Importance of Decision-Making in Advanced Critical Theories - Essay Example

?Importance of Decision-Making Different ways of performing a task give rise to the necessity of decision-making. Decision-making allows choosing thebest option available in a course of action. By choosing the best option, the decision makers make optimal use of resources (Kalaiselvan, 2009). Critical care is filled with uncertainty, variability, complexity and numerous constraints. It is very difficult to use controlled trials to obtain the required evidence for making good decisions regarding critical care capacity and organization (Buckingham and Adams, 2000). Much technological evolution has taken place in the critical care segment which provides potential for significant improvement in health care. The key to good decision making is the understanding of existing demands of critical care and the ability to predict the likely effects of changing capacity and organization (Montgomery, Lipshitz and Brehmer, 2005). The changing capacity and organization can be measured by using a historical data and validating them with models at the individual level. Practitioners make important clinical decisions that have a great impact on the patient’s care and the performance of the nurses as well (Young, 2008). Changes in the technology development, health care settings and new methods of patient care have increased the importance of clinical decision making. In order to take care of patients, clinical decision making is widely used by nurses and practitioners. Clinical decision making is a phenomenon that is frequently used in many areas of practice which involves stages of patient assessment, determining, accepting or rejecting the diagnosis, and selecting the best care strategies for patients (Standing, 2008). Critical care is different from other areas of nursing and thus the importance of clinical decision making increases (Chapman and Sonnenberg, 2003). Nurses are dealing with patients whose conditions change rapidly. So time is a limitation in this case (Chitty, 2005). A recent study shows that nurse make decisions in every 30 seconds about one of the following incidents; nursing interventions, communicating information and evaluating the patient’s conditions (Rycroft-Malone and Bucknall, 2010). So decision making for them is dynamic and unpredictable. The Process of Decision-Making Clinical decision making requires the early development of hypothesis diagnosis (Ramezani-Badr, Nasrabadi, Nikbakht, Zohre and Taleghani, 2009). The further data collection will be aimed at either approving or disproving the diagnosis. Specialist practitioners are generally trained to think in a particular way. They use the evidence based system to in their decision making process (King, Duke and O’Connor, 2009). Medical evidence is not normally concerned with broader patient concerns but accepting it routinely influences clinical recommendations (Chiappelli, 2010). However, this does not preclude that additional information is not needed in order to provide a more complete profile of each patient. The diverse nature of information is potentially valuable as well as the quality of interaction between the team members (McGloin and Mcleod, 2010). Team decisions are expected to arrive at decision routes that are different from those taken by individuals working alone (Perkins, Jensen, Jaccard, Gollwitzer, Oettingen and Pappadopulos et al, 2007). This also has an ethical stance associated to it in terms of counterbalancing any personal judgments formulated (Morrison and Monagle, 2009). This is because individual decisions are based on the narrow findings, so judgments can easily be covered by personal prejudice (Eccles et al, 2007). This will only serve the need of the practitioner more than the patient (Devettere, 2009). Effective vs. Ineffective Decision-Making Effective use of assessment information through decision making process is essential to improve the outcome of the critical care (Gambrill, 2005). The process of decision making can be seen from a variety of angles. Ineffective decision making may have serious consequences since they are influencing the patient’s outcome (Gambrill, 2005). It is important to understand the factors that affect the clinical decision making. Concept Attainment Theory Concept attainment theory provides a rational approach towards the study of decision making (Dalton, 2003). It states that in order to attain a hypothesis or concept, acquisition, retention and utilization of attributes with decision making is required. This outlines three main elements; attributes, concepts and strategies. Attributes are the different features of an event or condition which vary from time to time. It can include the history of a patient and the currents signs and symptoms. A concept is a network of ideas that are formed as a result of combining the attributes. A set of attributes can be combined with another set of attributes in order to develop a concept. A strategy is used to work out the decision making problem. It is a series of processes or mental operations for acquiring, retaining and utilizing the information. It is mostly referred to as a process of subconscious rather than a conscious plan. A strategic decision is usually dependent upon the nature of the concept, the resources available in the process and the potential consequence of each alternate decision (Buckingham and Adams, 2000). For example, in a cardiac arrest it is essential to attain a concept as quickly as possible without much concern to accuracy of results or the mental effort involved. However, there might also be a situation in which accuracy of results is the prime considerations. In general, decision making strategy is the ability to reach a decision with the least amount of information along with the strain, while achieving the greatest certainty and the least amount of error (Legare et al, 2008). Types of Decision-Making Theories Before describing the decision making theories it is important to understand the types of decisions making that influence the whole process. Descriptive decision theory: which concentrates on the immediate solution Normative decision theory: which has an idealistic approach Behavioral or Cognitive decision theory: which is a mediator between the descriptive and normative theory As decision making is highly complex, there is no single accepted theoretical approach or research based approach to clinical decision making (Legare, Stacey, Elwyn, Pluye, Gagnon, Frosch, Harrison, Kryworuchko, Pouliot, and Desroches 2008). Experts, however, have outlined three major approaches to decision making (Ito, Pynadath and Marsella, 2009): Decision analysis theory: this is also referred to as normative or prescriptive theory and it involves statistical modeling of the decision making process. Behavioral decision theory: this includes the social judgment analysis and uses experimental methods to observe real life decision making process. Information-processing theory: this uses process tracing approaches in combination with the verbal data reports to explain human cognition. The first approach is usually referred to as the prescriptive view of decision making while the other two are referred to as descriptive approaches to decision-making. The intersection in the model describes the space in which decision making and the psychological bias is rational. Descriptive Decision-Making The theories in descriptive decision making focus on how one actually makes decisions. These are complex techniques which are related to the fields of heuristics and biases. Several types of descriptive models have several types of comparison between attributes and alternatives (Koehler and Harvey, 2004). Theories of choice in organizational decision-making emphasize on the rational methods of decision-making on the basis of expectations. One of the central themes of descriptive decision-making is the concept of Bounded rationality which states that rational behaviours occur within certain constraints which include cognitive ones as well (Eder, 2010). A theory linked to this concept is the Satisficing Model Theory. This theory states that decision makers choose an alternative that exceeds some standard or criteria. Some of the other well-known descriptive theories of decision making are Prospect Theory of Kahneman and Tversky and Regret Theory by Bell, Loomes, and Sugden (Kunreuther, 2001). Normative Model of Decision-Making Effective decision making is a process by which individuals identify areas of a problem, outline the alternatives, measure the associated gains and losses and freely make a choice. The normative decision making model is based on this microeconomic concept. It describes how one should make a decision (Baron, 2004). The very well-known theories under this category include Expected Utility Theory of Von Neumann and Morgenstern and Subjective Expected Utility Theory by Savage (Ruger, 2007). It has been argued that theories for practitioners do not reflect the uniqueness of practitioners. One such theory is the self-efficacy theory to empower clients through education. Another is the theory of reasoned action which helps in informing about the nurse’s attitudes and caring behaviour. Cognitive Decision-Making Cognitive decision making does not include complex optimization techniques or numerical calculations. It includes properties of socio-cognitive individual or organizational decision making (Gadomski, 2006). These theories were developed for evaluating acts of acceptance or rejections based on judgments about particular propositions (Hardy-Valle, 2007). Cognitive models are also used to analyze risk taking behaviour (Galott, 2008). This puts better understanding in the factors underlying this behaviour. Cognitive continuum theory bridges the gap between the need for increased quality in decision-making and for practitioners to be accountable for their decisions (Greaves, 2009). Cognitive Continum Theory This theory provides a middle ground for decision making in clinical practice. It is both perspective and descriptive. It states how judgments are related to cognition. It suggests six broad modes of decision making based on cognition and judgment task structure (Cader, Campbell and Watson, 2005). This ranges from intuition to analysis. The judgment task goes from ill-structured to well-structured. The more structured the task the more it will be easier for decision making. The three dimensions of this concept include the analysis, intuition and quasirationality (Offredy, Kendall and Goodman, 2007). Analysis is the process of slow data processing, conscious awareness and task specific in method. Intuition is the unconscious and rapid data processing. There is low cognitive control, low awareness and low confidence in the method. Quasirationality includes the elements of both intuition and analysis method and is in the central region of the cognitive continuum. The six dimensions to the mode of inquiry that make different demands on human judgments are identified as follows (Standing, 2008): Mode 1 is the most analytical, it requires true experiments for supporting evidence of decision making Mode 2 is less analytical and requires statistical inferences. It is also known the mode of controlled group experiments. Mode 3 is the weakest analytical mode because of double-blind and random assignments which are often not feasible. Mode 4 is less analytical than mode 3 and relates to thought experiments Mode 5 have decisions of expert judgments, it is intuitive and relies on database experiment’s judgments. Mode 6 is purely based on intuitive thoughts and is formed of unrestricted judgments. Inferences drawn from patterns of information are the pattern recognitions of experiments. Inferences made from observation of statistical data constitute the functional relations. Oscillation is the shift of cognition from analysis to intuition and vice versa. Modes 2 and 3 are quasirational (analysis weighted) and modes 4 and 5 are quasirational (intuition weighted). Modes 1-3 apply to the assessment of functional relations of dependant and independent variables with decreased levels of control. In experimental mode measurements are based on experimental summaries and findings are generalized over a wider population. System aided judgments involve usage of tools like Baye’s theorem with subjective probabilities to guide clinical judgments. Peer-aided judgment involves taking opinions from colleagues and seeking expert advice where required (Cader, Campbell and Watson, 2005). Tasks in Cognitive Approach Tasks are more focused on direct, systematic, experimentation and research based solutions. These occur in modes 1-3. Unless the practitioners work in a well resourced facility where controlled trials occur, modes 1-3 rarely occur. Therefore, the nature of tasks presented depends on the task environment to make subsequent cognitive choices (Higgs, 2008). The tasks can be well structured or ill structured. Well structured tasks induce analysis and have a high level of certainty, for example a nurse deciding upon the significance of tracing form an electrocardiograph and takes time to compare it with normal cardiograph (Hollnagel, 2003). To increase the level of certainty the nurse can decompose the graph into sections to carry out the analysis. Ill structured tasks induce intuition and need to be resolved quickly, for example when a nurse attempts to support a falling patient, the speed of this incident is such that it is impossible to break it into subtasks (MacLeod, Hone and Smith, n.d.). This type of decision making links the information and thinking with the nature of the decision faced. This is essential to primary care where practitioner often experience a generalist perspective to particular demands in terms of providing information to support decision making (Offredy, Kendall and Goodman, 2007) An example of different modes of cognition and information related consequences include like the well structured pharmaceutical decision of dose A versus dose B for some medication. Decisions have more structure where previous experience helps with the signs and symptoms (Kam, Chismar and Thomas, 2004).. In the four middle range modes of cognition relating to quasirationality, two are biased towards intuition and two are biased towards analysis (Cader, Campbell and Watson, 2005). Applying the Cognitive Continuum in the Introduction of 12 hr shift Concerns of the 12hr shift 12 hr shifts usually have three concerns when being applied in any domain. First, there is a chance of potential exhaustion and mistakes because of the long working day. Second, there is a chance of lower quality and less efficiency in the service provided. Lastly, the dynamics of staffing and scheduling methods may be difficult to maintain with regard to switching and backing up of teams. (King, Duke and O’Connor, 2009) The research conducted on this issue mainly focuses on the staff’s fatigue i.e., how much sleep and rest they can get while off duty. Some research however shows that extended 12 hr shifts are as safe as any other less hour shift and the amount of sleep is improved because the staff gets more days off (Shiftwork Solution LLC, 2010). The risk is more where there is heavier patient workload and a greater nurse to patient ration. Researchers view on 12 hr shifts A substantial decline in the cognitive performance was experienced when nurses worked in five consecutive shifts (Dula, Hamrick and Wood, 2001) where as in 12 hr shifts the consecutive shifts are two or three. Nobody would want a nurse on the fifth or sixth consecutive night with a decrease in cognitive performance because patient’s safety is a priority here. 12 hr shift rotations have often shown improved continuity of care and communication between the staff and the health care professions (McGettrick and O’Neill, 2006). They get more time to plan and prioritize patient care and can obtain a better knowledge about the situation (Richardson, Turnock, Harris, Finley and Carson, 2007). This can also prove to be a recruitment and retention strategy demonstrating improved work life balance (William, 2008) because of lower stress level and physical and psychological advantage (Dwyer, Jamieson, Moxham, Ansten and Smith, 2007). Applying the Cognitive Continuum As 12 hr shifts are usually presumed to cause medical errors, the negative perception is because of the fact that they increase the complexity of judgmental tasks especially when medical resources are limited. Cognitive continuum theory imposes that changes in task environment will induce changes in the mode of cognition. According to this theory, in the dynamic medial environment a gradual movement along a continuum of intuition and analysis occurs as a result of changes in task properties (Kam, Chismar and Thomas, 2004). The accuracy of cognition depends on selection the right mode of cognition. What is most important in the longer shifts is how the staff handles the patients in accordance with the negative factors affecting them (Kelly, 2009). But this factor can be overcome by the fact that social care is important in decision making as suggested by the cognitive continuum theory. The longer shifts will give a chance to familiarize the work setting more intuitively. There will be opportunities for repeat learning and access to senior professionals all time (Cox and Hill, 2010). The theory can be used in any context where decision making is crucial even in nursing activities where they need to take decision to assist patients (Cader, Campbell and Watson, 2005). It assists them to find out the modes of cognition depending on the number and nature of cues by patients (Botti and Reeve, 2003). It will provide a framework to assist them in aiming for accuracy in decision making process (Pleskac, Dougherty, Busemeyer, Reiskamp and Tenenbaum, n.d.). With evidence based practice, the practitioners are encouraged to adopt the analytical approach in decision making. Intuitive thinking arises also when many cues are available (Higgs, 2008). The staff will have an environment in the longer shifts to learn from the cues until they gather enough experience. The quasirationality will balance both their intuitive as well as analytical thinking (Standing, 2008). The quasirational mode should offer the required framework to the practitioners in the shift to carry out the appropriate levels of analysis as required by their judgment tasks. It is crucial for nurses to be able to uses this theory provided they are given necessary education for this (Cader, Campbell and Watson, 2005). Conclusion This theory will offer them a comparison between analysis and intuition. Accuracy in decision making depends on the tasks they will be undertaking. This will exercise their skills better. The inclusion of Cognitive Continuum Theory in the 12 hr shift will not only increase the knowledge-base of nurses and practitioners, but will also ensure an explicit level of analysis in their decision-making process. It will also highlight the importance of using evaluation criteria in judgments and decisions. It will serve as a tool to assist in the decision making process making it transparent to peers and other professionals. References 1. 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