Reaching common ground: The role of shared mental models in patient safety

Can we ever really understand another person? People differ in their personal traits, patterns of thinking, perceptions, and word use. ¹ Their communication is influenced by their individual points of view, as influenced by life experiences, cultural and familial norms, and by their current physical, mental, and social state.^2,3 In addition, what people say is generally only a sketch of the full content they want to express. Everything we say is only an approximation of what we actually have in mind. ⁴

All this makes it clear that even in a single interaction between two people, we never achieve a complete understanding of what the other person means. The challenge for communication is to overcome those possible differences and reach a state of shared understanding or “common ground” ⁵ – a platform of shared knowledge, pre-suppositions, and beliefs that can be used to help achieve mutual goals.

It seems like this might be easier in health care, where workers have a lot in common. They share many things: the same foundation of medical science, the same treatments, environment and tools, the same knowledge base and guidelines, the same expectations about quality of care, and the same admonition to do no harm. There is already some established common ground.

Despite this, when communicating with each other, health care workers often fail to establish common ground. Preconceptions and perceptions still vary among those communicating – “where you stand depends on where you sit”. ⁶ Weller suggests that professional silos, hierarchies, and geographically distributed teams lead to differences in expectations and interpretations. All of these increase the chance for communication failures.

It is a common fallacy to assume that others “will know” or “understand” one’s intentions, feelings, thoughts, and meaning. ¹ Taking common ground for granted often leads to failures. Examples of this include when an on-call physician returns a page but misses the urgency implied by the nurse. Or when a clinician fails to understand the extent of a patient’s familiarity with drug names, and orders the medicine requested by the patient, which is in fact the wrong medicine.

“Shared mental model” is a concept related to common ground, which also relies on competent communication, and lies between two or more individuals. Rouse and Morris ⁷ defined mental model as “a mechanism whereby humans generate descriptions of a system purpose and form, explanations of system functioning and observed system states, and predictions of future symptom states.”

In health care, shared mental models can be defined as “individually held knowledge structures that help team members function collaboratively in their environments.” ⁸ It has been established in teamwork studies that shared mental models improve team ability to communicate and coordinate. ⁹ Shared mental models serve as an aid to cognition, reasoning, and decision-making, and are needed to enhance safe and effective care.

Incomplete information transfer can lead to misunderstanding and prevent the establishment of shared mental models. ¹⁰ System solutions have been suggested that include standardization of communication processes, technological support, and more two-way communication. ¹⁰ Fostering shared mental models is a core component of teamwork enhancing techniques and programs like SBAR and TeamSTEPPS.^11,12

In this issue of the Journal, Gisick and colleagues review different ways to measure shared mental models. ¹³ They point to a dearth of research on shared mental models in health care, which they attribute to difficulty in measuring them. Underlying this problem is the lack of a consensus definition. Their work provides useful tools for measuring shared mental models for different purposes. This could inform research on factors associated with successful application of shared mental models, their benefits, and interventions to improve their use.

Also in this issue, Nowotny and colleagues focus on the development of screening tools to predict complaints and medicolegal claims arising from maternity care. ¹⁴ Although their models did not have sufficient predictive power to be used routinely, the authors identified the ways to increase provider awareness of opportunities for improvement.

Hamblin-Brown and Ingram describe a program to improve the culture of patient safety in their hospital group, which has yielded early encouraging results. ¹⁵ Unsurprisingly, in serious incidents that they experienced in recent years, communication and teamwork stood out as themes for improvement.

Substantial and sustained improvements in patient safety will require more significant changes in safety culture. This will require a more general understanding of how communication works. ¹⁶ It will also require a deeper dive on communication training. Efforts to improve team functioning are likely to benefit from wider deployment of shared mental models. It is hoped that these measures will help us to expand the common basis for competent communication in health care.