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PubMed2006

An integrated framework for decision making in neurologic physical therapist practice.

Decision-making frameworks are used by clinicians to guide patient management, communicate with other health care providers, and educate patients and their families. A number of frameworks have been applied to guide clinical practice, but none are comprehensive in terms of patient management. This article proposes a unifying framework for application to decision making in the management of individuals who have neurologic dysfunction. The framework integrates both enablement and disablement perspectives. The framework has the following attributes: (1) it is patient-centered, (2) it is anchored by the patient/client management model from the Guide for Physical Therapist Practice, (3) it incorporates the Hypothesis-Oriented Algorithm for Clinicians (HOAC) at every step, and (4) it proposes a systematic approach to task analysis for interpretation of movement dysfunction. This framework provides a mechanism for making clinical decisions, developing clinical hypotheses, and formulating a plan of care. Application of the framework is illustrated with a case example of an individual with neurologic dysfunction.

Algorithms↗

PubMed2002

Evaluating participants' use of a hormone replacement therapy decision-making intervention.

BACKGROUND: Associations between optimal use of a tailored decision-aid and levels of accuracy of perceived breast cancer risk, confidence in decision-making, and satisfaction with decisions about HRT were evaluated in a randomized intervention trial with a community sample of women aged 45-54. METHODS: Data are from 289 women randomized to receive a computer-tailored three-step decision-aid. RESULTS: Forty-seven percent of participants reported optimal use of the intervention materials. African American women and those with low confidence in decision-making were less likely to use the intervention optimally than white women and those with higher confidence (P<0.05). Optimal use of the decision-aid was associated with increased accuracy of perceived risk and confidence to make a decision. DISCUSSION: When used optimally, self-directed decision-aids can improve women's ability to make decisions about HRT. Additional refinement of these aids is needed. For some subgroups of women, adjuncts such as telephone counseling also might be considered.

Black or African American↗

PubMedDate not supplied

[Design of an expert system for decision-making in an emergency situation].

OBJECTIVES: To study the clinical applicability of the expert system URGSANT as a help in making up decisions in emergencies. MATERIAL AND METHODS: URGSANT is an expert system implemented in INSIGT 2+ which is structured in a modular and hierarchical form. It contemplates 44 urgent situations relating to the central nervous system, hematopoietic, cardiovascular, respiratory, gastrointestinal, genitourinary, endocrinological, and miscellaneous group. Validation of the program was made by four anesthesiologists who evaluated the performance of the program in 25 emergency cases and in 25 other situations that were treated by other specialists. RESULTS: The rationale of the system was basically correct. In most cases the program was considered efficient or very efficient during the different clinical situations and only in one case its guidance was wrong. CONCLUSIONS: The URGSANT expert system is an efficient and useful method for the clinician during emergency situations.

Anesthesiology↗

PubMed1997

Decision-making task complexity: model development and initial testing.

Preparing skilled decision-makers requires an understanding of the decision-making tasks nurses face. This article presents the development and initial testing of a model of decision-making task complexity in nursing. The Decision-Making Task Complexity Model has its roots in Newell and Simon's (1972) Information Processing Theory. The Model includes two components, content and context, along with five characteristics in each component. The content component of the model was initially tested using a single sample repeated measures design. Case study examples of a weaning task in critical care were developed to include all combinations of the four independent variables: irrelevance, ambiguity, conflict, and change. Forty-one registered critical care nurses rated each case study example on a scale from 1 (least complex) to 7 (most complex). Results indicated that when conflict was manipulated the ratings were consistently higher. Implications for nursing education and the development of decision-making skills are described.

Decision Making↗

PubMed2004

A matter of trust--patient's views on decision-making in colorectal cancer.

OBJECTIVES: To determine which aspects of the treatment decision process, therapy and outcomes are most important to patients with colorectal cancer (CRC). DESIGN: Cross-sectional survey. PARTICIPANTS: A total of 102 men and 73 women who had completed primary treatment for CRC in two teaching hospitals in Central Sydney, Australia. MAIN OUTCOMES MEASURES: Patient's rating of the importance of the decision-making aspects and outcomes of treatment for CRC. RESULTS: Trust in their surgeon and confidence of specialty training are of paramount importance to CRC patients. Patients also have a strong desire to get on with treatment quickly and rate the risk of disease recurrence and quality of life as being very important in their treatment decisions. Gender, age and whether the patient had undergone adjuvant radiotherapy were all significant predictors of preferred mode of treatment decision-making. Fifty-eight per cent of women preferred a shared decision-making role compared with 36% of men, whilst older patients and those who had undergone adjuvant radiotherapy were significantly more likely to prefer that their surgeon decide upon treatment when compared with younger patients and respondents who have not had radiotherapy. CONCLUSIONS: Regardless of whether a patient prefers an active or more passive role in decision-making, having a surgeon explain treatment options in a clear, unhurried and open manner is vital to how patients feel about their treatment. Whilst acknowledging that individual patients will have different needs for information and preferences for treatment, there are several factors amongst many in the process of decision-making which are considered very important by patients with CRC. A surgeon who adopts a consultation style that is open and informative, that offers patients the chance to participate in the process of decision-making and clearly explain treatment options and outcomes will engender trust with their patient.

Aged↗

PubMed2001

Prefrontal, parietal, and temporal cortex networks underlie decision-making in the presence of uncertainty.

Decision-making in the presence of uncertainty, i.e., selecting a sequence of responses in an uncertain environment according to a self-generated plan of action, is a complex activity that involves both cognitive and noncognitive processes. Using functional magnetic resonance imaging, the neural substrates of decision-making in the presence of uncertainty are examined. Normal control subjects show a significant activation of a frontoparietal and limbic neural system during a two-choice prediction task relative to a two-choice response task. The most prevalent response strategy during the two-choice prediction task was "win-stay/lose-shift," where subjects will repeat the previous response if it successfully predicted the stimulus and switch to the alternative response otherwise. Increased frequency of responses that are consistent with this strategy is associated with activation in the superior temporal gyrus. In comparison, increased frequency of response inconsistent with win-stay/lose-shift is associated with parietal cortex activation. These results support the hypothesis that subjects use a frontoparietal neural system to establish a contingency based decision-making strategy even in the presence of random reinforcement.

Adult↗

PubMedDate not supplied

Informed decision making in outpatient practice: time to get back to basics.

CONTEXT: Many clinicians have called for an increased emphasis on the patient's role in clinical decision making. However, little is known about the extent to which physicians foster patient involvement in decision making, particularly in routine office practice. OBJECTIVE: To characterize the nature and completeness of informed decision making in routine office visits of both primary care physicians and surgeons. DESIGN: Cross-sectional descriptive evaluation of audiotaped office visits during 1993. SETTING AND PARTICIPANTS: A total of 1057 encounters among 59 primary care physicians (general internists and family practitioners) and 65 general and orthopedic surgeons; 2 to 12 patients were recruited from each physician's community-based private office. MAIN OUTCOME MEASURES: Analysis of audiotaped patient-physician discussions for elements of informed decision making, using criteria that varied with the level of decision complexity: basic (eg, laboratory test), intermediate (eg, new medication), or complex (eg, procedure). Criteria for basic decisions included discussion of the nature of the decision and asking the patient to voice a preference; other categories had criteria that were progressively more stringent. RESULTS: The 1057 audiotaped encounters contained 3552 clinical decisions. Overall, 9.0% of decisions met our definition of completeness for informed decision making. Basic decisions were most often completely informed (17.2%), while no intermediate decisions were completely informed, and only 1 (0.5%) complex decision was completely informed. Among the elements of informed decision making, discussion of the nature of the intervention occurred most frequently (71 %) and assessment of patient understanding least frequently (1.5%). CONCLUSIONS: Informed decision making among this group of primary care physicians and surgeons was often incomplete. This deficit was present even when criteria for informed decision making were tailored to expect less extensive discussion for decisions of lower complexity. These findings signal the need for efforts to encourage informed decision making in clinical practice.

Colorado↗

PubMed1991

Bringing social structure back into clinical decision making.

Although research in the past twenty years has resulted in an increasingly sophisticated understanding of clinical decision making processes, the dominant approach in this area of inquiry remains limited. Most studies emphasize normative models of how decisions ought to be made, others attempt to describe physicians' thinking, but few take the social context of decision making systematically into account. Research models typically assume that physicians are autonomous professionals practicing in socially insular clinical settings--an approach that is consistent with classic formulations of the social structure of medical practice, but they ignore 30 years of sociological research on research on patient-physician relationships and major historical changes in the structure of medical practice. Eisenberg's still timely advice to students of clinical decision making--that they need to describe decision making in the context of 'sociologic influences' (including patient, physician and practice setting characteristics)--is expanded in the present discussion. Recent studies are reviewed, highlighting important dimensions of social structure impinging on physicians' decision making. Findings indicate that the process of clinical decision making is likely influenced by patients' age, gender, socioeconomic status, and race, physicians' professional training and experience, as well as by larger structural features of organized clinical settings. Our review of these studies on the social context of clinical decision making, however, reveals major methodological limitations including those inherently imposed by secondary data analysis, normative approaches, written case vignettes, small, non-random samples and the inadequate control of confounding influences. We present a feasible, alternative research strategy, built on a factorial experimental design. Illustrative findings indicate how complex social structural influence on clinical decision making may be disentangled in an unconfounded manner.

Age Factors↗

PubMed2005

Promoting informed choice: evaluating a decision-making tool for family planning clients and providers in Mexico.

CONTEXT: The World Health Organization (WHO) has developed a decision-making tool to be used by providers and clients during family planning visits to improve the quality of services. It is important to examine the tool's usability and its impact on counseling and decision-making processes during family planning consultations. METHODS: Thirteen providers in Mexico City were videotaped with family planning clients three months before and one month after attending a training session on the WHO decision-making tool. The videotapes were coded for client-provider communication and eye contact, and decision-making behaviors were rated. In-depth interviews and focus group discussions explored clients' and providers' opinions of the tool. RESULTS: After providers began using the decision-making tool, they gave clients more information on family planning, tailored that information more closely to clients' situations and more often discussed HIV/AIDS prevention, dual protection and condom use. Client involvement in the decision-making process and client active communication increased, contributing to a shift from provider-dominated to shared decision making. Clients reported that the tool helped them understand the provider's explanations and made them feel more comfortable talking and asking questions during consultations. After one month of practice with the decision-making tool, most providers felt comfortable with it and found it useful; however, they recommended some changes to the tool to help engage clients in the decision-making process. CONCLUSIONS: The decision-making tool was useful both as a job aid for providers and as a decision aid for clients.

Adolescent↗

PubMed2006

Integrating Decision Making and Mental Health Interventions Research: Research Directions.

The importance of incorporating patient and provider decision-making processes is in the forefront of the National Institute of Mental Health (NIMH) agenda for improving mental health interventions and services. Key concepts in patient decision making are highlighted within a simplified model of patient decision making that links patient-level/"micro" variables to services-level/"macro" variables via the decision-making process that is a target for interventions. The prospective agenda for incorporating decision-making concepts in mental health research includes (a) improved measures for characterizing decision-making processes that are matched to study populations, complexity, and types of decision making; (b) testing decision aids in effectiveness research for diverse populations and clinical settings; and (c) improving the understanding and incorporation of preference concepts in enhanced intervention designs.

Journal Article↗

PubMed2001

An exploratory study of clinical decision-making in five countries.

PURPOSE: To identify the cognitive processes nurses use in their decision-making in long- and short-term care settings in five countries, and the demographic variables associated with their decision-making. METHOD AND SAMPLES: The instrument used was a 56-item questionnaire that has been shown to be reliable in earlier studies. The sample consisted of five convenience samples of registered nurses working in either geriatric wards (n = 236) or acute medical-surgical wards (n = 223) in hospitals or nursing homes in Canada, Finland, Sweden, Switzerland, and the United States. FINDINGS: Five models of decision-making were identified on the basis of factor analysis. They represent both analytical and intuitive cognitive processes. Analytical cognitive processes were emphasized in information collection, problem definition, and planning of care, and intuitive cognitive processes were emphasized in planning, implementing, and evaluating care. Professional education, practical experience, field of practice, and type of knowledge were significantly associated with decision-making models as well as with country of residence of the participants. The highest proportion of analytically oriented decision-makers was found among nurses in long-term care, the decision-making of nurses in short-term care was more intuitively oriented. CONCLUSIONS: The results indicate that decision-making of participants varied from country to country and in different nursing situations. Future research should be focused on reasons for these differences, the relationship between the task and the nurses' type of knowledge, and how nurses use their knowledge to make decisions in different nursing situations.

Canada↗

PubMed1991

Depression and decision-making among intravenous drug users.

Two short scales, the TCU Depression Scale and the TCU Decision-making Scale, were psychometrically evaluated in a sample of 145 intravenous drug users. Coefficient alpha reliabilities were .78 for the 6-item TCU Depression Scale and .77 for the 9-item TCU Decision-making Scale. Concurrent validity of the former scale was assessed by correlating scores with those on the Beck Depression Inventory, r = .75. Based on the Beck Depression Inventory Clinical cutoff scores, 83% of the sample showed some depression, with 23% severely depressed, 39% moderately depressed, and 21% mildly depressed. Individuals scoring higher on depression on both tests tended to score lower on decision-making. Significant demographic associations of age, gender, education, and race-ethnicity were found for the depression and decision-making scales. More depression was noted for women, those younger, white, and having less education. Older and more educated intravenous drug users tended to score higher on decision-making. Validity for the depression and decision-making scales was assessed by examining correlations with behaviors. Significant positive correlations were found between depression scores and intravenous use of cocaine only, heroin and cocaine combined, and heroin only. Also, intravenous use of cocaine only and of cocaine and heroin combined were negatively related to decision-making. AIDS sex-risky behavior was positively correlated with depression and negatively correlated with decision-making.

AIDS Serodiagnosis↗

PubMedDate not supplied

Developing an instrument to measure and describe clinical decision making in different nursing fields.

The purpose of this study was to develop and test a decision-making instrument for nursing, to consider the nursing decision-making models in different nursing fields, and to create a scoring system for the instrument. A 56-item instrument was developed on the basis of different decision-making theories and earlier studies about nursing decision making. The instrument was evaluated by using several different convenience samples of nurses from seven different countries (N = 1,460). Statistical analysis used were correlation coefficients, factor analysis, factor scores, and factor reliability coefficients. The results indicated that nurses from different countries and working in different fields of nursing respond similarly. The results of the studies using the 56-item instrument showed that nurses use four kinds of decision-making models (analytical, analytical-intuitive, intuitive-analytical, and intuitive). The factor reliability scores were high (alpha = 0.85-0.91). According to the results, 60 per cent of the nurses used the analytical-intuitive and intuitive-analytical decision-making models, 14 per cent used the analytical model, and 26 per cent used the intuitive model. However, these models vary both between and within different fields of nursing.

Decision Making↗

PubMed1999

Principles of medical decision making.

The consequences of medical decisions are inherently uncertain at the decisive moment. Using clinical examples related to the diagnosis and management of low back pain, the authors review some principles that can help physicians deal with this uncertainty. This article addresses the following: the use of probability as a useful representation of uncertainty, the use of Bayes' theorem to update probability estimates when new information is obtained, the measurement of a diagnostic test's accuracy, the use of the threshold model for choosing a diagnostic test, the principles of expected-value decision making, the use of utility assessment as a way of attaching value to outcomes, and the use of quality-adjusted life years as a measure of value. These principles can aid physicians in approaching complex and uncertain decisions with their patients. As the use of computers becomes more integrated into the process of care, the opportunity exists to move formal decision models from the policy level to the patient care level.

Cost-Benefit Analysis↗

PubMed2000

Adaptive decision making, ecological validity, and the frontal lobes.

Existing neuropsychological procedures assess veridical, but not adaptive, decision making, which are based on different mechanisms. This severely curtails the tests' ecological validity, because most real-life decision making situations are adaptive, rather than veridical. Veridical decision making entails finding the correct response intrinsic to external situations and is actor-independent. Adaptive decision making is actor-centered and priority-based. Prefrontal cortex is critical for adaptive decision making. Innovative actor-centered decision-making tasks are required to better understand frontal lobe functions. We have designed a prototype for such procedures, the Cognitive Bias Task (CBT). CBT elicited strong gender and hemispheric differences in the effects of focal frontal lesions, which are more robust than those elicited with veridical tasks, such as the Wisconsin Card Sorting Test.

Adaptation, Psychological↗

PubMed2002

Ethical challenges of decision making with pregnant patients who have schizophrenia.

OBJECTIVE: Because there is a dearth of literature, we developed an ethical framework to guide decision making about the management of pregnancy of patients with schizophrenia. STUDY DESIGN: We review pertinent literature on schizophrenia and pregnancy, including information on maternal and fetal risks and outcomes, and relate this information to ethical concepts. RESULTS: The ethical framework has five components: the concept of chronically and variably impaired autonomy, assisted decision making, surrogate decision making, strategies for dealing with the physician's feelings in response to these patients, and the concept of the fetus as a patient. We apply this ethical framework to clinical challenges of decision making during pregnancy with this patient population. CONCLUSIONS: The preventive ethics strategies of assisted and surrogate decision making can be used to prevent ethical conflicts in decision making about the management of pregnancy of patients with schizophrenia. These preventive ethics strategies should contribute significantly to reducing the vulnerability of these patients and therefore to enhancing their autonomy in the physician-patient relationship.

Child Rearing↗

PubMed2005

An exploration of accident and emergency nurse experiences of triage decision making in Hong Kong.

This study used a descriptive qualitative design to explore emergency nurse experiences of decision making about triage in Hong Kong. Seven experienced nurses who were working in three different accident and emergency departments participated in the study. Unstructured interviews were used to provide the nurses with opportunities to describe their experiences. The findings fall into three main categories, including the experience of triage decision making, the use of information in the triage decision-making process, and the factors that influence triage decision making. Although the experience of triage was generally positive, the nurses felt frustrated and uncertain in some circumstances. In addition, triage decision making was influenced by a series of factors that occur in daily practice. The findings of this study have implications for the development of formal triage training and triage decision-making protocols in accident and emergency nursing. They also provide positive reinforcement and support to triage nurses that will enhance their ability to make decisions about triage. Avenues for further research in the area are recommended.

Attitude of Health Personnel↗

PubMed2006

The significance for decision-making of information that is not exchanged by patients and health professionals during consultations.

Information exchange between patients and health professionals is fundamental to achieving patient participation in decision-making and shared decision-making is said to require the exchange of "all information relevant to decision-making". This paper reports on a qualitative investigation of instances in which information that was potentially relevant to decision-making was not exchanged in consultations. Consultations from 5 diverse clinical areas in the UK were video-recorded and the health professionals and patients involved were interviewed separately before and after their consultations. This analysis is based on cases involving 20 patients. It draws on data from their 26-recorded consultations and from the 137 associated interviews. Several strategies were used to identify instances in which patients and/or health professionals did not disclose information that was potentially relevant to decision-making. Analysis focussed on the types of information not disclosed, the reasons that health professionals and patients gave for non-disclosure, and the apparent or potential significance of the non-disclosure. We identified 34 instances of non-disclosure of information relating to the patient's problem and 52 instances of non-disclosure of information relating to treatment or management options. The types of information not disclosed were diverse and the reasons given for non-disclosure varied. Some, but not all, instances of non-disclosure had negative implications for the quality of decision-making and/or the patient's healthcare experience. Our findings have implications for future attempts to examine information exchange in consultations-whether for research or for professional assessment purposes. In particular, they highlight the importance of appraising instances of non-disclosure of information in context and of recognising the limitations of approaches that rely on single consultations and/or single perspectives for assessments of information exchange.

Adult↗