Situation Assessment and Decision Making Strategies of Emergency Medical Services Physicians in Routine and Non-Routine Situations

Abstract

Naturalistic decision making (NDM) research is focused on macrocognition - cognitive functions and processes used by experienced people working in real-world settings (Crandall, Klein, & Hoffman, 2006). These settings characterize ill-structured problems; uncertain dynamic environments; shifting, ill-defined, or competing goals; action/feedback loops; time stress; high stakes; multiple players; and organizational goals and norms (Orasanu & Connoly, 1993). Exactly such setting, with multifactorial influences on cognition, is health care. In this field evidence based medicine (EBM; Rosenberg & Donald, 1995) is preferred, representing the normative approach, sometimes difficult to meet in real-world situations. By contrast, the main idea of NDM is that professionals rely heavily on their previous experience stored in memory, as described by the Recognition-Primed Decision model (RPD model; Klein, 1997). It is viewed as the experiential basis of intuition that enables rapid recognition of situations and decisions. Simply put, intuition is recognition (Simon, 1992).Two of the primary macrocognitive functions are situation assessment and decision making (Klein et al., 2003), included in the RPD model. Situation assessment (SA) is about understanding of what is going on in the course of dynamic unfolding situations, during which elaboration of an existing SA or shifting to a new SA may occur repeatedly (Kaempf, Wolf, & Miller, 1993). From the SA viewpoint, clear situations are usually immediately identified (recognized), and ambiguous situations need to be diagnosed. In NDM, the term diagnosing has not been used only in a medical context, it has been used to express deliberative SA regarding different situational problems as well. Based on the review (Zsambok, Beach, & Klein, 1992), there are the following SA strategies included in the RPD model: pattern matching - is about matching larger observed patterns with remembered patterns of previous situations; feature matching - is about matching observed features with remembered features of previous situations; and mental simulation - is about imagining the likely causal chain of events that preceded the observed situation. Adopting the theory of two processes (Evans, 2007), pattern matching, as an intuitive process, is experiencebased, fast and cognitively effortless and mental simulation, as a deliberative process, is slower and more cognitively demanding (see Klein, 1999). Feature matching is a dominant SA strategy (Kaempf et al., 1993) that can be viewed as an intuitive process, when a decision maker immediately recognizes the features, and as a deliberative process, when a decision maker consciously notices the features and uses them to retrieve a hypothesis or to contrast different hypotheses, concerning the particular unclear situation (Zsambok et al., 1992).SA is usually followed by decision making (DM), which is defined as the selection of one option from a set of options (Klein, Calderwood, & Clinton-Cirocco, 2010) and is interleaved with acting in complex realistic situations (Orasanu & Conolly, 1993), requiring more than one decision. One way to make a decision is a straightforward identification of the situation along with an identification of the typical single option, which is usually automatically implemented. This experience-based, intuitive DM strategy, which corresponds with the RPD model, prevails in experienced people (Klein, 1999). However, when it is not clear what action to take, more cognitively demanding strategies are necessary. There are distinguished two types of option evaluation (Klein et al., 2010; Klein, Calderwood, & MacGregor, 1989): sequential evaluation, when only one option is examined at a time, and concurrent evaluation, when several options are considered at the same time. The first one is characteristic for mental simulation, as the way of imagining the likely consequences of a single option, arriving at a satisficing decision. …