A survey-based assessment of situation awareness in intensive care units: development of the ICU-SCOPE questionnaire

This study aims to develop and evaluate a multidimensional instrument, the ICU-SCOPE questionnaire, for assessing situation awareness in intensive care units (ICUs). The study sought to integrate clinical, organizational, and leadership perspectives to capture situation awareness as a system-level construct relevant to patient safety and quality of care.

A sequential exploratory mixed-methods design was employed between August and December 2025 in Bali, Indonesia. The qualitative phase involved in-depth interviews and focus group discussions with 42 ICU clinicians, hospital quality officers, and hospital administration and management experts from 12 hospitals. Thematic analysis was used to develop a conceptual model and generate questionnaire items. The quantitative phase involved a cross-sectional survey of 732 ICU healthcare professionals from 38 hospitals (19 government and 19 private hospitals), with psychometric evaluation conducted using exploratory factor analysis and descriptive domain-level analysis.

Qualitative analysis identified five interrelated themes shaping ICU situation awareness: situation perception of patient trajectory, communication and team coordination, operational environment and technology awareness, professional workload and cognitive preparedness, and executive leadership and safety climate. Exploratory factor analysis of the 25-item ICU-SCOPE questionnaire supported a five-factor structure consistent with the qualitative model, explaining 68.3% of the total variance. Domain-level analysis showed higher scores for communication and leadership domains, while workload and environmental domains demonstrated comparatively lower scores, indicating potential areas for improvement.

The study relied on self-reported data and was conducted within a single geographical region, which may limit generalizability. Further validation using confirmatory factor analysis and application in different healthcare systems is warranted to strengthen external validity.

The ICU-SCOPE questionnaire provides healthcare organizations with a structured tool to assess situation awareness across cognitive, team, environmental, workload, and leadership dimensions. The instrument can support targeted quality improvement initiatives, benchmarking, and monitoring of safety-related conditions in ICU settings.

By enabling systematic assessment of situation awareness, ICU-SCOPE has the potential to contribute to safer critical care environments, improved teamwork and enhanced patient safety outcomes. Improved situation awareness may also support staff well-being by identifying workload and organizational factors that contribute to cognitive strain.

This study is among the first to develop a situation awareness measurement instrument for ICUs using a mixed-methods approach that integrates frontline clinical experience with organizational and leadership perspectives. ICU-SCOPE advances existing safety culture assessments by explicitly operationalizing situation awareness as a multidimensional, system-level construct applicable to real-world intensive care practice.