In this module we will discuss the multidimensional and complex nature of clinical decision making. Health professionals are required to make decisions with multiple variables and individuals involved. Clinical decisions, and therefore health outcomes for patients, could be improved involving patients and teams of health professionals in the decision making process.
Quality decision making is an essential component of good clinical practice and quality health care. To improve decision making in health care settings, a broad perspective is required. Evidence-based practice must be integrated with factors such as the individual’s decision making attributes and the influence of external context on the decision making process.
The process of making a decision can be detailed in a series of steps. These steps are often committed to models of decision-making (Gil-Herrera, 2013; Wilson, 2013) and always starts with the need for as much information as possible in order to analyse this and culminate in a resolution. This resolution may be the generation of several possible alternatives.
This topic relates to the processes that are used to generate alternatives for the issue being addressed and the rationale selection of the most appropriate of these decisions for implementation.
At the completion of this module, you should be able to:
Overview the philosophical and theoretical foundations to judgement and decision making.
Understand how clinical judgement and decision making relate to clinicians and patients.
Explore the different perspectives and imperatives of clinical and patient decision making in the health context.
Strategic Decision Making In Healthcare And Its Relationship To Patients And The Clinical Setting
Decision making is present at all levels and all functional areas and departments in healthcare organisations, and making decisions is inherent to the medical practice. Current teaching, learning and training usually do not facilitate the acquisition of advanced clinical reasoning and judgement skills.
In order to understand strategic decision-making in healthcare there are a few definitions which are important in order to reach a shared understanding of the topic being discussed. The following are common terms that will be used throughout this topic and are important in developing a thorough and shared understanding of the materials (click on the hyperlinks below):
Judgment and decision-making
Decisions are at all levels of organisations and generally fall into three levels:
Clinical decision-making would most be categorised as operational decisions and the development of clinical decision making abilities may reduce the occurrence of clinical errors and adverse events, optimise strategic decision outcomes and improve health outcomes for patients and the population.
There are multiple factors influencing clinical decision making processes: patient situation; availability of resources; interpersonal relationships; time availability; multiple and diverse decision goals; conflicting decision elements; and the experience and expertise of the decision maker. Patients and their relatives are increasingly adopting an active position in the clinical decision making, being consulted and participating from the process.
Decision making is central to the overall functioning of organisations and as such, those assuming leadership and management roles of often confronted with high levels of uncertainty, the needs of multi-disciplinary teams and the individuals that comprise those teams, and changing landscapes of service planning, service delivery, workforce, financial management and consumer relations. Besides making immediate as well as short-term tactical decisions, there is a growing need for long-term, strategic decision making. The most successful managers have learned how to effectively use critical thinking and gain a deeper understanding of the role personal judgment and emotions play in the decision-making process which means that they are able to make decisions under uncertain conditions and in a variety of settings, build adaptability into the decisions that are made and importantly, provide the leadership to mitigate the effects of cognitive biases. This is achieved by them being able to understand the role of both emotions and ethics in decision making and implement strategies to improve individual and organizational decision making. These strategies are often aimed at understanding individual decision biases, knowing and ensuring that advice is sought and taken which involve multiple stakeholders with a goal of attaining strategic agility by building adaptability in the decisions that are made.
Thus, strategic decision-making is a mindset. That mindset will improve judgment and provide guidance to think rigorously and critically. To understand the decision process from start which begins with understanding the cognitive biases that may inhibit good decisions, to the end process that will lead to the execution of the decision(s), will develop leadership and management abilities to make individual, group, and organizational decisions. This will always be achieved by using a blend of research (evidence-based decision-making), behavioural, economics based input, and tested approaches to the decision-making process which will make an immediate impact on the quality of the decision and the implementation of sound leadership and management actions.
Theories of Decision-Making
Modern decision-making theory has really only developed since the middle of the 20th century. It is essentially an academic discipline and is often researched by economists, statisticians, psychologists, political scientists and philosophers. It has now become an area of study within the management sciences and is an important adjunct to a clinician’s skill set.
Until relatively recently, there has been the dichotomy that exists between normative and descriptive approaches however more recently a third approach of prescriptive decision-making has emerged forming a trichotomy.
The distinction between normative and descriptive theories is really quite simple. A normative decision theory is about how decisions should be made whereas a descriptive approach is more about how the decision is actually made. Now, it should be recognised that this is a very limited sense of the word “normative” as it is applied to decision-making and as such there is often a blurring in the understanding of the distinction between normative and descriptive interpretation of decision theories.
For further reading on descriptive and prescriptive decision-making read the article by Dillon and also the article by Divekar. et al, see the link under required readings below.
The classical model of decision making is a prescriptive approach that outlines how managers should make decision. Also called the rational model, the classical model is based on economic assumptions and asserts that managers are logical, rational individuals who make decision that are in the best interest of the organization. For more information on classical decision-making models, read the article by Li (2008) in the required readings below. Whilst this article argues against this model, it has a very good summary of its main features.
Naturalistic approaches to decision-making is an example of a normative approach to decision-making and first appeared in 1989 and it takes the position that it differs from tradition decision making because it focuses on understanding the situation and the changing situation through ongoing and constant feedback rather than developing multiple options which then must be compared. In order to fully explore and understand naturalistic decision-making (NDM) this excellent resource by Bryant will provide good background and insight.
So, NDM can be described as a process by which experts make decisions in the real world. It is a descriptive method that is used when there is a high degree of stress and time-pressure in which there are dynamic conditions, ambiguous information, and ill-defined goals. It is an heuristic method of decision making and as such is a mental shortcut that allows people to solve problems and make judgments quickly and efficiently. These rule-of-thumb strategies shorten decision-making time and allow people to function without constantly stopping to think about their next course of action.
While heuristics are helpful in many situations, they can also lead to biases. Heuristics play important roles in both problem-solving and decision-making. When we are trying to solve a problem or make a decision, we often turn to these mental shortcuts when we need a quick solution. There are criticisms of heuristics in that it is argued that they may introduce bias however they can be very powerful.
It is important to remember however, that while heuristics can speed up the problem and decision-making process, they can introduce errors. Just because something has worked in the past does not mean that it will work again, and relying on an existing heuristic can make it difficult to see alternative solutions or come up with new ideas.
The following table compares and contrasts both the Classical and Naturalistic models:
· Single agency or individual
· Predictability & Probabilistic
· Controlled setting
· Defined state
· All risk is quantified and accounted for
· Control for all confounding variables.
· Stable environment
· Time independent
· Without regard to context, experience and ecology
· Quantitative meaning is fixed to every variable and evidence
· Practical problems
· Field based
· Shifting, Ill-defined
· Multiple event feed-back loops
· Time Constraints
· High stakes
· Multiple players
· Organisational goals must be balanced against decision-makers personal choice
Since the early 1980’s there have been challenges relating to the dichotomy of normative and descriptive decision-making theories (Bell et.al., 1988). This began quite a groundswell of divided opinion and opposition to the idea that there is a dichotomy in the theories of decision making thus forcing decision-making into two diametrically opposed theories. Rather, it was being proposed that there was a need for theories to improving the quality of decisions and that the purpose for having such theories was to help people make better decisions. Thus, the scene was set for researchers to devise methods that incorporate the insights that were gleaned from normative approaches (this means the approach which aims at finding out not only how things are but above all, how they should be) and also recognise the cognitive limitation of individuals involved in the decision that is to be made and be able to explain rational models in a manner that would appeal to a large number of people. Bell et.al. (op.cit.) established a third philosophical stance known as prescriptive theory of decision-making creating a trichotomy. It is this approach that is commonly found in managerial decision-making.
Prescriptive theories set out to ‘improve’ the judgments and decisions of individuals by investigating how people make decisions (Bell, et.al.(op.cit.); Thompon&Dowding (2002)). The focus of prescriptive theories is to ‘help’ or ‘improve’ individual’s judgments. In evaluating the application of prescriptive models and theories that attempt to aid in the decision-making process, the central question asked is pragmatic, did it make the judgment any better?
The following diagram reproduced from the powerpoints slides that accompany these notes is instructive to summarise the differences between the approaches
Divekar A, Bangal, S, and Sumangala (2012) The study of prescriptive and descriptive models of decision making (IJARAI) International Journal of Advanced Research in Artificial Intelligence, Vol. 1, No. 1, 2012: 71-74
Li, B (2008) The Classical Model of Decision Making Has Been Accepted as not providing an Accurate Account of How People Typically Make Decisions International Journal of Business and Management, June, 151-154
Stuart M. Dillon Descriptive Decision Making: Comparing Theory with Practice Department of Management Systems University of Waikato New Zealand (Reproduced with kind permission from the author)
David J. Bryant Making Naturalistic Decision Making “Fast and Frugal” Defence Research Development Canada – Toronto (Reproduced with kind permission from the author)
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