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The seasoned executive's decision-making style.

Leaders make decisions every day of their lives, but how they do it changes dramatically over the course of their careers. At lower levels, the job is to get widgets out the door; action is at a premium. At higher levels, the job involves decisions about which widgets to offer and how to develop them. To climb the corporate ladder and be effective in new roles, managers need to change the way they use information and evaluate options. Based on a study of the decision-making profiles of more than 120,000 executives, the authors found that people make decisions very differently in public than they do in private and that the decision styles of successful managers evolve in highly predictable patterns. The most successful managers and executives become increasingly open and interactive in their leadership (or public) styles, and more analytic in their thinking (or private) styles, as they progress in their careers. The research shows that decision-making profiles do a complete flip over the course of a career; that is, the decision profile of a successful CEO is the opposite of a successful first-line supervisor's. When does the major change in focus occur? Somewhere between the manager level and the director level, executives find that formerly effective decision styles no longer work so well. At this point, decision styles fall into a "convergence zone", where managers use all styles more or less equally. From then on, the executives continue to evolve their styles. The most successful managers come to the convergence zone quickly and continue to adjust their styles as their careers progress. Low performers seem to stagnate once they hit the convergence zone; their styles do not evolve in new directions. Clearly, relying on past successes and habits is no guarantee of success-indeed, it may be the road to failure.

Administrative Personnel↗

A decision class analysis of critical care life-support decision-making.

Decision analysis is a powerful methodology that can help clinicians make good decisions. Because it is not practical to place a decision analyst at the bedside in critical care units, the application of this methodology will require leveraging the analyst through computer-based systems. A decision class analysis is a collective analysis of a group of decisions that provides the high-level specification for such a computer system. This paper presents a decision class analysis of critical care life-support decisions. Key elements of this analysis are: the simplification of an otherwise extremely complex multistage sequential decision problem by using a sequence of two-stage models, and the use of six generic knowledge maps that capture the extremely complex relevant medical knowledge.

Artificial Intelligence↗

Teens speak out about HIV/AIDS: focus group discussions about risk and decision-making.

PURPOSE: To better understand the factors teens consider when making decisions regarding sex and condom use. METHODS: Twenty-one same-sex focus groups were conducted with a total of 92 male and female teens from a range of high school programs; schools were selected based on the range of programs and diversity of students enrolled. Focus group moderators facilitated groups using a set of open-ended key questions about sexual decision-making and HIV/AIDS for each group; discussion on a specific topic area continued until no new information was generated. Group discussions were tape-recorded and transcribed, and themes were identified through independent content analysis of the transcriptions and assistant moderator notes. RESULTS: Although teens acquire HIV/AIDS knowledge in school and are aware of positive and negative outcomes of engaging in sexual behavior, many times the information does not seem salient or personally relevant and thus is not used in making decisions related to having sex. In general, results indicate that boys and girls seem to have different ideas/reasons for having or not having sex. Boys relate to the physical nature of sex, whereas girls relate to the emotional aspects. Teens report being bored with AIDS education, but suggest needing information that is more relevant for them. CONCLUSIONS: Attempts should be made to make HIV education more relevant for teens so that they use the information they have when making decisions about safer sexual behavior. Different approaches may be needed for boys and girls.

Acquired Immunodeficiency Syndrome↗

Decision-making skills and critical thinking ability among associate degree, diploma, baccalaureate, and master's-prepared nurses.

A key component of nursing practice is the nurse's ability to process information and to make decisions. One goal of most educational programs for nurses is to enhance students' cognitive abilities and clinical decision-making skills. This study investigated the differences in critical thinking ability and decision-making skills among 121 associate degree, diploma, baccalaureate, and master's-prepared nurses. Results indicated that nurses with master's and baccalaureate degrees had the highest scores in critical thinking ability. Subjects' decision-making skills were measured related to: 1) frequency in making decisions, 2) difficulty in making decisions, and 3) factors which influence decision making. No significant differences were found among the four groups related to the three dimensions of decision-making skills. Experience and knowledge were the most influential factors in decision making. Study findings have implications for investigating differences among nursing students related to cognitive abilities.

Clinical Competence↗

Shared decision making and decision aids - a literature review.

Shared decision making (SDM) is a process within a patient centred consultation that involves both the patient and doctor discussing management options and agreeing on management decisions in partnership. Decision aids are designed to help patients understand the options relating to management for certain conditions and their possible benefits and potential adverse effects. We discuss the evolution and rationale behind SDM and the evidence relating to outcomes, the types of decision aids available, and research relating to their use.

Decision Making↗

Referral for coronary angiography after exercise testing: traditional decision-making versus decision analysis.

To audit the referral decisions made by a single cardiologist for coronary angiography after exercise testing, we retrospectively reviewed the charts of 303 consecutive patients in a community hospital. The outcomes of these decisions, in terms of angiograms performed and quality-adjusted life expectancy gains as predicted by a decision analysis model, were compared with the theoretical decisions that would have been made using the model. The 97 patients sent for angiography exercised for a shorter time (5.6 +/- 3.1 vs. 6.9 +/- 3.2 min, p < 0.001) had more ST deviation (2.7 +/- 1.4 vs. 1.7 +/- 1.0 mm, p < 0.001), more angina (53.6 vs. 36.9% of patients, p < 0.01) and were more likely to have had a previous myocardial infarction (59.8 vs. 33.5% of patients, p < 0.001) than the 206 not referred. However, of those not referred, 137 were each predicted to gain up to 5.7 quality-adjusted life years (QALYs) from bypass surgery. The overall predicted gain from the cardiologist's decisions was only 0.1 +/- 2.5 QALYs/patient. Had the decisions been made using the model, the mean gain would have been 1.9 +/- 1.3 QALYs/patient, and an extra 128 patients would have been sent for angiography. Decision analysis makes consistent decisions with defined risks and benefits. Such decisions can be reproduced, reviewed and analysed, whereas traditional decision-making may inconsistently reflect the clinician's beliefs and values.

Aged↗

Shared decision making and determining decision-making capacity.

Shared decision making respects patient autonomy and allows patients to select how much they wish to become involved in various health care decisions. Advance care planning allows a person to document preferences that can become operative at a later time when the person has lost decision-making capacity. Structured methods exist for assessing the presence or absence of decision-making capacity, but some subjectivity cannot be eliminated from these assessments. An ethical challenge in the care of older patients who have diminished capacity is to show respect for their previously expressed wishes and for their present, experienced quality of life.

Activities of Daily Living↗

The role of doctor's opinion in shared decision making: what does shared decision making really mean when considering invasive medical procedures?

OBJECTIVE: The goal of this study was to gain understanding about patients' perspectives on decision making in the context of invasive medical interventions and whether patients' decision-making preferences influenced the type of information they desired to be provided by physicians. DESIGN: Questionnaire study of consecutive patients in a university-based general medicine clinic. INTERVENTIONS: Patients were presented with a randomized list of three types of information that physicians could provide (risk, benefit and physician's opinion on whether they should undergo the procedure). Patients were asked whether they preferred patient-based, physician-based, or shared decision making and then were asked to select which one or combination of these three information types was most important to them in their own decision making. Patients were also asked to self-report on how many invasive procedures they had undergone in their own lives. PARTICIPANTS: A total of 202 consecutive patients (mean age = 65.1 years, SD = 12.3, range 28-88; mean education 13.3 years, SD 2.9, range 2-23). MAIN OUTCOME MEASURES: Patient reports. RESULTS: Of the 202 patients, two patients reported no decision-making preference. These two patients were excluded from the analysis. Of the 200 remaining patients, 62.5% (125/200) preferred shared, 22.5%(45/200) preferred physician-based, and 15.5% (31/200) preferred patient-based decision making. More than half of all subjects chose physician opinion as the most important type of information for decision making. Older patients (odds ratio 1.028; confidence interval 1.003-1.053) were more likely to have ranked the doctor's opinion as the most important in their decision making for invasive medical interventions. CONCLUSIONS: Although most patients want to share decision making with their physicians regarding invasive procedures, the majority of these patients report relying on the doctor's opinion on whether to undergo the procedure as the most important information in their own decision making.

Academic Medical Centers↗

The Pre-Adult Health Decision-Making Model: linking decision-making directedness/orientation to adolescent health-related attitudes and behaviors.

In light of the broad consequences of the acquired immunodeficiency syndrome (AIDS) epidemic, as well as the increased rates of sexually transmitted diseases (STDs), pregnancy, and alcohol and drug abuse among adolescents, there is a great need to understand how adolescents make health decisions. This paper presents a model for adolescent health behavior, the Pre-Adult Health Decision-Making Model (PAHDM), which takes into account the differential information processing from peer sources, parent sources, or through critical or reflexive self-analysis. Also presented is a review of the large corpora of psychological and sociological literature on adolescent development, adolescent health behaviors, and, more specifically, AIDS and other STDs as a public health problem. The need for additional research in the area of adolescent health decision-making, and for a health behavior model that is specific to the "lifeworld" of the adolescent, is stressed.

Acquired Immunodeficiency Syndrome↗

Environmental elements affecting the decision-making process in nursing practice.

BACKGROUND: In their practice nurses constantly make decisions in a dynamic context including complex situations. Besides affecting elements related to the decision-maker and the task itself, the setting where the decision-making process takes place are of decisive importance to the quality of the decision-making outcome. AIM: The aim of this study was to explore environmental elements related to the decision-making process in nursing practice. METHODS: Six expert nurses, from three Swedish nursing settings, participated voluntarily in the study, which were designed of participated observations in everyday nursing practice. Permission to carry out the study was given by the clinics and an ethical committee. A content analysis was used to analyse the field notes where themes emerged which were found to be environmental elements affecting decision-making process of nurses. CONCLUSIONS: The most striking theme, environmental elements, included the sub-themes interruptions and the work procedures are presented in this report. The implications of environmental elements, are discussed from a perspective of nurses' competence, where the elements could be seen as a facilitator or as a hindrance to developing nursing competence. It were concluded that environmental elements have to be well considered before knowledge can be reached about decision-making in practice. RELEVANCE TO CLINICAL PRACTICE: Interpersonal and technological interruptions were features highlighted in the study, features which could jeopardize the decision-making outcome. Therefore, it is of greatest importance that nurses learn to use decision-making strategies to guarantee patient care security and patient care quality.

Decision Making↗

Decision making and decision support for hereditary breast-ovarian cancer susceptibility.

Genetic testing for disease susceptibility has the potential to revolutionize health care by allowing for individually tailored disease prevention strategies. To achieve this promise, patients and physicians must use the information obtained through genetic testing to make medical decisions that are consistent with patient preferences and that lead to reduced disease morbidity and mortality. However, decisions associated with genetic testing can be complex. In this article, the authors review decision making associated with genetic testing and the medical management of hereditary breast-ovarian cancer susceptibility. They focus on decisions regarding BRCA1/2 testing and prophylactic surgery among BRCA1 and BRCA2 mutation carriers. They highlight the role of patient preferences and decision support in this population. The studies reviewed indicate that although patients' preferences do predict genetic testing and management decisions, other factors also influence their decision making. In particular, the authors discuss the role of anxiety and worry in relation to testing and surgery decisions.

Breast Neoplasms↗

Decision-making in nephrology: shared decision making?

Shared decision-making is considered an important ideal for physician-patient interaction. The ideal states that health-related values should be discussed together. It raises two questions: (a) for which decisions is the ideal of shared decision-making relevant? (b) Which aspects of treatment should be discussed? The nephrological practice under consideration in this article answers question (a) as follows: decisions about the type of dialysis are shared decisions, while decisions about the moment to start dialysis are medical decisions that should be taken by nephrologists. This situation can be criticized as important health-related values play a role in decisions about starting dialysis. Question (b) is answered in the nephrological practice under consideration by discussing at least all important health-related aspects that raise uncertainty about its worth for a patient. This approach to question (b) is morally and practically defensible.

Adult↗

The physician's role in women's decision making about hormone replacement therapy.

OBJECTIVE: To ascertain the sources of information women use when making decisions about hormone replacement therapy (HRT). METHODS: A cross-sectional, population-based computer-assisted telephone survey of 1082 randomly selected women aged 50-80 years (80.3% response rate) was conducted at Group Health Cooperative of Puget Sound, a large staff-model health maintenance organization in Washington state. RESULTS: Overall, 460 participants (42.5%) were current HRT users, 226 (20.9%) were past users, and 396 (36.6%) were never users. Discussions with physicians dominated as the major source of information used in decision making by current (83.4%) and past (65.5%) users, but were less often cited by never users (44.4%); printed material was used by 44.5% of women. Although 72.1% of current users reported that the amount of information received from their physician about the benefits of HRT was about right, only 48.2% of past users and 33.6% of never users shared this view (P < .001 current versus never), and 13.3% of current users, 32.6% of past users and 58% of never users reported receiving no information from their physician about HRT's benefits. CONCLUSION: Hormone replacement therapy use is strongly related to interactions between women and their physicians. Many women use written materials to make decisions about HRT. A large proportion of women feel inadequately informed about HRT's risks and benefits. Much work remains to be accomplished toward meeting the goal of the US Preventive Services Task Force that all perimenopausal and postmenopausal women be counseled about the potential benefits and risks of HRT.

Aged↗

Capacity for decision-making in Alzheimer's disease: selfhood, positioning and semiotic people.

The aim of this article is to explore some of the ethical issues surrounding the assessment and determination of capacity of people with dementia in light of their meaning-making ability as shown through discourse. Discourse analysis, two illustrative cases, social construction theory and positioning are used to highlight some of the ethical dilemmas involved in basing a determination of capacity on the diagnosis of dementia and neuropsychological tests of cognitive function. Although neuropsychological tests have their place in assessing some aspects of cognitive function, aspects cognition such as meaning-making ability and selfhood cannot be assessed in a standard format. In dementia, there can be a differential impairment of recall memory while the personality, values and substantial long-term memory remain intact, as does implicit memory for recent events. People with dementia are vulnerable to being negatively positioned, thereby unfairly undermining their rights to make decisions about aspects of their lives. Assessing the capacity of a person with dementia to engage in decision-making is presently in need of examination so as to take into account the person's meaning-making ability and selfhood. Incorrect negative positioning, based on the diagnosis and defects in recall memory, can obscure intact cognitive abilities that allow a person to make decisions about aspects of living, creating the possibility of lasting harm being inflicted on the person with dementia.

Alzheimer Disease↗

Risk taking and decision making of adolescent long-term survivors of cancer.

Late effects of multi-modal treatments for long-term survivors of childhood cancer may affect their ability to make decisions related to risk behaviors. Adolescent survivors may be at greater risk than those in the general population because of late effects of organ compromise and oncogenesis. The purposes of this study were to (1) describe the prevalence of risk behaviors among adolescent long-term survivors of cancer; (2) describe these survivors' perceptions of the quality of their decision making; (3) test the hypothesis that the poorer the decision-making quality, the more risk behaviors exhibited by an adolescent long-term survivor; and (4) examine the effects of central nervous system (CNS) prophylactic leukemia therapy and academic achievement problems on quality of decision making and risk behaviors. In this descriptive study, a semi-structured interview was used at the time of the yearly clinic visit. The sample consisted of 36 long-term survivors who were disease-free for five years, had no medical treatment for two years, and were 14-19 years of age. The major conclusions drawn regarding adolescent long-term survivors were that (1) although there was a trend toward higher experimental use of some risk behaviors, essentially, the prevalence rates were comparable to those of the general population; (2) some were good decision makers; however, quality decision-making skills were poorly practiced by the majority; (3) with better decision-making quality, fewer risk behaviors were exhibited; and (4) prior CNS prophylactic leukemia therapy and academic achievement problems may be associated with poor quality decision making.

Adolescent↗

Decision making in CPR: attitudes of hospital patients and healthcare professionals.

OBJECTIVE: To examine the opinions of patients and healthcare professionals regarding the process of making decisions about cardiopulmonary resuscitation (CPR). DESIGN AND PARTICIPANTS: A cross-sectional survey of 511 healthcare professionals (doctors, nurses and allied health professionals) (64% response rate) and 152 patients (58% response rate) at the John Hunter Hospital, Newcastle, New South Wales, in June 1994. MAIN OUTCOME MEASURES: Opinions on who should be involved in CPR decision making; what issues are important when making the decision; and how these decisions should be communicated. RESULTS: 80% (95% confidence interval [CI], 72%-86%) of patients and 99% (95% CI, 98%-100%) of healthcare professionals (P<0.001) thought patients' views should be taken into account when making CPR decisions. More patients (29%; 95% CI, 22%-38%) than healthcare professionals (14%; 95% CI, 11%-17%) indicated that doctors should be the main decision makers. Two-thirds of respondents regarded the patient's wishes, diagnosis and quality of life as important factors. Most respondents (82%) felt comfortable discussing CPR, but only 29% (95% CI, 22%-37%) of patients and 57% (95% CI, 52%-61%) of healthcare professionals had actually discussed CPR with others (P<0.001). More than half of all respondents preferred to express their wishes about CPR in writing (47% [95% CI, 39%-55%] of patients, 69% [95% CI, 64%-73%] of healthcare professionals; P<0.01); the others preferred to tell a family member or close friend. Most patients (60%; 95% CI, 52%-68%) and healthcare professionals (85%; 95% CI, 81%-88%) wanted their views in their medical records (P< 0.001). CONCLUSION: Most patients want to be involved in CPR decision making and many want some form of advance directive. Although there are some differences in opinions between patients and healthcare professionals, both perceive decision making at the end of life as a shared process, primarily involving the patient and doctor.

Adult↗

A role for neural integrators in perceptual decision making.

Decisions based on uncertain information may benefit from an accumulation of information over time. We asked whether such an accumulation process may underlie decisions about the direction of motion in a random dot kinetogram. To address this question we developed a computational model of the decision process using ensembles of neurons whose spiking activity mimics neurons recorded in the extrastriate visual cortex (area MT or V5) and a sensorimotor association area of the parietal lobe (area LIP). The model instantiates the hypothesis that neurons in sensorimotor association areas compute the time integral of sensory signals from the visual cortex, construed as evidence for or against a proposition, and that the decision is made when the integrated evidence reaches a threshold. The model explains a variety of behavioral and physiological measurements obtained from monkeys.

Action Potentials↗