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 Table of Contents  
ORIGINAL RESEARCH ARTICLE
Year : 2018  |  Volume : 31  |  Issue : 2  |  Page : 87-94

Gibson's theory of affordances and situational awareness occurring in urban departments of pediatrics, medicine, and emergency medicine


1 Weill Cornell Medicine/New York-Presbyterian Simulation Center, Weill Cornell Medical College, New York, USA
2 Department of Emergency Medicine, New York-Presbyterian Hospital, New York, USA
3 Department of Medicine, Weill Cornell Medical College, New York, USA
4 Department of Emergency Medicine, Weill Cornell Medical College, New York, USA
5 Department of Emergency Medicine, Weill Cornell Medicine New York-Presbyterian Simulation Center, Weill Cornell Medical College, New York, USA

Date of Web Publication30-Nov-2018

Correspondence Address:
Timothy C Clapper
525 East 68th Street, New York 10065
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/efh.EfH_33_18

  Abstract 

Background: The Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS®) program provides a situation-monitoring tool that allows health-care professionals to perform an environmental scan. This process includes scanning the status of the patient, team members, and the environment, to ensure that patient care is progressing toward the goal. It is assumed that health-care professionals will act in a certain way by providing feedback and support based on the scan. However, there is limited research supporting the impact of the clinical environment on behavior among health-care professionals. Methods: This qualitative research used in situ simulation and a theoretical sampling of six day and overnight shift clinical teams (n = 34) from three departments in an urban hospital in New York City: pediatric medicine, emergency medicine, and internal medicine. Notebook entries by the participants at three intervals during the case and a debriefing following the cases captured participant views, observations, and concerns about the immediate clinical environment. Results: In all six cases, and with every shift, there were documented examples of someone in the environment who saw something but did not speak up, possibly making a difference in regard to patient safety and the outcomes in the case. Some of the noted reasons include not wanting to be wrong, not wanting to hurt someone's feelings, or not being sure. Discussion: Our research explored the environmental scan that health-care team members conducted in three unique department settings, including how they perceived affordances, and the reasons why individuals may not speak up when another team member is not performing properly. Each person possesses a unique awareness and deficit of available affordances because of his/her position in the environment. Patient safety is somewhat reliant on the views and observations of each team member. Educators should use these outcomes to justify teamwork and communication training that includes targeted emphasis on providing candid feedback, situation monitoring, and mutual support.

Keywords: Gibson's Theory of Affordances, mutual support, situation awareness, team strategies and tools to enhance performance and patient safety


How to cite this article:
Clapper TC, Lee J, Phillips J, Rajwani K, Naik N, Ching K. Gibson's theory of affordances and situational awareness occurring in urban departments of pediatrics, medicine, and emergency medicine. Educ Health 2018;31:87-94

How to cite this URL:
Clapper TC, Lee J, Phillips J, Rajwani K, Naik N, Ching K. Gibson's theory of affordances and situational awareness occurring in urban departments of pediatrics, medicine, and emergency medicine. Educ Health [serial online] 2018 [cited 2020 Oct 24];31:87-94. Available from: https://www.educationforhealth.net/text.asp?2018/31/2/87/246753




  Background Top


Our perception of the environment is what we perceive, and this perception is influenced by our location (and other factors in the surrounding environment).[1] One person may see or sense something in the environment that another cannot, or they may see it differently depending on where they are positioned. Gibson[1] observed that objects in the environment hold little meaning until they come into a person's view or into the light. We may not directly observe affordances in our environment unless it stimulates us in some way or until someone or something redirects our attention to the objects or phenomena. Likewise, optical or acoustic information may focus our attention on potential threats in the environment.[1] A person is unaware of the affordances provided in the environment unless they are uncovered or brought to his/her attention. It is then that we perceive the meaning of the object and give attention to the behavior. By virtue of position in the environment and the task, a clinical provider may become so fixated on a particular event, object, or phenomenon occurring in the environment as to miss another critical affordance or event.

Situation awareness (SA) requires one to scan the environment, a process we know as situation monitoring. From where we are positioned in the clinical environment, we may not see that a patient's condition has changed considerably. This may result from a local distraction or from incomplete information that might have been provided through the perceptions of others. Our shortcomings in the environment may include what we can see, hear, or feel and do not call out to other team members.

The Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS®) program was developed by the Agency for Healthcare Research and Quality in 2005 in collaboration with the United States Department of Defense.[2] TeamSTEPPS® provides a situation-monitoring tool that allows health-care professionals to perform an environmental scan.[2] This process includes scanning the status of the patient, team members, the environment, and ensuring that patient care is progressing toward the goal. It may be assumed that health-care professionals will act in a certain way in an environment, by providing feedback and support based on the environmental scan. However, there is limited research supporting the impact of the clinical environment on behavior among health-care professionals.

This qualitative research used in situ simulation and a theoretical sampling of actual clinical teams from three urban medicine departments: pediatric medicine, emergency medicine, and internal medicine. We explored what clinical teams focused on in their environment to identify if team members shared information readily, especially when they saw a need to intervene to improve a team member's performance and, thus, clinical outcomes for patients.

In 1977, Gibson[3] of Cornell University described his Theory of Affordances as what the environment affords a person, including objects and information from others that are available to them. It was further defined as the relationship between the environment and the animal or person in the particular space.[4] People form their perception of the environment using all of their senses. The purpose of perception is to acquire knowledge; however, inadequate perceptions can lead to error in knowledge[5] and hence errors in the clinical setting. Poor perception and faulty frames of reference can affect our decision-making process in negative ways. In an environment, a person is “both a perceiver and a behaver” (p. 4).[4] A person's behavior is likely to be dependent on his/her perception of the environment[1] based on the affordances that it provides. Affordances form facts about the environment, and they are not limited to objects placed in the environment.[3] We use our existing frames of reference or ways of knowing along with affordances to piece together our perception of the environment. If the information from which learners perceive their environment is insufficient at any moment in time, then they may experience an error in judgment, which can impact performance/clinical outcomes. Ultimately, these outcomes may include misdiagnosis and patient harm.

TeamSTEPPS® may improve situation monitoring and hence SA, leading to the mutual support of team members.[2] However, it is important to first understand how perception influences SA and mutual support in real time. Similarly, teaching and empowering team members to voice their concerns and observations may not occur if we do not encourage members to be very candid. Using in situ simulation, we aimed to explore what clinical teams focused on in their environment. We also needed to identify if team members shared information readily, especially when they see a need to correct an intervention or intervene to improve a team member's performance. This research provides baseline data that can guide the way educators implement TeamSTEPPS®, debrief teams, and conduct many other forms of team-based instruction.


  Methods Top


This qualitative research used in situ simulation and a theoretical sampling of actual clinical teams from three departments in an urban hospital: pediatric medicine, emergency medicine, and internal medicine. We explored what clinical teams thought about when caring for a patient during resuscitation in their natural working environment. We studied two clinical teams from each department, including day and overnight shifts to construct a dataset of emerging themes and narratives.

Theoretical framework for this intervention and research plan

The theoretical framework for the intervention is Gibson's Theory of Affordances and Perception. Gibson suggested that one's perception of the environment and his/her consequent behaviors are based on his/her position in the environment. The location and usefulness of affordances can go unnoticed unless brought to a person's attention and that can apply to his/her own behaviors.

Sample

Six teams (n = 34), two teams from each department, participated in simulations held during day and overnight shifts. Creswell[6] stated that theoretical sampling is useful when the researchers need to generate a theory or discover specific concepts from an existing theory. In line with our institutional research review board-approved research protocol, and to protect our participants, we kept the data as de-identified as possible, only collecting demographic information which may be important to understand the phenomena [Table 1].
Table 1: Sample demographics

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As the sample in each team was relatively small, and participants are well aware of who participates in research projects in their departments, to keep the data as de-identified as possible, we do not report gender information.


  Procedure Top


Participants were consented for participation in this study. Notepads were provided to all participants. Each notebook was numbered to correspond to a number worn by the participant on each team. The numbers allowed us to match the data to the participants and their profession (i.e., PGY-1, nurse, and respiratory therapist) while keeping the participant's identity anonymous. Participants were told that at three points in the simulation case, we would use reflective pauses and ask them to write down their thoughts about the case and their immediate clinical environment in their notebook. They would be responding to four questions posted on the wall in the room [Table 2].
Table 2: Questions answered at each pause in the simulation

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The participants were encouraged to write as freely as they wished when responding to the questions. They were told that they did not need to share their responses with other members of their team, but could do so if they elected. The facilitator/debriefer provided the simulation pre-briefing that included the suspension of disbelief components, asking the learners to treat the simulation as a real case, including performance of any clinical interventions such as inserting intravenous (IV) catheters. The start time for the cases began when the team or member of a team walked into the room to respond to the code. The pauses occurred at 2, 5, and 8 min from the start time of the case. The simulations were stopped at about the 9-min mark to begin the debriefing.

We used an age-appropriate patient simulator coupled to a bedside patient monitor for each department's simulation. The monitor was positioned directly adjacent to the patient simulator and was viewable from multiple angles around the room. Participants were required to attach electrode leads and other devices in order to visualize the data on their patient monitors. A defibrillator, step stool, and code cart with resuscitation medications were available and were easily accessible in each simulation. To balance the effects of differing unit conditions between day and overnight shifts on our research, we conducted in situ simulations for the staff of both shifts.

Every case involved an asystole, also known as flat line, with no cardiac output. A fully stocked code cart with simulation medical supplies was used in each case that included a fully functioning defibrillator. The same two researchers gathered additional information from the participants during the case and the debriefing process. Trained faculty instructors conducted the debriefings in each department. The faculty not only focused on debriefing the case but also incorporated the four questions which were kept covered until the time of each pause.

Data analysis

Two researchers experienced with qualitative analysis codified the data and recorded the supporting narratives. We used another principle of qualitative research known as layering themes because sometimes dominating themes differ slightly.[6] Layering identifies both major and minor themes that may emerge from the coding process. This was important in our research because we could analyze any connected levels of themes in the coding process that might provide richer and more meaningful results and supporting narratives to address the central phenomenon.


  Results Top


Several themes emerged from the data analysis. As shown in [Table 3], each theme was unique to day or overnight teams in the three departments. Teams in each department focused on particular affordances in the environment. Upon entering the room, all teams in our study quickly assessed their patients. The actions that followed distinguished the teams from each other. The narratives captured from the notebook or journal entries provide additional support for the themes shown in [Table 3]. We observed notable intra- and interdepartmental similarities and differences between the teams.
Table 3: Major and minor coding themes

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Internal medicine

The leader of this team entered the room first, quickly assessed the patient, and started chest compressions on determining the cardiac arrest. As soon as the next team member entered the room, the team leader instructed that person to retrieve the step stool from the room. The team leader then directed that person to manage the airway. Throughout the resuscitation, the team leader performed an environmental scan, made corrections, and/or provided feedback (IMEPGY2: “Good quality CPR…. good compressions”) (IMERN1: “We started continuous CPR until the leader quickly noticed and reminded us we were supposed to be doing 30:2 compressions to ventilations”). Although the overnight team was also observed to perform environmental scans, they did not notice that the nurse overseeing their code cart and regulating entry into the room was the only person wearing personal protective equipment. Teamwork and communication emerged as the major theme for the overnight team. The major theme for the day shift, closed-loop communication, differed slightly from that for the overnight shift. The affordances that the day shift team members were looking for were the behaviors and actions that the leaders and other team members could not see. The leader and the team continually searched for patient information and the actions of team members (IMDPGY3: “I wanted more closed-loop information, but didn't request it” “I told the nurse to draw epi but she drew it up and administered it. Didn't stop her”). Other team members saw something and would like to say something but held back (IMDPGY1: “Concerned for need for fluids.”). However, this concern was not shared until after the third pause when 8 min had lapsed. IMDPGY1 and another nurse noticed an improper compression to ventilation ratio, but did not speak up because, “they didn't want to be wrong”. Some were aware of their own status, but not the status of other team members. IMDPGY1 performed one set of chest compressions and then asked to be relieved. IMRN took over chest compressions and nobody relieved him/her even after several cycles (IMRN: “I was tired of doing compressions. I think I should've said that to the team”).

Pediatric medicine

The pediatric teams fixated on their inability to bring up vital signs on the patient monitor, because they did not realize that their monitor required the same electrode leads in simulation as in real life. As a result, there was a significant delay before they obtained a cardiac rhythm. Similarly, both the day and overnight teams were slow to recognize that there was a defibrillator in the room and neither team used it. Both teams refrained from sharing information or assisting their team's progress toward the team's goal. (PDPGY1: “Not sharing that we should prioritize. We should be concentrating on getting rhythm rather than on the IV fluids. Not shared because not certain”). The leader of the day shift team was overly concerned with the quality of chest compressions. However, neither the leader nor any other member of the team used the step stool that was nearby and visible. Moreover, team members did not provide feedback to other team members even when they required a correction (PNPGY1: “PNPGY3B not performing chest compressions fast enough.” PNPGY1: “I wish I could lock the bed and find the backboard.” PNPGY1: “I think we are bad at resuscitation.” PNPGY1: “PNPGY3B is not performing breaths well. I feel bad telling her.”). Even when the team was diverging from pediatric advanced life support or advanced cardiac life support (ACLS) algorithms, team members hesitated to share this observation with the team or solicit input (PNPGY3B: “I think we are missing steps”).

Emergency medicine

Gathering patient information emerged as a major theme for the emergency medicine team. In this environment, members of the team and family both held key information about the patient. Although individual team members considered their situation, they did not share their perceptions and suggestions with other members (EMPGY1-2: “I did not mention the possibility of opioid overdose and pushing Naloxone.” “I have not shared that we need the pads (defibrillator), compression monitor, and we are due for our first dose of epi”). The day shift nurses expressed their discomfort and frustrations with the direction of the case and their lack of role clarity (EDRN-1: “missing steps in ACLS” “No comprehensive approach” “Still trying to figure out role…wasn't directly assigned”). The affordances provided in the environment were not brought to their attention. Nurses frantically withdrew all of the items in the bottom of the code cart in their search for airway equipment. The leader of the team realized the need to solicit input from the team about the patient and the direction for care but did not verbalize it (EMPGY1: “I should have brought up the patient's surgery and asked if any team members had thoughts on why patient was unresponsive”). Chest compressions were too shallow; however, nobody on the team appeared to notice and no one spoke up about it. The overnight team was also very concerned about gathering patient information. They repeatedly looked for affordances to reveal their patient's condition and a reason for their patient's location (EMERN2: “team is confused” “patient status is not clear,” EDERN4: “Environment is confusing because we don't know status” EMEPGY4: “Unclear how patient is in the adult trauma room and we don't know how he got here”). Much of the confusion centered around two affordances in the environment: information provided by team members and a fixation on an unfamiliar monitor. EMEPGY1 and EMEPGY1-2 both assessed for the patient's pulse at the beginning of the case. EMPGY1 verbalized that he/she felt a pulse. EMEPGY1-2 did not feel a pulse, but did not challenge him/her (”I didn't feel a pulse”). As noted above, EMERN2 was suspicious about the pulse and revealed this during the debriefing, though he/she never challenged or verbalized his/her concern. Thinking the patient had a pulse, the team refocused their attention on the monitor, another affordance in the environment with critical information (EMERN3: “I thought we had a monitor problem and not a patient problem”). No team members noticed or verbalized their concerns that the patient was missing his/her monitor's electrocardiogram (EKG) leads. Moreover, no team members noticed or verbalized their concerns about the poor quality chest compressions. They did not use the three step stools that were within arm's reach of the team in plain sight. The team also sought information as they tried to make sense of the environment. Another affordance for them was the team leader who they needed to help sort through the information as it was occurring (EMERN3: “EMEPGY4 should be audible with findings on repeat”). In addition, like the saying, “do as I say, say as I do,” during the debriefing, EMERN3 noticed that he/she was the only one wearing personal protective equipment and logged it as such in the notebook, but did not share this concern during the case.


  Discussion Top


A person's behavior is dependent on his/her perception of the environment[1] and the affordances that it provides. A large meta-analysis by Hines, Hungerford, and Tomera[7] found several variables associated with responsible environmental behavior, including knowledge of issues, knowledge of action strategies, locus of control, attitudes, verbal commitment, and an individual's sense of responsibility. However, before an individual can intentionally act on a problem, he/she must be cognitively aware of its existence.[7] A key principle of TeamSTEPPS® is that everyone on a team is empowered to speak up. Each team member is responsible for scanning the environment, the status of the patient, and other team members, to ensure that the team is progressing toward the goal.[5] During this process, each team member is empowered to share concerns, provide task assistance to one another, and identify errors before they can occur. Both internal medicine teams performed this task best; this was especially true of the overnight team.

As noted earlier, in all the simulations in all three departments, the patient monitors were positioned near the patient simulators. They provided the same information as real-life patient monitors and operated the same way, requiring users to attach leads to obtain patient vital signs. Some teams struggled with the monitor. In every instance where teams struggled to obtain a working monitor, they did not seem to realize that the problem was not the monitor. The health-care worker had to attach the electrode leads to obtain the vitals they needed to see. A defibrillator was in plain view and was another affordance that could have provided the cardiac rhythm. The pediatric and emergency medicine teams fixated the most on the monitors. Nothing was hidden from the teams and all equipment was positioned in plain sight. As stated by Gibson,[1] the affordance in these cases (e.g., the monitor EKG leads and the defibrillator) had to be noticed by someone or “brought into the light” by another member of the team who could see it and think about using it. If they became fixated on a specific location in the environment, the affordance would likely go unnoticed unless someone saw it, spoke up, and brought it to the team's attention.

While pediatrics focused on equipment affordances, the emergency medicine teams looked to others in the environment to provide information. The day shift team of emergency medicine performed the process in a large simulation space and the overnight shift cared for their patients in the resuscitation room of the emergency department. As with every case, the equipment was the same, nearby, and within visible reach of the team. Since the environment was different from what they were normally accustomed to, the day shift team had to rely on one another to expose a specific affordance or the suggestion to use it. For them, information was the affordance that team members in the environment could provide. Unlike the other teams, the internal medicine team did not become fixated on the physical affordances in the environment, but instead, continuously sought affirmation of the team member's actions through closed-loop communication. By virtue of position in the environment, team members, and especially the leader, could not see every action performed. The team members needed to share their observations and report on actions as they were started and completed.

In every case, the participants frantically searched for additional information or resources to assist them with improving patient care. In general, affordances and certain behaviors went unnoticed by the team members unless others in the environment brought them to their attention. Participants noted calls for affordances and changes in behaviors in their notebooks that could have made a difference, but in many cases, did not share their concerns with the team. As a result, the team did not address many behaviors requiring feedback and correction to improve patient care.

Endsley[8] described multiple research studies involving operator SA using a validated instrument referred to as Situation Awareness Global Assessment Technique. His research focused on fighter pilot simulations that were similarly paused at particular points to assess SA. Endsley suggested that three levels of SA could be assessed in the flight simulations including the following:

  • Level 1 SA: How the pilot perceived relevant information
  • Level 2 SA: Understanding and meaning of the situation based on the data the pilot accumulated to that point
  • Level 3 SA: Timely decision-making based on a prediction of future events and state of the systems.


Endsley's research is important for understanding a person's existing mental frame in a given situation and the possible reasons for the critical follow-on actions that he/she may or may not implement. His simulations also included a single participant (the pilot). Our research is similar in process; however; we explored the environmental scan that health-care team members conducted in three unique department settings, including how they perceived affordances, and the reasons why individuals may not speak up when another team member is not performing properly. Okuyama, Wagner, and Bijnen[9] noted that a hesitancy to speak up might contribute to poor communication and adverse events. Poor teamwork and communication issues are contributing factors to many errors created in the health-care community.[10],[11],[12],[13] In all six cases, and with each shift, there were documented examples of someone in the environment who saw something and did not say something that could have made a difference for patient safety and the outcomes in the case. Some of the reasons included not wanting to be wrong, not wanting to hurt someone's feelings, or not being sure. Recall that a participant–leader in an internal medicine team logged in the notebook that a nurse was asked to draw up epinephrine. The leader did not ask the nurse to administer the medication. The nurse prepared and administered the medication, while the leader failed to intervene. The preferred manner would be for the nurse to announce that the medication was drawn and to ask if the leader wants the dose administered. If the nurse is observed starting the process of medication delivery, the leader should call out to wait until the order is given and provide an explanation (e.g., the medication is no longer needed; it has not been 2 min, etc.).

Silence or unwillingness to speak up even on the part of the leader was not limited to our research. Härgestam et al.[14] observed that their leaders remained silent for the majority of their team trauma simulations. They proposed that the silent leaders may have been uncertain about their own knowledge and expressing it to the team. The researchers also suggested that the silence on the part of the leaders could be related to power inequities among team members or as a means of avoiding conflict. This signifies a need to create supportive environments where all professionals feel able to speak up about the safety issues without fear of blame or retribution.[15]

Two important TeamSTEPPS® competencies that can improve the culture of safety include situation monitoring and mutual support. Scanning the environment and applying task assistance or mutual support are not just nice gestures we do for members of our team. These acts should be expectations. However, if teams are not trained in TeamSTEPPS® and do not feel comfortable with speaking up candidly, they are not likely to know how to share observations and advocate for the patient and one another to improve a situation. Although the overnight team in internal medicine did not perform flawlessly, they demonstrated good SA and mutual support. At the time of this research, the teams in each department had not yet completed the TeamSTEPPS® intervention. However, the overnight team from internal medicine had a significant number of graduates who had completed a code team course that is rich in TeamSTEPPS® principles, especially closed-loop communication, SA, and mutual support. Teams are taught to actively scan the environment for affordances such as a step stool and location of the defibrillator, while mutually supporting one another by placing the step stool under the chest compressor and positioning the defibrillator to face the leader. That is, as Gibson suggested,[1] bringing the affordance into the light, as it may otherwise go unnoticed. The environmental scan conducted through TeamSTEPPS® training could also address the task-fixation issues that occurred in some cases. Training in situation monitoring allows the team to think about the next steps that need to be taken and alerts team members to look for opportunities to support their team leader and other members.[16] As noted by Hester,[17] a person can pay attention and still not notice something in his/her environment. Someone in the environment could have brought specific affordances or behaviors to the team's attention. Likewise, team members need to protect themselves and the patient, but may not insist that others do the same. The overnight shift members of internal medicine team did not seem to notice that the nurse overseeing code cart and regulating entry into the room was wearing a protective mask and gloves while no one else did. The researchers wondered why the same nurse did not insist or assist others with donning their protective equipment.

Team members could have suggested that the EKG leads on the monitor should be attached, or that they look beyond difficulties with the monitors and secure the defibrillator, as they would likely need that tool anyway. While for the most part we tend to think of affordances in the environment as objects, it is interesting that the team members also perceived one another as affordances. The need for information about the environment, the action of members of the team, and the patient, from human sources was very clear. Leaders and team members in these cases, in all three departments, sought information from one another and potentially family members in the case. If it did not exist, it created the same stressful environment generated by not being able to see a physical affordance.

Limitations and suggestions for future research

This research was conducted in three departments in a single organization with interprofessional teams from different professions. A larger study including a larger sample size and additional specialties could be beneficial to observe any change in the themes. This research was conducted before TeamSTEPPS® training. A follow-up study to determine the effect on the affordance theory as a result of the TeamSTEPPS® intervention would also be valuable to the health-care community. Our research used high-fidelity simulation. Additional research methodology and procedures using nonemergent cases with actual patients and simulators could produce different results and add to the literature.


  Conclusion Top


This research is important because it is assumed that the behaviors we described occur in the clinical environment; however, this is the first research that we know of that documents and describes human factor issues associated with clinicians and the affordances in their natural environments. There are several possible implications suggested by the results of this research, but most importantly, it justifies the necessity to apply situation monitoring and mutual support. Noted earlier in this article was Gibson's belief that a person was both a perceiver and a behaver, with behavior being dependent on his/her perception of the environment.[3] We can add that since each person may possess a unique awareness and deficit of available affordances because of his/her position in the environment, he/she is somewhat reliant on the views and observations of other team members. We can improve patient safety by building stronger, more capable teams while preventing medical errors before they occur. Team members need to be empowered to speak up to improve practice and prevent errors. Part of the solution requires creating a culture and environment that encourages all team members to do so. This requires educators or professional development organizations to be familiar with Gibson's theory of Affordances and Perception and develop interventions that prepare teams to operate safely and more effectively in their health-care environments.

Acknowledgment

We would like to express our appreciation to the participants in the three departments of our institution. They make a difference every day and through this research helped us to identify ways that we can assist them with improving our education initiatives.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Gibson JJ. The Ecological Approach to Visual Perception. New York, NY: Psychology Press; 1986.  Back to cited text no. 1
    
2.
Agency for Healthcare Research and Quality. TeamSTEPPS_Fundamentals Course. TeamSTEPPS Instructor Guide; 2006. Available from: https://www.ahrq.gov/teamstepps/instructor/fundamentals/index.html. [Last retrieved on 2017 Aug 23].  Back to cited text no. 2
    
3.
Gibson JJ. The theory of affordances. In: Shaw R, Bransford's J, editors. Perceiving, Acting, and Knowing. Hillsdale, NJ: Lawrence Erlbaum Associates Publishers. 1977.  Back to cited text no. 3
    
4.
Gibson JJ. The Ecological Approach to Visual Perception. Boston, MA: Houghton Mifflin; 1979.  Back to cited text no. 4
    
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Shaw R, Bransford J. Perceiving, Acting, and Knowing. Hillsdale, NJ: Lawrence Erlbaum Associates Publishers; 1977.  Back to cited text no. 5
    
6.
Creswell JW. Educational Research. Upper Saddle River, NJ: Pearson; 2008.  Back to cited text no. 6
    
7.
Hines JM, Hungerford HR, Tomera, AN. Analysis and synthesis of research on responsible environmental behavior: A meta-analysis. J Environ Educ 1987;18:1-8.  Back to cited text no. 7
    
8.
Endsley MR. Measurement of situation awareness in dynamic systems. Hum Factors 1995;37:65-84.  Back to cited text no. 8
    
9.
Okuyama A, Wagner C, Bijnen B. Speaking up for patient safety by hospital-based health care professionals: A literature review. BMC Health Serv Res 2014;14:61.  Back to cited text no. 9
    
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Aaronson EL, Brown D, Benzer T, Natsui S, Mort E. Incident reporting in emergency medicine: A Thematic analysis of events. J Patient Saf 2017. Doi: 10.1097/PTS.0000000000000399.  Back to cited text no. 10
    
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Agency for Healthcare Research and Quality. Agency for Healthcare Research and Quality's Patient Safety Initiative: Building Foundations, Reducing Risk. Rockville, MD: Agency for Healthcare Research and Quality; 2003. Available from: http//www.archive.ahrq.gov/research/findings/final-reports/pscongrpt/psini2.html. [Last retrieved on 2017 Dec 15].  Back to cited text no. 11
    
12.
Kohn LT, Corrigan JM, Donaldson MS, editors. Committee on quality of health care in America, institute of medicine. To Err is Human: Building a Safer Health System. Washington, DC, USA: National Academies Press; 2000.  Back to cited text no. 12
    
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Lee A, Mills PD, Neily J, Hemphill RR. Root cause analysis of serious adverse events among older patients in the Veterans Health Administration. Jt Comm J Qual Patient Saf 2014;40:253-62.  Back to cited text no. 13
    
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Härgestam M, Hultin M, Brulin C, Jacobsson M. Trauma team leaders' non-verbal communication: Video registration during trauma team training. Scand J Trauma Resusc Emerg Med 2016;24:37.  Back to cited text no. 14
    
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World Health Organization Medication. Errors: Technical Series on Safer Primary Care. Geneva: World Health Organization; 2016. Available from: http//www.apps.who.int/iris/bitstream/handle/10665/252274/9789241511643-eng.pdf; jsessionid=BA9A21DFA47FC6639EC9DA8D17847864?sequence=1. [Last retrieved on 2018 Jul 25].  Back to cited text no. 15
    
16.
Clapper TC, Kong M. TeamSTEPPS: The patient safety tool that needs to be implemented. Clin Simul Nurs 2012;8:e367-73.  Back to cited text no. 16
    
17.
Hester M. Visual attention and sensibility. In: Shaw R, Bransford's J, editors. Perceiving, Acting, and Knowing. Hillsdale, NJ: Lawrence Erlbaum Associates Publishers; 1977.  Back to cited text no. 17
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3]


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