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PubMedDate not supplied

Nurse educators and decision making: a female perspective.

Quality of work life issues are major concerns of nurses today. Decision making is one such issue. This article is part of a larger case study of a Canadian hospital school of nursing that asked whether women nurse educators bring unique orientations to the workplace that have relevance for the administration of nursing organizations. The process of decision making, a small part of the larger study, is discussed in this article. The results suggested that women nurse educators used a cooperative, collaborative, highly participatory style of decision making that resulted in decisions based on consensus. The implications this female style of decision making has for nurses and nurse administrators is discussed.

Adult↗

PubMed1996

Non-medical influences on medical decision-making.

BACKGROUND: The influence of non-medical factors on physicians' decision-making has been documented in many observational studies, but rarely in an experimental setting capable of demonstrating cause and effect. We conducted a controlled factorial experiment to assess the influence of non-medical factors on the diagnostic and treatment decisions made by practitioners of internal medicine in two common medical situations. METHOD: One hundred and ninety-two white male internists individually viewed professionally produced video scenarios in which the actor-patient, presenting with either chest pain or dyspnea, possessed various balanced combinations of sex, race, age, socioeconomic status, and health insurance coverage. Physician subjects were randomly drawn from lists of internists in private practice, hospital-based practice, and HMO's, at two levels of experience. RESULTS: The most frequent diagnoses for both chest pain and dyspnea were psychogenic origin and cardiac problems. Smoking cessation was the most frequent treatment recommendation for both conditions. Younger patients (all other factors being the same) were significantly more likely to receive the psychogenic diagnosis. Older patients were more likely to receive the cardiac diagnosis for chest pain, particularly if they were insured. HMO-based physicians were more likely to recommend a follow-up visit for chest pain. Several interactions of patient and physician factors were significant in addition to the main effects. CONCLUSIONS: The variability in decision-making evidenced by physicians in this experiment was not entirely accounted for by strictly rational Bayesian inference (the common prescriptive model for medical decision-making), in-as-much as non-medical factors significantly affected the decisions that they made. There is a need to supplement idealized medical schemata with considerations of social behavior in any comprehensive theory of medical decision-making.

Adult↗

PubMedDate not supplied

A computer simulation for the entry-level RN: enhancing clinical decision making.

Staff development educators struggle to prepare today's entry-level RN for effective decision making in a new healthcare climate that demands both skill and expertise with patients with high acuity levels. The clinical decision making simulator is an innovative approach to teaching and learning decision-making skills. The authors discuss the development and use of a computer simulation that provides repeated opportunities for clinical decision making for the newly licensed nurse without jeopardizing patient safety.

Clinical Competence↗

PubMed1995

A Windows-based tool for the study of clinical decision-making.

Studies of health-provider decision-making, and of their practice patterns, play a central role in efforts to improve the quality and effectiveness of care and in decreasing costs of healthcare delivery systems. Researchers from a variety of disciplines have studied a broad range of clinical conditions, using a number of methodological approaches and measurement tools, including self-report, written clinical vignettes, simulated clinical encounters using actors as patients and analysis of medical records and administrative data. Although these provide information about the outcomes of clinical decisions, they provide little or no information about the process of the decision. Most clinicians agree that the decision process is as important as the outcome, and indeed it is not unusual to have an exemplary process but a poor outcome. Process information is therefore a crucial dimension of care evaluation. In this paper, we describe a new software product that was originally used to measure diagnostic reasoning in the basic medical science of immunology; subsequently adapted to measure key steps in the clinical decision-making process. This Windows-based software is user-friendly, inexpensive, and requires only commonly available hardware for its operation. It is very flexible, permitting the creation of unlimited numbers and types of clinical scenarios, with diagnostic and/or management approaches. Being clinically "real-world," the scenarios are familiar to the user, who is therefore likely to respond in a "real-world" fashion, with the consequent improved accuracy of data. In addition, a wide range of users may be accommodated. The clinical activities of physicians, nurses, pharmacists, and any other clinical providers may be measured and analyzed by the system. Non-clinical providers, such as managers and administrators, could also be assessed. The system has three major modes. In the Authoring Mode, the author creates a menu, which is common to a number of linked scenarios. For example, the menu for physicians might include the History, Physical examination, Laboratory tests, Radiology, Consultations, etc. The actual details of each related clinical case may then be varied. There is virtually unlimited flexibility in the design of the menu and the clinical details, depending on the needs of the author, and the type of information desired. Both diagnostic and management scenarios are easily constructed. The cost for each individual step may be assigned, using any scoring scale desired. Actual dollar costs, or a suitable point score, are equally possible. Once the menu and associated scenarios are generated, the candidate is asked to solve the clinical problem in the User Mode. The candidate obtains information by "mouse-clicking," so it is not necessary to be a computer expert to use the system. Eventually, the candidate is presented with a short vignette outlining the desired solution, which may include the authors comments, sources for further information, etc. In the Data Collection and Analysis Mode, the candidate proceeds to solve the scenario, the software captures and stores each individual information request i.e., each step in the candidates reasoning process. Thus, the reasoning process can be examined, including timing and order and types of information used; this may be done both for individual candidates, and also for groups. A "gold standard" reasoning may be predetermined by the author for comparison purposes. The software has already been used to teach immunology to medical students, and is currently being expanded to train gynecology surgeons in the use of Clinical Practice Guidelines. The software has potential applications in many aspects of the healthcare field. For educators, it could serve in traditional exit examinations for the clinical disciplines, both undergraduate and postgraduate. (abstract truncated)

Computer-Assisted Instruction↗

PubMed1999

Clinical scoring system: a valuable tool for decision making in cases of acute appendicitis.

OBJECTIVE: Decision making in cases of acute appendicitis poses a clinical challenge specially in developing countries where advanced radiological investigations do not appear cost effective and so clinical parameters remain the mainstay of diagnosis. The aim of our study was to devise a scoring system from our local database and test its accuracy in the preoperative diagnosis of acute appendicitis. METHODS: Clinical data from 401 patients having undergone appendectomy were collected to identify predictive factors that distinguished those with appendicitis from those who had a negative appendectomy. Ten such factors were identified and using Bayesian probability a weight was assigned to each and the results summated to get an overall score. A cut-off point was identified to separate patients for surgery and those for observation. The scoring system was then retrospectively applied to a second population of 99 patients in order to compare suggested actions (derived from the scoring system) to those actually taken by surgeons. The sensitivity, specificity and accuracy for the level of decision was then calculated. RESULTS: Of the 99 patients, the method suggested immediate surgery for 65 patients, 63 of whom had acute appendicitis (3.1% diagnostic error rate). Of the 33 patients in whom the score suggested active observation, 18 had appendicitis. The accuracy of our scoring system was 82%. The method had a sensitivity of 78%, specificity 89% and a positive predictive value of 97%. The negative appendectomy rate determined by our study was 7% and the perforation rate 13%. CONCLUSION: Scoring system developed from a local database can work effectively in routine practice as an adjunct to surgical decision making in questionable cases of appendicitis.

Acute Disease↗

PubMed2006

Health care decision-making capacity: a legal perspective for long-term care providers.

While federal law establishes guidelines that designated facilities must follow in providing information about a patient's rights regarding self-determination in the health care decision-making process, state law determines the decision-making process and the legal requirements pertaining thereto. A person's capacity to make health care decisions or to have the authority and capacity to delegate the right to make such decisions is a legal conclusion based on statutory and common law principles. This article discusses the legal perspective of capacity in health care decision making and the legal framework of the question of whether or not a person has the capacity to make health care decisions. Western civilization's concepts of personal autonomy and self-determination are at the core of health care decision making, but health care providers must be aware that other cultures do not always share that value system. Sensitivity to multicultural diversity in this context is imperative to maintain individual self-esteem and respect, both for the patient and the patient's family.

Advance Directives↗

PubMedDate not supplied

Technology decision making. A constructive approach to planning and acquisition will require a paradigm shift.

Technology should be viewed as an integrating rather than a divisive element in hospital planning. In the past, technology decision-making responsibility has often been diffused throughout hospitals, but providers are beginning to take a more considered and coherent approach. The process of making decisions about technology has four key elements: assessment, planning, acquisition, and management. The most important aspect of the assessment phase is the formation of a technology advisory committee to review and evaluate requests for new and emerging technology; review capital budget requests for new and replacement technology; and set mission-based and strategic priorities for new, emerging, and replacement technologies. Technology planning allows hospitals to set long-term goals for technology acquisition. The process involves an audit of existing technologies, evaluation of other hospitals' technologies, and review of technology trends. A well-defined technology plan will, in turn, facilitate the acquisition and management process, allowing hospitals greater flexibility in negotiating costs and budgeting for training, spare parts, service, upgrades, and support. By pooling resources with other providers in their region, hospitals can further enhance the effectiveness of their use and acquisition of technology. Collaboration allows providers to share the risks of technologically volatile and intensive services and avoid costly duplication of equipment and facilities.

Capital Expenditures↗

PubMed2006

Medical decision-making in the nursing home: a comparison of physician and nurse perspectives.

The purpose of this study is to clarify the perspectives of physicians and nurses in the medical decision-making process at the time of status change events in nursing home residents. The decision-making processes studied involved 28 cognitively impaired nursing home residents in a large suburban nursing home. In interviews, the authors ascertained the personal opinions of physicians and the nurses related to the status change event and the decision-making process using the Medical Decision-Making During a Status Change Event Questionnaire. Nurses reported a greater degree of familiarity with the family's and resident's wishes than did physicians. Physicians reported considering more treatment options and choosing more treatments for residents than nurses. Both physicians and nurses reported that the physicians had a major role in decision-making and that nurses did not, yet the gap in reported roles was greater based on physicians' reports in comparison to nurse reports. In a third of the reported cases, physicians and nurses disagreed about whether advance directives had been followed. These findings reflect a division of roles and perspectives of nurses versus physicians in the medical decision-making process. This study demonstrates the ability of the questionnaire to reveal several key differences in perceptions of care. This information could be useful in developing forums for communication among the professionals to enhance mutual understanding.

Advance Directives↗

PubMed1975

Evoked brain potentials as indicators of decision-making.

The effects of decision-making processes on evoked brain potentials recorded at the vertex were studied in human subjects. Significantly different visual evoked potentials to the same physical stimulus were obtained in trails that resulted in different behavioral decisions. The results suggest that certain characteristics of evoked potentials may perhaps be used as indicators of specific behavioral outcomes.

Decision Making↗

PubMed2006

Women's experience of decision making about mode of delivery after a previous caesarean section: the role of health professionals and information about health risks.

OBJECTIVE: To explore women's experiences of decision making about mode of delivery after previous caesarean section. DESIGN: A qualitative interview study. SETTING: Two city maternity units in southwest England and Eastern Scotland. SAMPLE: Twenty-one women who had recently delivered a baby and whose previous child was delivered by caesarean section. METHODS: Semi-structured interviews analysed using the framework approach. MAIN OUTCOME MEASURES: Women's views on the influence of uncertainty on decision making, issues concerning information provision and decision-making roles. RESULTS: Experiences of decision making varied considerably. Some women were certain about choosing either vaginal birth after caesarean or repeat elective caesarean section, others were very uncertain and for some this uncertainty persisted after the birth. Information was most commonly provided by hospital doctors (mainly consultants) and more often related to procedural issues rather than possible health risks and benefits. Women felt they had to actively seek information rather than it being provided routinely. Most women were able to make their own decision about mode of delivery. Health professionals generally took a supportive role whichever mode of delivery was chosen. Although many women were comfortable with this approach, some felt they would have liked more guidance. CONCLUSION: On the whole, women experienced having control over the decision about planned mode of delivery. For many, making this decision was difficult and for some it was the cause of prolonged anxiety. Women were often making the decision without being provided with comprehensive and specific information about possible health risks and benefits. We are currently conducting a randomised controlled trial to investigate whether access to a decision aid is beneficial to women in this situation.

Adult↗

PubMed2006

Clinical decision-making: Patients' preferences and experiences.

OBJECTIVE: To determine the congruence between patients' preferred style of clinical decision-making and the style they usually experienced and whether this congruence was associated with socio-economic status and/or the perceived quality of care provided by the respondent's regular doctor. METHODS: Cross-sectional survey of the American public using computer-assisted telephone interviewing. RESULTS: Three thousand two hundred and nine interviews were completed (completion rate 72%). Sixty-two percent of respondents preferred shared decision-making, 28% preferred consumerism and 9% preferred paternalism. Seventy percent experienced their preferred style of clinical decision-making. Experiencing the preferred style was associated with high income (OR, 1.59; 95% CI, 1.16-2.16) and having a regular doctor who was perceived as providing excellent or very good care (OR, 2.39; 95% CI, 1.83-3.11). CONCLUSION: Both socio-economic status and having a regular doctor whom the respondent rated highly are independently associated with patients experiencing their preferred style of clinical decision-making. PRACTICE IMPLICATIONS: Systems which promote continuity of care and the development of an on-going doctor-patient relationship may promote equity in health care, by helping patients experience their preferred style of clinical decision-making.

Adult↗

PubMed2004

[Development and evaluation of a training program in shared decision making for primary care of depressive patients].

Patient surveys show that many patients want broad information about their disease and treatment. Often they are interested to participate in the process of medical decision making, which could be realised with the concept of shared decision making where patient's values and needs are considered to the same extent as the treatment recommendations of evidence-based medicine. In depression care, it has been demonstrated so far that the active involvement of patients contributes to higher motivation for treatment. For enhancing patient's acceptance and motivation to avail themselves of medical treatment, a training program for general practitioners was developed and evaluated. It was the aim of the training to involve depressive patients in medical decision making. The training consists of depression-specific components (e. g. diagnosis, patient information, therapy) and general components (communication and shared decision making). The training was carried out in five sessions within a 6-month period (May to October 2003) embracing 20 h of training. Participants were 20 general practitioners in Southwest Germany. Physician's satisfaction with the training program is high. Especially in the fields of diagnosis and shared decision making the physicians clearly benefited. Transfer of shared decision making into daily routine was assessed as possible by the large majority of the trainees. Application of the training concept to other diseases and evaluation on the basis of daily routine is recommended. The training effects on medical care are presently being assessed in a randomised controlled trial.

Adult↗

PubMed1983

Locus of decision making and job satisfaction of department chairpersons in schools of allied health.

In an era of ample resources in higher education, an estimated 80% of all administrative decisions occurred at the departmental level rather than at higher levels in the administrative hierarchy. As financial resources have become limited, it appears that the locus of decision making has begun to change in the university setting. This study explored the relationship between allied health department chairpersons' perceptions of the locus of decision making in their universities and their job satisfaction. Chairpersons who perceived the level of decision making to reside at the faculty level were shown to be less satisfied with their jobs than chairpersons whose perceived locus of decision making was at the chair level. In addition, as the locus of decision making moved away from the chairperson, either to the faculty or to more central levels of the administration, satisfaction with both the administrative and academic aspects of the chair appeared to diminish. From this study, allied health chairpersons appear to be more comfortable with clear decision-making powers than general academic chairs. This finding has implications for the structuring of the allied health chairperson's role and for the advancement and development of the allied health fields within educational institutions. Future limitations in financial resources may bring about closer alignment in the role and job satisfaction of general academic and allied health chairs.

Administrative Personnel↗

PubMed2003

Semantic decision making in early probable AD: a PET activation study.

We studied the neural correlates of semantic decision making in early probable Alzheimer disease patients and age-matched controls by measuring changes in relative cerebral blood flow by PET (oxygen-15) while they performed a category-specific word-matching task with either animal or artefact names. In comparison to a baseline (matching words by physical identity), semantic decision making elicited increased blood flow in the left frontal lobe (BA 6, 11, 47) and in the contralateral cerebellum in the controls. The only category-specific difference in controls was activation of the left supplementary motor area (BA 6) when making decisions on artefacts. In contrast, the patients recruited more extensive brain regions, encompassing areas in the left frontal lobe (BA 44, 45, 47), right occipital cortex (BA 18), midbrain, and the cerebellum bilaterally. Behaviorally, the patients performed the tasks with equal success albeit more slowly. No animal-artefact differences emerged in the patients' activation patterns, indicating that their activation increases reflected a generalized, presumably compensatory reaction to higher task demands in the face of a progressive neurological disease.

Aged↗

PubMedDate not supplied

Does choosing a treatment depend on making a diagnosis? US and French physicians' decision making about acute otitis media.

BACKGROUND: The classic sequential processing model of clinical decision making-in which the treatment choice follows and depends on the diagnostic judgment-may in some cases be replaced by a processing model in which the treatment choice depends on an independent assessment of the diagnostic and other cues. The aim of this study was to determine which processing model would better describe physicians' treatment choices in a simulated clinical task. METHODS: Seventy-five US and French primary care physicians were presented twice, in a different order, with the same set of 46 scenarios of 15-month-old children suspected of having acute otitis media (AOM). They rated in one set the probability of AOM and in the other set whether they would treat the child with antibiotics (and how confident they felt in their decision). Linear regression analyses revealed the individuals' 2 judgment policies. Hierarchical discriminant analysis was used to analyze the variance explained in the treatment choice by, 1st, the diagnostic judgment, 2nd, the cues specific to treatment, and 3rd, the cues specific to diagnosis. RESULTS: Even when choosing treatment, the participants placed greatest weight on diagnostic cues, especially the ear findings. Only 28% used the cues that reflected parental issues. For 36%, the diagnostic cues had an effect on the treatment choice independent of the effect (if any) of the diagnostic judgment. CONCLUSION: In deciding how to treat AOM, the majority of the participating US and French primary care physicians followed the classic sequential processing model, but a substantial minority used instead an independent processing model.

Acute Disease↗

PubMed2005

Decision-making capacity of elderly patients assessed through the vignette method: imagination or reality?

This article evaluates whether providing hypothetical or realistic information influences the assessment of decision-making capacity in elderly patients with (and without) cognitive impairment. Decision-making capacity was assessed by means of a clinical vignette that presented a choice about whether to undergo an endoscopic procedure. The following standards of decision-making capacity were evaluated quantitatively and qualitatively: ability to evidence a choice, to understand, to reason, and to appreciate a situation. The vignette was presented to patients in either a hypothetical or real situation. In the hypothetical situation cognitively impaired patients performed significantly poorer than cognitively non-impaired patients on all abilities associated with decision-making capacity (with the exception of evidencing a choice). The realistic situation showed the same pattern among cognitively impaired and non-impaired patients in their ability to understand and in the total vignette score. Both types of patients reasoned about and appreciated the realistic situation equally well. Qualitative analysis revealed that patients gave comparable answers in both hypothetical and realistic situations. The answers were not related to standards of decision-making capacity. Moreover, personal circumstances were taken as a reference point for making a decision, regardless of the situation. We did not find any major differences between the hypothetical and realistic situation. Our findings do raise questions about the validity of hypothetical vignettes, however, especially when used with cognitively impaired persons.

Aged↗

PubMedDate not supplied

Citation analysis of the field of medical decision making: update, 1959-1985.

This article updates a prior citation analysis of medical decision making, published in this journal in 1984. Building on the original core list, decision making papers were added based on any of three criteria: citation of three papers already on the list, identification by a MEDLINE search (CATLINE for books) as relevant to the topic, or mention in a recent review article on decision analysis. The revised core list contains 105 articles and five books. The changes in the field of medical decision making from 1978 to 1981 are reviewed, and key areas of development are identified by co-citation clustering.

Bibliographies as Topic↗

PubMed2006

Exploring the subconcepts of the Wittmann-Price theory of emancipated decision-making in women's health care.

PURPOSE: To explore the subconcepts of the Wittmann-Price Theory of Emancipated Decision-Making (EDM); which is proposed as a new theoretical model for the nursing care of women to increase women's satisfaction with decision-making about healthcare issues. Infant feeding method was used as the clinical exemplar. DESIGN AND METHOD: A descriptive correlational design was used to test the five identified subconcepts of EDM (empowerment, flexible environment, personal knowledge, reflection, and social norms) in women's healthcare. The relationship of emancipated decision-making and satisfaction were explored with the Subject Demographic Questionnaire (SDQ), the Wittmann-Price Theory of Emancipated Decision-making Scale (EDMS), and the Satisfaction with Decision (SWD) scale. The research design was retrospective, without random sampling of subjects. Four research questions were posed for this investigation. Women who had uncomplicated deliveries and met the selected criteria were enrolled (N=97). FINDINGS: All five subconcepts of EDM were scored on subscales on the EDMS; flexible environment and personal knowledge had the highest mean scores. Pearson correlations showed that all five subscales were significantly related to each other except reflection with personal knowledge and reflection with social norms. A significant relationship was found between the EDM and satisfaction with the decision. Personal knowledge and flexible environment were the best predictors of satisfaction with the decision. CONCLUSIONS: The Wittmann-Price Theory of EDM is a theoretical model with implications for nursing care of women who are involved in a healthcare decision, such as choice of infant feeding. Further studies are needed to determine the importance of each of the subconcepts in relation to emancipated decision-making.

Adolescent↗