Frontline Decision Makers Research Articles

Bracing for the next wave: A critical incident study of frontline decision-making, adaptation and learning in ambulance care during COVID-19.

To explore frontline decision-making, adaptation, and learning in ambulance care during the evolving COVID-19 pandemic. Descriptive and interpretative qualitative study. Twenty-eight registered nurses from the Swedish ambulance services described 56 critical incidents during the COVID-19 pandemic through free-text questionnaires. The material was analysed using the Critical Incident Technique and Interpretive Description through the lens of potential for resilient performance. The findings were synthesized into four themes: 'Navigating uncharted waters under never-ending pressure', 'Balancing on the brink of an abyss', 'Sacrificing the few to save the many' and 'Bracing for the next wave'. Frontline decision-making during a pandemic contribute to ethical dilemmas while necessitating difficult prioritizations to adapt and respond to limited resources. Learning was manifested through effective information sharing and the identification of successful adaptations as compared to maladaptations. During pandemics or under other extreme conditions, decisions must be made promptly, even amidst emerging chaos, potentially necessitating the use of untested methods and ad-hoc solutions due to initial lack of knowledge and guidelines. Within ambulance care, dynamic leadership becomes imperative, combining autonomous frontline decision-making with support from management. Strengthening ethical competence and fostering ethical discourse may enhance confidence in decision-making, particularly under ethically challenging circumstances. Performance under extreme conditions can elevate the risk of suboptimal decision-making and adverse outcomes, with older adults being especially vulnerable. Thus, requiring targeted decision support and interventions. Enhancing patient safety in ambulance care during such conditions demands active participation and governance from management, along with decision support and guidelines. Vertical communication and collaboration between management and frontline professionals are essential to ensure that critical information, guidelines, and resources are effectively disseminated and implemented. Further research is needed into management and leadership in ambulance care, alongside the ethical challenges in frontline decision-making under extreme conditions. Findings are reported per consolidated criteria for reporting qualitative research (COREQ). No Patient or Public Contribution.

Open to change but stuck in the mud: Stakeholder perceptions of adaptation options at the frontlines of climate change and protected areas management

In recent decades, the literature on climate change and biodiversity conservation has proposed numerous climate change adaptation options; however, their effectiveness and feasibility have rarely been evaluated by those involved in frontline decision-making. In this paper, we use data from a two-day climate change adaptation workshop held at Bruce Peninsula National Park and Fathom Five National Marine Park, in Ontario, Canada, to understand stakeholder views on different types of adaptation options. We found that most (45%) adaptation options identified by participants were “conventional” (i.e., they are already in use and are relatively low risk and familiar to practitioners) and oriented towards directing change (i.e., they aim to help species and ecosystems respond to change and transition to a desired future state). These options also received higher effectiveness and feasibility ratings than “novel” ones. The remaining options (55%) were either “conventional” and aimed towards resisting change, or else were “novel.” Our results suggest that practitioners are open to working with change; however, there is some management resistance to more dynamic “novel” options (e.g., adjusting species assemblages), which in many instances will be required to effectively deal with inevitable climate change impacts. By focusing on understanding the factors that influence the prioritization and feasibility of adaptation options at the regional scale, and by providing practical recommendations to enhance organizational capacity to adapt to climate change, we address key implementation gaps identified in the literature.

Resident and nurse perspectives on the use of secure text messaging systems.

As hospitals shift away from pagers and towardssecure text messaging systems (STMS), limited research exists on the drawbacks of such systems. Preliminary data show that introduction of STMS can lead to a dramatic increase in interruptions, which may contribute to medical errors. This study aimed to investigate residents' and nurses' experiences with STMS at a quaternary care children's hospital. This was a qualitative study with focus groups. Participants were pediatric residents and nurses at Lucile Packard Children's Hospital. Focus groups were audio recorded, transcribed verbatim, and coded by 2 independent coders. Codes were discussed until consensus was reached. Data was analyzed through a thematic, descriptive content analysis approach. Themes were developed alongside a framework of teamwork, patient safety, and clinician well-being. Three resident focus groups (n = 14) and three nurse focus groups (n = 21) were held. Six themes were identified: (1) STMS can facilitate teamwork through multiple communication modalities and technological features. (2) STMS can negatively impact teamwork by decreasing face-to-face communication and frontline decision-making. (3) STMS can promote patient safety through closed-loop communication and ready access to team members. (4) STMS can negatively impact patient safety through alarm fatigue, interruptions, and miscommunication. (5) STMS can positively impact clinician well-being through satisfaction and relationship building. (6) STMS can negatively impact clinician well-being through increased stress related to communication volume. Use of STMS in the hospital setting has many advantages as well as drawbacks. With appropriate guidelines and training designed to mitigate the drawbacks, STMS have the potential to be valuable means of communication for healthcare team members.

Deliberation and Deliberative Organizational Routines in Frontline Decision-Making

AbstractDeliberation is a widely recognized but understudied aspect of frontline decision-making. This study contributes to theory development by exploring deliberative practices in frontline organizations and their implications for decision-making. Drawing on a multi-sited ethnographic study in three Danish child welfare agencies, the analysis clarifies the multiple purposes of deliberation in everyday practice and shows how deliberation is enabled and structured by formalized and informal deliberative organizational routines. Findings show that deliberation may influence individual decision-making or amount to collective decision-making. Depending on how deliberative organizational routines are enacted, deliberation may serve to enhance professional judgment, ensure appropriate justification for decisions, and alleviate uncertainty and emotional strain. Yet, while deliberation represents a productive form of collective coping, deliberative routines may also obscure transparency and reify dysfunctional group dynamics. A conceptual framework is developed to support further research into the purposes, practices, and implications of deliberation across diverse street-level contexts.

Homelessness and the ‘over-judicialisation’ of welfare

AbstractMembers of the senior judiciary have expressed concern about the ‘over-judicialisation’ of welfare in the context of homelessness decision-making and adjudication. This paper examines how those fears have been manifested and makes a link with the concept of proportionate dispute resolution (PDR). It argues that the statutory scheme incorporates elements of PDR and judges should therefore refrain from introducing additional layers. The courts’ denial of the application of Article 6 of the European Convention on Human Rights to the homelessness context is disputed, and the paper makes the case for continuing rigorous judicial oversight of front-line decision-making, recommending that attention is focused on assessing procedural safeguards rather than disputing the ambit of Article 6.

Regional anaesthesia practice for arteriovenous fistula formation surgery.

SummaryWe conducted a survey and semi‐structured qualitative interviews to investigate current anaesthetic practice for arteriovenous fistula formation surgery in the UK. Responses were received from 39 out of 59 vascular centres where arteriovenous access surgery is performed, a response rate of 66%. Thirty‐five centres reported routine use of brachial plexus blocks, but variation in anaesthetic skill‐mix and practice were observed. Interviews were conducted with 19 clinicians from 10 NHS Trusts including anaesthetists, vascular access and renal nurses, surgeons and nephrologists. Thematic analysis identified five key findings: (1) current anaesthetic practice showed that centres could be classified as ‘regional anaesthesia dominant’ or ‘local anaesthesia/mixed’; (2) decision making around mode of anaesthesia highlighted the key role of surgeons as frontline decision makers across both centre types; (3) perceived barriers and facilitators of regional block use included clinicians’ beliefs and preferences, resource considerations and patients’ treatment preferences; (4) anaesthetists’ preference for supraclavicular blocks emerged, alongside acknowledgement of varied practice; (5) there was widespread support for a future randomised controlled trial, although clinician equipoise issues and logistical/resource‐related concerns were viewed as potential challenges. The use of regional anaesthesia for arteriovenous fistula formation in the UK is varied and influenced by a multitude of factors. Despite the availability of anaesthetists capable of performing regional blocks, there are other limiting factors that influence the routine use of this technique. The study also highlighted the perceived need for a large multicentre, randomised controlled trial to provide an evidence base to inform current practice.

Cloud-based mobile gateway operation system for industrial wearables

Abstract With the prosperity of wearable computing and industrial sensing technologies, industrial wearables are widely adopted in industries to collect real-time information, facilitate daily operations, and support front-line decision-making. Although many attempts have been made, the heterogeneity of industrial wearables makes them knotty and time-consuming to integrate with complex business/operation logics. Aiming at facilitating their efficient implementation in real-life complex scenarios, this paper proposes Cloud-based Mobile Gateway Operation System (CMGOS) for industrial wearables. It has two core components: Mobile Gateway Operation System (MGOS) and Microservices Cloud (MssC). MGOS is designed as a lightweight mobile middleware to deal with the heterogeneity of industrial wearables, in which reconfigurable mobile agent is proposed to realize Hot Universal Plug and Play (HUPnP) management of industrial wearables. MssC is built to serve MGOSs with cloud computing resources in microservice architecture, which could enhance the computing capabilities of industrial wearables. Finally, a prototype of CMGOS is developed and implemented to verify the proposed solution for managing heterogeneous industrial wearables in an E-commerce order picking scenario.

Beyond the law: processes underlying religious accommodation decisions

PurposeCurrently, the academic understanding of religious accommodation in the workplace is skewed toward a consideration of legal decision making. The purpose of this paper is to move beyond these legal considerations and provide a fresh perspective on antecedents of religious accommodation decisions when managerial discretion is high. To this end, the authors present a model that incorporates psychological and relational processes.Design/methodology/approachThis research draws on a variety of theoretical perspectives from psychology, organizational behavior and human resource management to theorize a descriptive model of managerial decision-making regarding religious accommodation requests.FindingsThe authors develop a conceptual framework and research agenda for examining front-line decision-makers’ responses to employees’ religious accommodation requests. The focus is on characteristics of the decision maker, the requester and the request that can influence the perceived sincerity of a request and the perceived accommodation cost.Research limitations/implicationsThe proposed model moves beyond US-based legal perspectives of religious accommodation and facilitates the identification of novel theoretical perspectives for better understanding accommodation decisions.Practical implicationsTwenty-first century managers are faced with a wide variety of religious accommodation requests. Identification of underlying mechanisms through which these decisions are made facilitates effective interventions to build and sustain an inclusive culture.Originality/valueThis work is among the first efforts in the management literature to theorize about the process of religious accommodation decision making. The authors address the paucity of academic research in this area by introducing perceptual drivers of religious accommodation decisions.

Tyrosine Kinase Inhibitors in the Treatment of Chronic-Phase CML: Strategies for Frontline Decision-making.

Over the past two decades, the introduction of tyrosine kinase inhibitors (TKIs) has transformed the treatment of chronic myeloid leukemia (CML). With four agents currently approved for frontline use in chronic-phase (CP) disease, it follows that treatment decision-making has been rendered more challenging. Here we will review recent advances that help inform the selection of a first-line TKI. Extended follow-up of the seminal CML trials has demonstrated the long-term efficacy of TKIs, while also highlighting significant differences in their respective toxicity profiles and potency. Dasatinib and nilotinib generate deeper molecular responses than imatinib, particularly among patients with higher risk disease, but this has not translated into a significant survival advantage. Similar results have been obtained at 1year with bosutinib; its efficacy and toxicity were well balanced at a dose of 400mg daily, prompting its recent approval for this indication. Lastly, multiple studies have demonstrated that TKIs can be safely discontinued in select individuals who have maintained deep responses for extended periods, establishing treatment-free remission as a novel goal in CP CML. The careful consideration of parameters such as disease risk, the potency, and toxicity profile of each TKI, as well as each patient's unique comorbidities and preferences, enables truly individualized therapeutic decision-making in CP CML, with the goal of ensuring that a high quality of life accompanies the survival advantage conferred by these agents.

Abstract TP290: Tertiary Center Telestroke

Introduction: Telestroke is used increasingly at hospitals where on-site stroke expert support is not available. Even at tertiary teaching hospitals senior stroke experts are not generally on-site out of hours. Here front-line decision-making is made either by junior doctors with or without telephone back-up by more senior staff or senior staff drives in from home to attend the case in person. Telestroke for remote expert support is not commonly used in this setting. Hypothesis: That telestroke at a tertiary centre is feasible without adversely affecting quality of care. Methods: This is a sequential comparison capturing all stroke patients thrombolyzed out-of-hours 12 months before implementation of tertiary hospital telestroke and 12 months after. Main outcomes were thrombolysis rate, treatment times and symptomatic intracerebral hemorrhage rate. Participating neurologists were surveyed about their experience. Results: Over the 24-month study period, 80 patients (38 pre- and 42 telestroke) were thrombolyzed out of 584 patients admitted with ischemic stroke. The overall thrombolysis rate of all patients presenting with ischemic stroke was 20.2% pre- and 21.6% post-telestroke with 26.0% and 28.8% out-of-hours rates respectively. Median (IQR) out-of-hours door-to-needle time was 65 (45-100) minutes before and 57 (41-78.5) minutes after with 45.7% treated within 60 minutes of arrival pre and 52.3% post (OR (95%CI) 1.30 (0.53-3.17);p=0.56). Median door-to-CT time dropped from 34 (26-58) pre to 25.5 (17.5-46.5) post (p=0.21). The sICH rate was 2.6% pre- and 2.3% post-telestroke (OR (95%CI) 0.38 (0.03-4.41); p=0.42). The neurologists were highly satisfied with the new model as it meant they no longer had to drive in from home out-of-hours and co-ordination of on-call activities, which include provincial telestroke was less stressful. Conclusion: Tertiary center telestroke can be safely implemented to reduce on-call burden for neurologists while maintaining a high thrombolysis rate and acceptable door-to-needle times and sICH rates. Especially where the same neurologists also support out-of-hours regional telestroke managing both patient groups in the same manner can streamline processes of care.

Displacement as Regulation: New Regulatory Technologies and Front-Line Decision-Making in Ontario Works

AbstractThis paper explores how new regulatory technologies and front-line decision-makers reshape one another. Drawing on a recent qualitative study of caseworker decision-making in the Ontario Works program, it demonstrates the dialectical relationship between new case management software and caseworkers. While new technologies may attempt to deskill and decentre front-line decision-makers, transforming them into data entry clerks, caseworkers learn how to expertly translate and input client data to produce decisions that more closely match their interpretation of clients’ needs and welfare laws. The ways in which workers “manipulate the system” to produce a particular decision, though common knowledge among their colleagues, are black boxed to program managers, auditors, and benefits recipients.

Holistic, expert and centralised models for organising care placement decisions: findings from Finland

This article examines the organisational models of decision-making regarding care placements in child welfare. Many countries currently report reorganising and economising their services and greater use of independent and voluntary agencies, all of which will have a direct and indirect influence on placement decisions about children in care. Very little is known about how public authorities make these decisions, what processes achieve the best option for a child and how different organisational models interact with front-line decision-making. The article is based on a study of placement decisions in Finland. The data comprise 49 phone interviews and five focus group interviews with social workers and their managers in charge of substitute care in different municipalities. The analysis presents three decision-making models: the holistic model, the shared expertise model and the centralised model. Each of these rests on different understandings of knowledge, expertise and client participation. The study predicts that the centralised model is likely to become more common due to the reorganisation of social services. While this may strengthen the managerial process and enhance the quality of decision-making, it is likely to diminish the relationship-based casework that is typical for the holistic model.

Inclusive intake screening: shaping medical problems into specialist-appropriate cases.

This paper examines medical intake screening through the process of making appointments with medical specialists. By employing a multi-method, qualitative approach, it shows how decisions to schedule doctors' appointments are based on medical knowledge about physicians' specialties and specific organisational practices. It draws on insights from first-contact interactions between clients and institutional gatekeepers to enrich our understanding of intake screening. In relation to gatekeeping, rationing commonly gets framed as restrictive screening practices, with a preference for denying or limiting access to treatment. Restrictive screening practices are typically organised to elicit a narrow range of information ('facts') relevant to specific eligibility criteria; whereas inclusive intake screening tends to involve less scripted, more complex and open-ended interactional exchanges between workers and clients, wherein workers help clients frame their claims in ways that will increase their chances of getting accepted. Front-office workers hold a preference for inclusive intake screening, a preference that is undergirded by the referral-driven nature of this stage of patient processing, and by a work environment that favours inclusive screening. This finding builds on the literature within medical sociology, but also extends our understanding of frontline decision-making and the distribution of resources within a variety of people-processing institutions.