Friday, 10 May 2013

Decisions, decisions, decisions...

Have I got time for a cup of tea before work?
Do I need a haircut?
Left sock then right sock or right sock then left sock?

The majority of the decisions we make are trivial, having only a small effect on our lives or the lives of others. However, at times we make decisions which do affect others.

Will I drive home after a few beers?
Am I alright to have the last cigarette of the day in bed?
Should I alert somebody to that suspect package?

Although these decisions may have greater and graver consequences, the answers are still straightforward (No. No. Yes.) The decisions that we see being made in the simulation courses are of a different type. They are often time-sensitive, the consequences are poorly understood and the number of possible decisions can be colossal.

In her book "Sitting in the hot seat", Rhona Flin describes the traditional decision making (TDM) process (p.141):

  1. Identify the problem
  2. Generate a set of options for solving the problem
  3. Evaluate these options concurrently using one of a number of strategies
  4. Choose and implement the preferred option
Unfortunately TDM is not applicable in the pressured, time-critical, life-threatening environment of a healthcare crisis. It is here that naturalistic decision making (NDM) occurs. Although there are a number of NDM models, they are similar to the extent that there is no step-wise progression from problem to solution. Instead problem-identification, option-appraisal and problem-solving occur almost concurrently and cyclically.

The principal NDM model is recognition-primed decision making (RPD). In RPD the decision-maker is thought to try and recognise the situation, choose the correct response and then implement this response. Flin (p.145) describes the 3 variants of RPD although Wikipedia does a better job of making them easy to remember:
  1. If... then... : The standard response as detailed above
  2. If??? then... : The situation is unclear/not recognised. The decision-maker knows a number of correct responses but does not know which one to use. The decision-maker must gather further information.
  3. If... then???: The situation is clear but a lack of knowledge means the decision-maker does not know which response to choose. The decision-maker must mentally simulate the consquences of a given response and consider whether these are acceptable. If they are not then the decision-maker must choose more responses until he/she finds one with the desired outcome.
RPD relates back to the post about experts and their unknown knowns. Experts, because of their time spent doing the job, are more likely to recognise the situation and are more likely to know what the correct response to a given situation is.

Flin (p.147) tells us that the key features of the RPD model include a "focus on situation assessment" and an "aim to satisfice, not optimize". "Satisfice" may not be a word you see every day but it relays the need to look for a solution that is "good enough" not "brilliant/amazing/superb". And Flin's placement of the need for situation assessment as a key feature is spot on. Without appropriate situation assessment all subsequent decisions will be prone to failure.

The benefit of simulation-based education is that everybody can review the decisions they made by using video-assisted debrief. Alternatives can be discussed and, because the simulator can be "reset", those alternatives can be played out to see what the consequences are on outcome. The goal is to make all of us better decision-makers when time is short and the stakes are high.

Naturalistic decision-making
8 characteristics of NDM: p.52 of stress and human performance:
A NDM environment

  1. ill-structured problems
  2. Uncertain and dynamic environments
  3. Shifting, ill-defined, or competing goals
  4. Action/feedback loops
  5. Time stress
  6. High stakes
  7. Multiple players
  8. Organizational goals and norms
    Time for some NDM

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