Abstract
Leaders of high-risk healthcare environments encounter a variety of factors that can adversely affect the culture of safety within their organizations. One essential element of safety involves situational awareness of patient conditions and the surrounding environment. In this Dissertation in Practice, a case study was conducted to evaluate how the human and organizational factors of fatigue, distraction, complacency, training, and teamwork affect the situational awareness of direct care staff in monitoring psychiatric patients. In a private psychiatric hospital, the researcher employed 14 closed and open ended questions in learning how these human and organizational factors affected situational awareness. Eight themes emerged from the analysis of the qualitative data including the importance of experiential learning, teamwork and trust, causes of complacency, use of body language in assessing risk, common distractions, safety as a motivator, the natural ability of awareness, and fatigue caused by mentally taxing activities and physical work. The aim of the study resulted in a training and monitoring program for healthcare staff and leaders. Implications of this study include an enhanced understanding of the safety risks related to situational awareness that any type of healthcare setting can utilize and the need for leaders to be situationally aware in order to provide prompt training and support in a transformative manner.|Keywords: situational awareness, complacency, fatigue, distraction, teamwork, training