Background: Rationale and Aims

Situational Awareness (SA) is a cognitive process that involves perceiving and comprehending critical elements of information during a certain task1. Put another way, it is simply “having an idea of what’s going on around you”. This is a crucial process for nursing and paramedic undergraduates to be exposed to during their formative education, as they will need to make potentially life-threatening decisions in complex, unpredictable and demanding situations. A common educational strategy to develop this process is through immersive simulation techniques with appropriate feedback2 (enacted through mannequins or actors), with recent evidence that practising in a safe simulated setting does have an impact on patient safety3-4. The theoretical underpinning for a simulation-based educational approach is the belief that the non-technical skills necessary for practice are best acquired through a situated learning experience, an approach supported by Experiential Learning Theory (ELT)5.

While OSCEs and simulation techniques are the main assessment approaches used to measure non-technical skills such as SA in nursing and paramedicine, a number of issues currently exist. Firstly, video recordings of OSCEs are time consuming and are unable to accurately isolate levels of SA. Secondly it is well established that effective feedback is integral to student learning, yet students frequently report dissatisfaction with the feedback they receive during simulation2. This project addresses these issues to enhance students’ learning and the capacity to recognise and develop SA using eye-tracking technology.

Eye tracking technology was originally developed for the marketing and aviation industries. The technology is used to identify individuals’ area of interest, gaze fixation/duration, and scan path (e.g. a focus on particular supermarket shelves or television advertisement) and enables analysis of where individuals are looking when a decision is made6. Based upon the ‘eye mind hypothesis’, the assumption is that gaze fixation is normally the focus of thought6. Eye tracking measurements therefore enrich our understanding of behaviour and will enable a deeper understanding of emergency performance and improve learning outcomes.

The key aims of this project were:

  1. To evaluate the effectiveness of eye tracking technology for improving feedback and SA for nursing/paramedic undergraduate students’.
  2. To develop preliminary guidelines and resources for best practice in the use of this new technology in undergraduate teaching and learning.
  3. To disseminate the outcomes to key partners in the sector.


Undergraduate nursing and paramedic students were invited to attend a two hour individual training program where they completed initial paper based questionnaires of demographic, knowledge and confidence ratings, prior to attending three scenarios with a simulated patient actor who was acutely deteriorating.  Eye tracking glasses were worn through each scenario video recording the scene and tracking eye movements. On completion of each scenario participants were questioned on their level of situation awareness and debriefing feedback provided using the eye tracking video records.  Post course knowledge, confidence and evaluations surveys were completed.


  • Thirty-nine final year students (20 nurses and 19 paramedics) participated in the project from three Australian Universities.
  • Participants’ clinical skills improved significantly between the start and the end of the program (p = <0.001).
  • Situation awareness also improved significantly (p = 0.02) as did participants’ post course ratings of their skills and competence (p <0.001).
  • Course evaluations and satisfaction levels showed strong approval, and most indicated that the ‘eye tracking’ component had improved learning and aided feedback.
  • Participants placed a high value on the video debriefing (and attention focus component) as it created an opportunity to reflect on aspects of their practice.
  • Participants reported a greater insight into their performance and the possible positive impacts on practice.


Outcomes were predominantly positive but should be balanced against the feasibility of the approach. The program was resource intensive and would require adaptation for those working with large cohorts in the undergraduate sector.  Therefore, in order to translate these findings into feasible practice for educators, we recommend:

  1. That eye tracking or point of view cameras are incorporated into clinical training (and potentially clinical practice).  Point of view cameras are significantly cheaper but do not provide eye tracking data which may be of particular value to the educator/student.
  2. Educational programs that make use of team based scenarios, thereby increasing student throughput and enhancing teamwork.
  3. Consideration for less resource intensive debriefing approaches, such as student self-review (providing DVDs of performance for students).