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At least 613 records · Page 34Linked to original sources
PubMed2000

Classifying clinical decision making: interpreting nursing intuition, heuristics and medical diagnosis.

This is the second of two linked papers exploring decision making in nursing. The first paper, 'Classifying clinical decision making: a unifying approach' investigated difficulties with applying a range of decision-making theories to nursing practice. This is due to the diversity of terminology and theoretical concepts used, which militate against nurses being able to compare the outcomes of decisions analysed within different frameworks. It is therefore problematic for nurses to assess how good their decisions are, and where improvements can be made. However, despite the range of nomenclature, it was argued that there are underlying similarities between all theories of decision processes and that these should be exposed through integration within a single explanatory framework. A proposed solution was to use a general model of psychological classification to clarify and compare terms, concepts and processes identified across the different theories. The unifying framework of classification was described and this paper operationalizes it to demonstrate how different approaches to clinical decision making can be re-interpreted as classification behaviour. Particular attention is focused on classification in nursing, and on re-evaluating heuristic reasoning, which has been particularly prone to theoretical and terminological confusion. Demonstrating similarities in how different disciplines make decisions should promote improved multidisciplinary collaboration and a weakening of clinical elitism, thereby enhancing organizational effectiveness in health care and nurses' professional status. This is particularly important as nurses' roles continue to expand to embrace elements of managerial, medical and therapeutic work. Analysing nurses' decisions as classification behaviour will also enhance clinical effectiveness, and assist in making nurses' expertise more visible. In addition, the classification framework explodes the myth that intuition, traditionally associated with nurses' decision making, is less rational and scientific than other approaches.

Cooperative Behavior↗
PubMed2005

An exploration of the decision-making processes at the point of referral to an Admiral Nurse team.

The Admiral Nursing Service supports individuals caring for people with dementia. As a response to the high demand for one team's service, a temporary closure to referrals was agreed. This provided the impetus to explore the influence of nurses' decision making at the point of referral on demand for the service. The research questions addressed were: How do Admiral Nurses make decisions regarding referrals and What factors influence this decision-making process? Sixteen case studies were retrospectively reviewed through the auspices of a semi-structured interview aimed at identifying which factors influenced the nurses' acceptance or rejection of these referrals. Results indicated that the Admiral Nurses had a clearly identified focus in supporting the carers of people with dementia, but that the complexity of the carers situation which included the person with dementia was significant. However, the desire to fulfil a case-management role while attempting to provide a service that is of a specialist nature and of limited capacity generated tensions. The decision to offer a service to carers was consequently influenced not only by perceived need but also upon the nurses feeling professionally responsible for perceived gaps in service provision.

Aged↗
PubMed2006

Cultural influences on the physician-patient encounter: The case of shared treatment decision-making.

OBJECTIVE: In this paper we discuss the influence of culture on the process of treatment decision-making, and in particular, shared treatment decision-making in the physician-patient encounter. We explore two key issues: (1) the meaning of culture and the ways that it can affect treatment decision-making; (2) cultural issues and assumptions underlying the development and use of treatment decision aids. METHODS: This is a conceptual paper. Based on our knowledge and reading of the key literature in the treatment decision-making field, we looked for written examples where cultural influences were taken into account when discussing the physician-patient encounter and when designing instruments (decision aids) to help patients participate in making decisions. RESULTS: Our assessment of the situation is that to date, and with some recent exceptions, research in the above areas has not been culturally sensitive. CONCLUSION: We suggest that more research attention should be focused on exploring potential cultural variations in the meaning of and preferences for shared decision-making as well as on the applicability across cultural groups of decision aids developed to facilitate patient participation in treatment decision-making with physicians. PRACTICE IMPLICATIONS: Both patients and physicians need to be aware of the cultural assumptions underlying the development and use of decision aids and assess their cultural sensitivity to the needs and preferences of patients in diverse cultural groups.

Culture↗
PubMed2002

Reviewing intuitive decision-making and uncertainty: the implications for medical education.

CONTEXT: Intuition and uncertainty are inescapable conditions of many instances of clinical decision- making. Under such conditions biases and heuristics may operate, distorting the decision-making process. Physicians and students are generally unaware of these influences. PURPOSE: To review the extant literature regarding the role of uncertainty and intuition and associated biases on medical decision-making, to highlight the implications this holds for medical education. CONTENT: Using literature identified via Medline and Bioethicsline searches of the past 3 decades, this paper reviews the sources of uncertainty in clinical practice and the role of intuitive decision-making. A detailed description of associated heuristics and biases is provided, and linked with demonstrable examples from medical decision-making. CONCLUSIONS: It is argued that although uncertainty can be reduced, it can never be completely eliminated from decision-making. Therefore most decision-making performed in medicine contains an irreducible intuitive element and is thus vulnerable to these biases and heuristics. Given that few medical curricula overtly address the process of medical decision-making, both medical students and physicians remain vulnerable to these effects on their own (and their patients') decision-making. Insight via education appears the major means in which to avoid distorting decision-making processes.

Clinical Competence↗
PubMed1989

Critical care nurses' participation in ethical decision making.

Critical care staff nurses' participation in ethical decision making was studied in relation to the perceptions of environmental social support of 45 female staff nurses. Data obtained measured perceived environmental social support from six organizational subgroups and individual participation in ethical decision making. Validity and reliability testing was done on the instrument. When involved in an ethical situation, critical care nurses perceived low levels of environmental social support from hospital administrators, nursing administrators, and physicians. Co-workers were consistently perceived as most supportive across all aspects of social support. The majority of the nurses surveyed (74%) reported that ethical decisions were made by physicians or with reference to hospital policy, and that there were limited roles for individual, family, or nurse participation in such decision making. It was concluded that critical care nurses perceive a lack of free agency necessary to engage in ethical decision making in hospital environments or to act in an advocacy role in such situations.

Adult↗
PubMed2006

Neuropsychological correlates of decision-making in ambiguous and risky situations.

Decision-making situations in real life differ regarding their explicitness of positive and negative consequences as well as regarding the directness of probabilities for reward and punishment. In neuropsychological research, decisions under ambiguity and decisions under risk are differentiated. To assess decisions under ambiguity the Iowa Gambling Task (IGT) is one of the most frequently used tasks. Decisions under risk can be measured by a task that offers explicit rules for gains and losses and stable winning probabilities, as the Game of Dice Task (GDT) does. In this contribution we firstly summarize studies that investigated decision-making in various groups of patients using the IGT or the GDT. We also propose a new model of decision-making in risky situations and describe differences between decisions under ambiguity and decisions under risk from a theoretical and clinical perspective.

Animals↗
PubMed2005

Integrating benefits decision making.

Integrated employee benefit decision making helps employees use their benefits more wisely and identify opportunities to balance their immediate benefits needs (such as health care) and future benefits needs (such as retirement). This article discusses how employers can overcome employees' behavioral barriers to making integrated employee benefit decisions by changing the ways benefits are communicated and employees are presented with action decisions. Undertaking these steps allows employers to not only improve their employees' overall financial perspectives, but also furthers plan sponsors' goals of actively promoting personal responsibility with respect to retirement funding and changing employee behavior with respect to controlling health care costs.

Choice Behavior↗
PubMed2001

[Information disclosure when screening for trisomy 21: a decision-making aid for pregnant women?].

We examined the contribution to decision-making of the information that is disclosed to women confronted with the proposition of screening for Down syndrome and when receiving the results. This review highlights the main results of a survey initiated by the French Ministry of Health. The purpose of this survey was to assess the modalities of prescription and results communication of the test, and also to determine the women's opinion concerning the information they had received. A large percentage of the women were dissatisfied with the information received before the test prescription, a percentage that was even more marked when the test results were delivered. Information was frequently regarded as not contributing to the decision-making process about testing and the data analysis suggested that information may not be adequate to prepare women for the decisions implied in the test results. However, a direct relationship cannot be established between satisfaction with information and contribution of the information to decision making: information may be considered as contributing to the decision although women did not understand the explanations; the contribution to decision-making does not have the same meaning when the test is proposed as a routine test (i.e. a self-evident act) or not. Finally, from the women's point of view, to make the "best possible" decision would require that health professionals' preferences regarding the information to be disclosed converge with the women's expectations regarding information, and with their preferences concerning the implication of health professionals in the decision-making process. In an operational perspective, the use of information and decision-making aid instruments could facilitate the elicitation of preferences and expectations.

Attitude to Health↗
PubMed2004

Risk taking during decision-making in normal volunteers changes with age.

Risk taking in a large cohort of adults (N = 177; ages 17-73) decreased with age, demonstrated by performance on a computer based gambling task, which has previously been shown to be sensitive to certain pharmacological manipulations including tryptophan depletion, lesions of the orbitofrontal cortex and neuropsychiatric disorders such as mania. Aging was also associated with longer deliberation times, poorer decision making, reduced risk taking, but no significant change in delay aversion. Subjects with a higher (NART-estimated) IQ were faster to make decisions and showed a greater modulation of risk-taking. Both sexes showed similar patterns of decision making, although male participants exhibited a greater modulation of risk-taking in response to the probability of winning. The Decision-Gamble task provides a variety of behavioral measures, corresponding to different aspects of impulsivity. Factor analysis of these measures suggested that two independent traits underlies performance on the task in normal individuals: one associated with risk tolerance, and a second associated with delay aversion. Age was related to decreases in the risk tolerance factor, but unrelated to the delay aversion; neither factor was significantly related to verbal IQ. This study thus provides support for the concept that impulsivity can be fractionated into 2 or more components.

Adolescent↗
PubMed2005

The San Francisco Syncope Rule vs physician judgment and decision making.

OBJECTIVE: To compare a clinical decision rule (San Francisco Syncope Rule [SFSR]) and physician decision making when predicting serious outcomes in patients with syncope. METHODS: In a prospective cohort study, physicians evaluated patients presenting with syncope and predicted the chance (0%-100%) of the patient developing a predefined serious outcome. They were then observed to determine their decision to admit the patient. All patients were followed up to determine whether they had a serious outcome within 7 days of their emergency department visit. Analyses included sensitivity and specificity to predict serious outcomes for low-risk patients and comparison of areas under the receiver operating characteristic curve for the decision rule, physician judgment, and admission decisions. RESULTS: During the study period, there were 684 visits for syncope with 79 visits resulting in serious outcomes. The area under the receiver operating characteristic curve was 0.92 (95% confidence interval [CI], 0.88-0.95) for the SFSR compared with physician judgment 0.89 (95% CI, 0.85-0.93) and physician decision making 0.83 (95% CI, 0.81-0.87). Physicians admitted 28% of patients in a low-risk group, with a median length of stay of 1 day (interquartile range, 1-2.5 days). The SFSR had the potential to absolutely decrease admissions by 10% in this low-risk group and still predict all serious outcomes. CONCLUSIONS: Physician judgment is good when predicting which patients with syncope will develop serious outcomes, but contrary to their judgment, physicians still admit a large number of low-risk patients. The SFSR performs better than current physician performance and has great potential to aid physician decision making.

Clinical Competence↗
PubMed2003

Increased activation in the right insula during risk-taking decision making is related to harm avoidance and neuroticism.

Decision making and risk taking are interrelated processes that are important for daily functioning. The somatic marker hypothesis has provided a conceptual basis for processes involved in risk-taking decision making and has been used to link discrete neural substrates to risk-related behaviors. This investigation examined the hypothesis that the degree of risk-taking is related to the degree of activation in the insular cortex. Seventeen healthy, right-handed subjects performed a risk-taking decision-making task during functional magnetic resonance imaging (fMRI) using a fast event-related design. This investigation yielded three main findings. First, right insula (BA 13) activation was significantly stronger when subjects selected a "risky" response versus selecting a "safe" response. Second, the degree of insula activation was related to the probability of selecting a "safe" response following a punished response. Third, the degree of insula activation was related to the subjects' degree of harm avoidance and neuroticism as measured by the TCI and NEO personality questionnaires, respectively. These results are consistent with the hypothesis that insula activation serves as a critical neural substrate to instantiate aversive somatic markers that guide risk-taking decision-making behavior.

Adult↗
PubMed2006

Impaired decision-making in Parkinson's disease.

The present study demonstrated that individuals with Parkinson's disease display impairments in making profitable decisions, as evidenced by poorer performance on the Iowa Gambling Task relative to matched controls. The ability to make beneficial judgments solely correlates with ability to appropriately attribute internal mental-state to other people, as shown in a mind-reading task. However, decision-making ability for individuals with Parkinson's disease is not associated with effective execution, intellectual function or depressed mood. These findings offer a new perspective on the cognitive impairments that affect social living and adaptive decisions for individuals with Parkinson's disease.

Affect↗
PubMedDate not supplied

Gender reassignment in children: ethical conflicts in surrogate decision making.

Parents, as surrogate decision makers for their infants, are generally expected by health care providers to act in the child's "best interest." However, when the wishes of the parents are contrary to those of the medical profession, an ethical dilemma occurs. Whose decisions are best for the infant? Whose recommendations are in the child's best interest? This article explores an issue that may not involve a life and death decision, but one in which the parents clearly refuse expert medical recommendations for what the providers believe are in the best interest of the infant. Specifically, the case study explores the parents' refusal to proceed with gender reassignment to female for their genetic XY baby born with micropenis and nonpalpable testes. The issue calls into question the possible limits of surrogate decision making. The ethical principles of beneficence, respect for persons, nonmaleficence, and justice are addressed in relation to this particular case.

Adult↗
PubMed2000

Practical issues in assisting shared decision-making.

To facilitate treatment decision-making, one aims to provide information, present it in a way that makes it as easy as possible to understand, and to help the decision-maker through the cognitive processes that result in a treatment decision. Decision aids aim to accomplish just these goals and this paper identifies practical issues that we have encountered in creating a decision aid for men with early stage prostate cancer. We highlight the results of studies we carried out to provide an empirical basis for the decision aid that we were developing. Several of the studies were designed to identify what information key players (health professionals, patients and family members) thought was important for the decision-making process. Another investigation studied methodological considerations in identifying important information. The final study focused on presentation issues. These studies, designed to explore what information was considered important, found great variability among both health care professionals involved in treating patients with prostate cancer (urologists, radiation oncologists, nurses in cancer clinics, and radiation technologists) and among the patients, themselves. The studies also showed that not all information contained within a typical category is of equal importance. A methodological study showed that the information that patients deem to be important to their decision depends on whether they are rating the information that could be provided, or questions that could be answered. Finally, presentation studies showed that the various formats used in presenting quantitative information are processed with differing degrees of accuracy and ease. Each of the above results has implications for those creating decision aids; these implications are highlighted.

Journal Article↗
PubMed2000

Classifying clinical decision making: a unifying approach.

This is the first of two linked papers exploring decision making in nursing which integrate research evidence from different clinical and academic disciplines. Currently there are many decision-making theories, each with their own distinctive concepts and terminology, and there is a tendency for separate disciplines to view their own decision-making processes as unique. Identifying good nursing decisions and where improvements can be made is therefore problematic, and this can undermine clinical and organizational effectiveness, as well as nurses' professional status. Within the unifying framework of psychological classification, the overall aim of the two papers is to clarify and compare terms, concepts and processes identified in a diversity of decision-making theories, and to demonstrate their underlying similarities. It is argued that the range of explanations used across disciplines can usefully be re-conceptualized as classification behaviour. This paper explores problems arising from multiple theories of decision making being applied to separate clinical disciplines. Attention is given to detrimental effects on nursing practice within the context of multidisciplinary health-care organizations and the changing role of nurses. The different theories are outlined and difficulties in applying them to nursing decisions highlighted. An alternative approach based on a general model of classification is then presented in detail to introduce its terminology and the unifying framework for interpreting all types of decisions. The classification model is used to provide the context for relating alternative philosophical approaches and to define decision-making activities common to all clinical domains. This may benefit nurses by improving multidisciplinary collaboration and weakening clinical elitism.

Clinical Competence↗
PubMed2000

Clinical decision-making in the context of chronic illness.

This paper develops a framework to compare clinical decision making in relation to chronic and acute medical conditions. Much of the literature on patient-physician decision making has focused on acute and often life-threatening medical situations in which the patient is highly dependent upon the expertise of the physician in providing the therapeutic options. Decision making is often constrained and driven by the overwhelming impact of the acute medical problem on all aspects of the individual's life. With chronic conditions, patients are increasingly knowledgeable, not only about their medical conditions, but also about traditional, complementary, and alternative therapeutic options. They must make multiple and repetitive decisions, with variable outcomes, about how they will live with their chronic condition. Consequently, they often know more than attending treatment personnel about their own situations, including symptoms, responses to previous treatment, and lifestyle preferences. This paper compares the nature of the illness, the characteristics of the decisions themselves, the role of the patient, the decision-making relationship, and the decision-making environment in acute and chronic illnesses. The author argues for a different understanding of the decision-making relationships and processes characteristic in chronic conditions that take into account the role of trade-offs between medical regimens and lifestyle choices in shaping both the process and outcomes of clinical decision-making. The paper addresses the concerns of a range of professional providers and consumers.

Journal Article↗
PubMed1984

Dollars and sense: the economics of personal health decision-making.

The economic consequences of personal health care decision-making have received relatively little attention in the United States. The majority of the American public is shielded from an awareness of the cost impact of health services by first dollar health insurance coverage and modest out-of-pocket personal payments. As the various current structural changes in the reimbursement system for health care begin to manifest themselves in terms of mandating individual responsibility for paying a significant portion of health care, Americans will require and demand a deeper understanding of how much their health is costing them. In addition, as individuals realize that up to 50% of disability and death can be attributed to negative lifestyle health behaviors, the interrelationship of personal economic status and health status will create a new consciousness of the value of preventive health practices and health education. This article provides an in-depth analysis of the social forces in America compelling individual health decision-making in economic terms, barriers to informed health decision-making, a suggested matrix for making quality-vested health decisions (with case examples) and a discussion of available resources for assisting in the decision-making process.

Community Participation↗