We appreciate the time and effort Ms Fore took to read and think about our article, as well as share some of her thought with us and the ANS readers. We are pleased to have the opportunity to continue the dialogue about this important concept.

Ms Fore raises a legitimate point in terms of retrospective analysis of situation awareness. Although retrospective analysis does have some limitations, it is currently one of the most viable methods available to study situational awareness (SA). "Real" time measurement and analysis can only be done in the laboratory, with a simulated situation, which has its own set of inherent limitations, such as when measuring momentary SA. Momentary SA is measured when the observer interrupts a particular activity to test current SA. The interruption is then itself a cognitive interruption and not a reflection of the real world context. The SAGAT1 has been previously described along with its inherent limitations, including but not limited to, interruptions resulting from the probe technique. Critical decision method (CDM) is also commonly used to describe and explain situation awareness. Experts in the field, such as Klein,2 contend that CDM is a valid method to examine the connection between SA and decision making. In CDM, incidents are probed carefully with the subject and the researcher examines SA as the incident unfolded, the interpretation of each stage, and alternative interpretations that were considered but rejected. We are confident that in the future other techniques such as "talking aloud" may be able to be used, but it is likely that this method will also suffer some limitation as all methodologies do. The researcher must weigh carefully the issues and limitations and make the best choice possible--we believe we did this.

We appreciate the discussion points raised by Ms Fore related to her interpretation of our premise absent consideration of automatic decision making and complacency. We still believe Benner's novice to expert model provides a very useful framework for the study of attentional dynamics and SA. In fact, many other fields have examined that relationship and their data supports our premise. For example, in addition to the studies cited in our article, Bellenkes et al3 contrasted the 2 levels of pilot skill-novice to expert-in flight scenarios involving a series of climbing, turning, and accelerating maneuvers. There were great differences in attentional dynamics when experts and novices were compared. Differences included the capacity for the novice to scan as a result of fixation. Novice fixation on a single aspect of the situation influenced their SA and their capacity to anticipate the aircraft state, as well as their overall flight performance.4 We would posit that as one considers the nurse with less than 2 years experience in the current nursing work environment where the average nurse spends less than 30 seconds on more than 50% of tasks,5 it becomes clear that expertise would make a difference.

We agree with Ms Fore's point that all nurses demonstrate expertise as defined by Benner et al,6 as well as her point that experience is not synonymous with expertise. We do not believe we ever stated that experience and expertise were one and the same, but if we left room for that interpretation we would like to clarify our intent here. We appreciate the notion of automaticity in competent nurses and factors that might influence their inability to notice subtle changes in patient's conditions. In fact, experts suggest an alarming number of nurses with more than 5 years of experience but who have not developed beyond the competent stage of practice provide inadequate care.

We suggest that emotionally disengaged nurses or experienced nonexpert nurses are limited in terms of clinical knowledge and ethical judgment in providing care to those they are privileged to serve.7 We strongly agree that years of experience alone are insufficient which is why we chose the term expertise, in contrast to years of experience, and appreciate Ms Fore emphasizing that aspect of the discussion on this very important area. We would also propose that there is the opportunity to enhance levels of SA by implementing strategies that might expedite the trajectory from advanced beginner to competent to expert through situated coaching.7 Finally, in relation to this same point, we would agree (and experts concur) that there is marginal agreement on what constitutes knowledge and expertise.8

We completely agree that there is emerging interest in team-based SA and support the recommendation that future research should examine how we might describe, explain, and predict team situation awareness in nursing and patient care. However, the aim of this article was to understand the cognitive work of the individual nurse. Team SA is multidimensional, comprising individual SA, shared SA between team members, and also the combined SA of the entire team culminating in one "shared picture."9^(p308) We believe that there are limitations in moving to team SA before understanding how to define and understand factors influencing individual nurse SA.

Although the intent of the article was not to address team SA, we would propose that what is paramount specific to team situation awareness is a sensitivity to operations10,11 that includes, but is not limited to, an understanding of team expertise. For additional information specific to the definition and measurement of team situation awareness, we propose a review of research conducted by Weick et al,10 Vogus et al,11 Salas et al,12 and Salmon, et al.9

We thank Ms Fore for her thoughtful review of the work and for stimulating how we might collectively move this work forward.

Sincerely,

-Mary Sitterding, MSN, RN, CNS

Indiana University Health

[email protected]

Marion Broome, PhD, RN, FAAN

Indiana University School of Nursing

Linda Everett, PhD, RN, NEA-BC, FAAN

Indiana University Health

Patricia Ebright, PhD, RN, CNS

Indiana University School of Nursing

REFERENCES