malissa Rayfield, Sophia Ansari and Ed Prosser-Snelling on 24 November 2017 Midwives Magazine Stillbirth

Malissa Rayfield, Sophia Ansari and Ed Prosser-Snelling look at how preventing morbidity and mortality among mothers and babies rests on midwives and their leaders improving situational awareness.

The Norfolk and Norwich University Hospital (NNUH) was awarded £79,900 from Health Education England’s Maternity Safety Training Fund as part of the national ambition set out by health secretary Jeremy Hunt to reduce stillbirth, neonatal and maternal deaths and intrapartum brain injuries in babies in England by 20% by 2020 and 50% by 2030 (Department of Health, 2016). 

NNUH used this funding to implement a sustainable human-factors training programme for all members of its maternity team. The programme uses classroom teaching, simulation and social media to encourage learning, and is led by a multiprofessional team including a midwife and two doctors. Midwives form a key audience and are ambassadors for this project, and their long-term support is invaluable to its success. The aims of this project are twofold. First, to improve safety within maternity by increasing staff awareness of the reasons we make errors – human factors – including our understanding of why we lose situational awareness. This is a key human factor identified in recent national reports as leading to fetal harm during labour. And second, to improve our understanding of how we can overcome these issues. 

Here, we highlight the contribution of a loss of situational awareness to the mortality and morbidity of mothers and babies. We will then explain the meaning of situational awareness and explore in depth its barriers and facilitators.

Contribution to mortality and morbidity 

The Each baby counts report (RCOG, 2017) recognised that loss of situational awareness was a key contributory factor to babies dying or experiencing severe brain injury at birth. Loss of situational awareness featured in 44% of these 556 babies for whom different care might have led to a different outcome (RCOG, 2017). The MBRRACE-UK maternal report (2014) recognised that staff failed to explore all the options and causes when women fell ill, and lost situational awareness. The Morecambe Bay investigation also reflected staff’s loss of situational awareness; staff maintained a ‘wait and see’ approach, and did not plan ahead (Kirkup, 2015). Outcomes may have been different if midwives and doctors had maintained an overview of the whole clinical picture. 

What is situational awareness?

Situational awareness is a dynamic cognitive process in which individuals and teams gain complete awareness and understanding of the situation around them (Flin et al, 2008; Endsley, 1995). It involves the ability to maintain the bigger picture and requires individuals to work together in order to share knowledge, to perceive the elements in their environment, to develop understanding of their meaning and to make projections and plans in the near future (Edozien, 2015; Endsley, 1995). The figure below shows a schematic overview of situational awareness, which demonstrates how it is always impossible to know all of the facts around you.

Three stages are involved in maintaining situational awareness: perception, comprehension and projection (Endsley, 1995). When members of the multiprofessional team share their perception and understanding of a situation, they begin to move their situational awareness away from the limits of the individual into the ideal situation. All members are then able to comprehend the overall situation and make plans and projections together. 


This involves the receipt of information in its raw form before it is understood (Flin et al, 2008). Midwives receive information in various forms: verbal, non-verbal, observational, written and electronic. For example, the fetal heart rate, the woman’s current risk status, her behaviour, and so on. The list is exhaustive.


The second stage of situational awareness involves the processing of information in order to understand its significance. For example, fetal heart rate decelerations in a non-labouring woman are of different significance to those in a labouring woman. Information can mean different things in different contexts, and it is only with experience that one is able to truly comprehend its significance (Endsley, 1995). This is also why it is crucial to share knowledge: it helps inexperienced midwives develop, broadening their ability to improve their level of situational awareness.   


This is the final stage of situational awareness, in which our perceptions and comprehensions are used to predict future outcomes, plans and goals. These may range from the time of the next vacuum extraction to whether a woman requires a CS. Experienced practitioners are able to make projections more efficiently, consulting a large bank of experience, apply stored mental models and map out future outcomes (Flin et al, 2008). 

The NMC (2015) states that midwives must ensure that patient safety is protected. For situational awareness, this translates to the safety of mother and baby forming our core projection. However, due to lack of awareness of the clinical situation, safety is sometimes jeopardised (RCOG, 2017; MBRRACE-UK, 2014). 

We now look at some barriers to and facilitators of situational awareness.

Working memory

Once information is perceived, it is stored in our working memory. We then combine this information with existing knowledge in order to comprehend and project the information (Endsley, 1995). However, we are only able to retain seven (plus or minus two) pieces of information in our working memory (Miller, 1956). Therefore it is imperative that our handovers are concise and pertinent. Information overload can be reduced by using structured handover tools such as SBAR (situation – background – assessment – recommendation) as this focuses our communication on pertinent information (Edozien, 2015). Ensuring that we update the board only with essential details will prevent information overload. 

Checklists can also focus attention and reduce the load on the working memory (Gawande, 2010); however, they can also encourage acting without thinking (Edozien, 2015). A solution is to encourage teams to carry out a checklist together, discuss it and form a plan. This recognises the wisdom of teams versus individuals because ‘man is fallible, but maybe men are less so’ (Gawande, 2010: 67). It is also important that the team understands the reasons for the checklist: this creates ‘buy in’. 

Working memory is affected by fatigue, hunger, stress and distraction (Flin et al, 2008; Arnsten, 1998). It is important to take regular breaks at work, ask for help when overloaded with tasks, use memory aids such as handover sheets, and minimise distractions and interruptions, especially during critical tasks. For example, if a midwife is performing a handover or checking a drug, delay interrupting them until the task is completed. 


Multitasking is difficult, and human attention is limited (Rall et al, 2014). If we multitask, we are likely to lose sight of the overall situation because we cannot split our attention between two or more complex tasks (Pashler, 1994). Each baby counts (RCOG, 2017) highlights a midwife caring for two women in early labour simultaneously. One woman was violent towards the midwife, who became distracted. The midwife lost awareness of the second woman, who progressed unexpectedly quickly; fetal monitoring was insufficient for her stage of labour and the result was a poor outcome for the baby (RCOG, 2017). Delegating tasks could be a solution; however, this is not always possible in a busy unit. Alternatively, applying the ‘10 seconds for 10 minutes’ principle, which is encouraged in anaesthetics (Rall and Oberfrank, 2015; Rall et al, 2014), could help. Taking 10 seconds to scan our environment every 10 minutes can help us maintain situational awareness. Safety huddles may also promote situational awareness: these involve a periodical regrouping of staff to re-evaluate the situation. This reflects the statement that ‘to maintain situational awareness is to be eternally vigilant’ (Edozien, 2015: 66). 

Each baby counts (RCOG, 2017) recommends that a senior member of staff must maintain oversight of the activity on delivery suite, especially when others are engaging in multiple complex technical tasks. The authors introduce this concept as taking the ‘helicopter view’.This role may be taken on by a senior team member such as the coordinating midwife; however, if they become involved in a complex task, another senior team member must take over the ‘helicopter view’. Using a phrase such as ‘I am now busy, please take over the helicopter view’ can help ensure that one person retains oversight of the activity on delivery suite.

Incorrect mental models

Mental models are knowledge maps held in our long-term memory that allow us to map out information, comprehend the meaning of that information and plan for future events (Endsley, 1995; Rouse and Morris, 1985). However, these mental models are subject to error because they are formed by what we think is true (Edozien, 2015). If perception is incorrect, the wrong mental model may be triggered, which will lead to incorrect situational awareness. Midwives are subject to difficult situations every day; they are presented with information stating that a woman is low risk, and therefore the assumed model is that this woman will progress to birth physiologically. However, this model is only correct in hindsight. Perhaps the correct mental model would be that this woman is currently low risk, but her labour may not be, and therefore we will plan and anticipate problems, safeguarding her and her baby against rare but life-threatening situations. This is not to downgrade the importance of savouring and delighting in physiological birth, but to accept the true situation that women enter every time they labour. 

A solution to incorrect mental model retrieval is to consult the team; does information mean the same thing to each member? Writing the plan on the board will allow the identification of any mental model errors and give the team a chance to discuss their differences in opinion.

Feeling unable to speak up

Another barrier to situational awareness is not feeling able to speak up. This means that information is not shared with the team, which may result in loss of situational awareness. For example, if a midwife was involved in an emergency and the leader forgets a crucial step in care, or performs a task incorrectly, the midwife may feel unable to state that something is wrong. Rall et al (2014) explain that in crisis situations, lower-status team members tend to defer to higher-status individuals, even if that individual is performing poorly. 

Hierarchy is a deeply entrenched cultural aspect of healthcare, and reducing the authority gradient will take time and top-down commitment (Clinical Human Factors Group, 2013). However, it is everyone’s responsibility to assertively challenge a poorly performing leader. Sensitive yet critical phrases such as ‘I am uncomfortable with this situation’, ‘I feel confused about this’ or ‘I am concerned’ might alert the leader to a problem. This critical language has been applied in the airline industry and could also be useful within maternity (Leonard et al, 2004). Midwives could ask a colleague for their opinion or seek that of the consultant if they are reluctant to speak up or concerned about situational awareness (RCOG, 2017).  

Hearing does not imply understanding

Another barrier to situational awareness is that information may be lost in transmission because listening does not imply understanding (Rall et al, 2014). When we are involved in complex tasks, hearing is the first sense lost as we focus our limited attention on the task ahead. A resolution to this problem is to ensure closed-loop communication. For example, if a midwife is asked to call a neonatologist, the midwife should state that they will call the neonatologist, and state they have completed this task once done. This confirms that the message was understood and successful. 

Separate professional handovers

There are several handovers every day, at differing times and between different individual professional groups. This process can be long and divisive, and information may be lost in transfer. This could impinge on the first stage of situational awareness: perception, or information gathering.
It would make sense to create multiprofessional handovers, at which every member of the team is able to listen and learn from one another, improving the team’s ability to perceive, comprehend and predict future outcomes. This would improve everyone’s situational awareness at the outset of a shift.


The General Medical Council directly recognises the importance of situational awareness and states it as a prerequisite of its professional values and behaviours (GMC, 2017). However, within midwifery the NMC standards for pre-registration midwifery education do not make explicit reference to the importance of maintaining situational awareness (NMC, 2015) – this is a potential area for development.  

Malissa Rayfield is a midwife and midwifery simulation fellow, Sophia Ansari is a clinical simulation fellow, and Ed Prosser-Snelling is a senior specialty registrar, all at NNUH

Maintaining situational awareness

The RCOG commissioned NNUH to produce a film showing how to maintain situational awareness; this film now forms part of the first Each baby counts report’s implementation package and is available for all to view at

Situational awareness: Key points 

  • Loss of situational awareness is a key contributory factor in the mortality and morbidity of mothers and babies
  • Situational awareness involves three levels: perception, comprehension and projection
  • We can only retain around seven pieces of information in our working memory
  • Information transfer should be pertinent and concise; SBAR can aid this
  • Update the board with essential information only
  • Try to avoid distracting others during critical tasks, and be aware of the effect of distractions upon memory
  • Keep the labour ward board pristine; it’s key to our shared understanding of what is happening
  • Use teams to carry out checklists
  • Be aware that multitasking is difficult; applying the ‘10 seconds every 10 minutes’ principle can ensure vigilance
  • Use safety huddles to update the team on the situation regularly
  • Ensure someone takes the ‘helicopter view’ and delegate this if involved in a task
  • Use the team to ensure the correct mental model is recalled; write the plan on the board for everyone to see
  • Use critical language or seek a second opinion if you see a colleague make an error
  • Use closed-loop communication
  • Educate all midwives and students on situational awareness.