Klein (1993, 1995, 1998) describes versions of recognition-primed decision making. At the basic level, the decision maker recognises the situation and knows an appropriate response. When the situation is more complex, there is a longer assessment which involves searching for cues to match a possible explanation. If the decision maker is less confident of a course of action, they may run a mental simulation to check for problems and allow for change. Only if a course of action is rejected is another sought. Only one option is considered and the whole process feels automatic.
This method has the advantages of:
- rapid recognition and response
- requiring less mental effort
- usually giving a workable solution (even if not the optimal solution)
- being useful in routine situations
- being reasonably resistant to stress
The limitations of recognition-primed decision making include:
- the need for a correctly and completely identified situation; situations with variability, uncertainty, chaos, ambiguity and delayed outcomes are particularly difficult (is the tachycardia and hypotension really hypovolaemia, or is it anaphylaxis?)
- that it may reinforce seeking evidence that supports expectation rather than challenging the hypothesis
- the assumption of experience
- that it may be difficult to justify if erroneous
Simulation training may help us to learn patterns for later recognition providing the simulation is sufficiently realistic.
Rule-Based Decision Making
Rule-based decision making is very rapid if the appropriate rule has been learned and remembered; for example:
When a patient is not breathing or does not have a pulse, we need to be able to respond immediately, without a prolonged consideration of history, examination or investigation. Rule-based decision making is a significant part of life support courses. As the guidelines and protocols have been decided in advance, the mental effort to reach a decision is reduced to deciding which protocol to apply.
In order to be useful, the rule needs to be available (whether remembered, displayed on a chart, or looked up on a handheld computer or mobile phone) and presented in a form that is rapidly intelligible.
Advantages of rule-based decisions include:
- being useful for life-threatening emergencies where a rapid, accurate response is needed
- being useful for novices and changing teams
- that the thinking has been done calmly at a distance
- that it is easy to justify your actions – ‘the guideline said I should do …’
- that sequences may be performed without staff having to be aware of the evidence and the reasoning behind the treatment at the time
Disadvantages of rule-based decisions include:
- that it can be time consuming to consult a manual if you already know what to do
- situations where the rule cannot be accessed – if it has been forgotten, the computer is down or the checklist is mislaid
- it is possible to miss a step, as when interrupted
- the rule may be out of date
- the wrong rule may be selected
- use may foster lack of thought and understanding and cause decay of decision-making skills
Stress
Task performance, including decision making, is not optimal when we have low levels of arousal or stress. Performance improves with more stress, but above a threshold of increasing stress, our performance deteriorates (see Chapter 8). This is known as the Yerkes–Dodson law or curve. This deterioration in performance impairs our ability to make good decisions under significant stress. As a non-clinical example, we can see contestants on a TV quiz struggling to answer questions that appear straightforward to viewers who are not under such stressful scrutiny.
Practical Strategy and Application
Selecting and Implementing an Option/Option Appraisal
We can compare options, identifying the benefits and hazards of each course of action. We could make this into a decision tree, implicitly or explicitly attempting to put probabilities onto the framework. This process requires mental effort and time, as well as a basic knowledge of the field, so its usefulness in a time-critical emergency is limited.
There are decision aids to improve the efficiency of option selection; they usually have the following stages:
- SA to recognise and define the problem
- generation or consideration of one or more options
- selection and implementation of an option
- review of the outcome of the action
British Airways pilots are taught to use T-DODAR:
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