Mechanisms for maintaining situation awareness in the micro-neurosurgical operating room

• Situation awareness in neurosurgery is influenced by extensive use of microscope.
• Nurses develop proactive strategies and roles to deal with challenging environment.
• Bottlenecks and potential weak links are discovered.
• The notion of situation awareness is expanded by proactive action beyond perception.
• Implications for new interactive technologies are presented.

Interactions in micro-neurosurgical operating rooms form a complex orchestration of labor and information flows. In the center, there is the focus on patient safety and outcome quality in shortest possible time, while a neurosurgeon is fully focused on the task using a surgical microscope. To guarantee a successful outcome, maintaining a high level of situation awareness (SA) is essential. Suspension of action due to instrument exchange, interaction with a device, or communication affects information flows and collaboration. Situation awareness underlies these interactions. To further understand the mechanisms of SA, we used observations and interviews to gain insight into interactions in micro-neurosurgical theaters. We describe behaviors and strategies exhibited to maintain the interaction flow, in particular, between the scrub nurse and the surgeon. Results show how interactions based on action prediction and active observation within the well-organized environment are influenced, both positively and negatively, by the reliance of the work on the microscope. From this understanding, we discuss the opportunities in future technologies and interfaces for supporting situation awareness maintenance in operating rooms.