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J Emerg Nurs. 2011 Sep;37(5):444-52. doi: 10.1016/j.jen.2010.07.023. Epub 2010 Sep 21.

Theory development for situational awareness in multi-casualty incidents.

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School of Nursing, Vanderbilt University,Nashville, TN, USA.



Nurses and other field-level providers will be increasingly called on to respond to both natural and manmade situations that involve multiple casualties. Situational Awareness (SA) is necessary for managing these complicated incidents. The purpose of the study was to create new knowledge by discovering the process of SA in multi-casualty incidents (MCI) and develop substantive theory with regard to field-level SA for use by emergency response nurses and other providers.


A qualitative, grounded theory approach was used to develop the first substantive theory of SA for MCI. The sample included 15 emergency response providers from the Southeastern United States. One pilot interview was conducted to trial and refine the semi-structured interview questions. Following Institutional Review Board approval, data collection and analysis occurred from September 2008 through January 2009. The grounded theory methods of Corbin and Strauss (2008) and Charmaz (2006) informed this study. Transcribed participant interviews constituted the bulk of the data with additional data provided by field notes and extensive memos. Multiple levels of coding, theoretical sampling, and theoretical sensitivity were used to develop and relate concepts resulting in emerging theory. Multiple methods were used for maintaining the rigor of the study.


The process of SA in MCI involves emergency responders establishing and maintaining control of dynamic, contextually-based situations. Against the backdrop of experience and other preparatory interval actions, responders handle various types of information and manage resources, roles, relationships and human emotion. The goal is to provide an environment of relative safety in which patient care is provided. SA in MCI is an on-going and iterative process with each piece of information informing new actions. Analysis culminated in the development of the Busby Theory of Situational Awareness in Multi-casualty Incidents.


SA in MCI is a growing need at local, national and international levels. The newly developed theory provides a useful model for appreciating SA in the context of MCI thereby improving practice and providing a tool for education. The theory also provides a catalyst for further research refining and testing of the theory and for studying larger-scale incidents.

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