Recognition-primed Decision-making Research Articles

Systems Forces Leading to Feeding Tube Placement in Patients with Advanced Dementia: A Qualitative Exploration of Clinical Momentum.

Background: Older adults with serious illness near the end-of-life often receive invasive treatments. We developed a conceptual model called clinical momentum that describes system-level forces producing a trajectory of care that is difficult to modify and contributes to overtreatment. We sought to evaluate the empirical fit of our model by examining an event with clear guidelines against intervention: permanent feeding tube placement in patients with advanced dementia. Methods: We screened three hospitals and identified patients 65 years and older with advanced dementia who received a permanent feeding tube. We interviewed 34 family members and clinicians. We coded transcripts and characterized factors that arose during the course of care and their relationships to feeding tube placement. We used abductive analysis to compare the data with theory and identify areas of discordance and alignment. Results: We found that the course of care started with a temporary tube to correct an acute problem. As problems were identified, multiple clinicians were consulted to address a specific problem without collective discussion of the patient's health trajectory. Eventually, clinicians had to address the temporary tube, which was framed to families as a decision to place a permanent feeding tube or withdraw treatment. Conclusion: Elements of the model-including recognition-primed decision-making, "fix-it," and sunk costs-contributed to placement of a feeding tube, which set in motion a path toward intervention long before a goals-of-care conversation occurs. Clinical momentum expands our understanding of overtreatment at the end-of-life and may reveal opportunities to reduce other nonbeneficial interventions.

Decision-Making During High-Risk Events: A Systematic Literature Review.

Effective decision-making in crisis events is challenging due to time pressure, uncertainty, and dynamic decisional environments. We conducted a systematic literature review in PubMed and PsycINFO, identifying 32 empiric research papers that examine how trained professionals make naturalistic decisions under pressure. We used structured qualitative analysis methods to extract key themes. The studies explored different aspects of decision-making across multiple domains. The majority (19) focused on healthcare; military, fire and rescue, oil installation, and aviation domains were also represented. We found appreciable variability in research focus, methodology, and decision-making descriptions. We identified five main themes: (1) decision-making strategy, (2) time pressure, (3) stress, (4) uncertainty, and (5) errors. Recognition-primed decision-making (RPD) strategies were reported in all studies that analyzed this aspect. Analytical strategies were also prominent, appearing more frequently in contexts with less time pressure and explicit training to generate multiple explanations. Practitioner experience, time pressure, stress, and uncertainty were major influencing factors. Professionals must adapt to the time available, types of uncertainty, and individual skills when making decisions in high-risk situations. Improved understanding of these decisional factors can inform evidence-based enhancements to training, technology, and process design.

One Minute in Haditha: Ethics and Non-Conscious Decision-Making

ABSTRACTIn November 2005, U.S. Marine Sergeant Frank Wuterich fired on and killed five unarmed Iraqi men standing by a car near the site of an improvised explosive device explosion (IED) in Haditha, Iraq. Moments earlier, the IED had destroyed a vehicle in the convoy that Wuterich led, killing one of the men in it. This article argues that analyzing Wuterich's conduct as a rapid non-conscious response captured by the model of Recognition-Primed Decision-Making (RPD) allows us to reconstruct his implicit decision-making in ways that provide insight into psychological processes that may operate during combat. Emerging research in neuroscience suggests that RPD in situations with moral significance involves a complex neural computational process in which emotion plays a powerful role. This article maintains that incorporating these insights can provide greater understanding of the moral psychology of behavior in combat, and may help guide military-ethics training for asymmetric conflicts that pose difficult significant challenges in distinguishing combatants from civilians.

The role of planning in outdoor adventure decision-making

ABSTRACTThis article explores the influential role of planning on recognition-primed decision-making. Considerable prior thinking occurs and there is a need to trace and account for the cognitive processes that precede and guide decisions in dynamic outdoor environments. Seven expert leaders from four countries were interviewed about memorable decisions made on outdoor journeys with an educational focus on land, sea and ice. Four stages of planning were identified: (1) long-term preparation; (2) formal leadership meetings; (3) day-by-day planning on route and (4) thinking immediately prior to the event. The stages sequentially capture the planning progression, illuminating the cognitive processes at each stage to culminate in option selection. In each decision situation, planned goals and actions were implemented through the creation and re-creation of micro-plans. As windows of opportunity presented themselves, the flexible execution of plans was a key feature. Planning provided the solid bedrock upon which decisions were made.

Identification of Barriers to Pediatric Care in Limited-Resource Settings: A Simulation Study.

Eighty percent of the 10 million annual deaths in children aged <5 years in developing countries are estimated to be avoidable, with improvements in education for pediatric emergency management being a key factor. Education must take into account cultural considerations to be effective. Study objectives were: (1) to use simulation to identify factors posing barriers to patient care in limited resource settings (LRS); and (2) to understand how simulations in LRS can affect communication and decision-making processes. A qualitative study was conducted at 17 different sites in 12 developing countries in Asia, Latin America, and Africa. Data from observations of 68 in situ simulated pediatric emergencies were coded for thematic analysis. Sixty-two different "key informants" were interviewed regarding perceived benefit of simulations. Coding of observations and interviews yielded common themes: impact of culture on team hierarchy, impact of communication and language barriers on situational awareness, systematic emergency procedures, role delineation, shared cognition and resource awareness through simulation, logistic barriers to patient care, and use of recognition-primed decision-making by experienced clinicians. Changes in clinical environments were implemented as a result of simulations. Ad hoc teams in LRS face challenges in caring safely for patients; these include language and cultural barriers, as well as environmental and resource constraints. Engaging teams in simulations may promote improved communication, identification of systems issues and latent threats to target for remediation. There may be a role for training novices in use of recognition-primed or algorithmic decision-making strategies to improve rapidity and efficiency of decisions in LRS.

Supporting Naturalistic Decision Making Through Location-Based Photography: A Study of Simulated Military Reconnaissance

Close Target Reconnaissance (CTR) patrols can be characterized by activities that involve naturalistic decision making to develop situation awareness through processes of sense-making. Any technology that is introduced into such activity needs to be sufficiently “invisible” so as not to disrupt or otherwise interfere with the activities of search and interpretation. It is proposed that some technologies, such as imaging devices, can support recognition-primed decision making (RPDM). It is suggested that providing CTR patrols with cameras could supplement existing technologies, such as night vision goggles or binoculars, and provide an opportunity to capture useful intelligence. The concept of location-based photography (in which metadata are collected in parallel with images) provides a means of effectively producing patrol reports in real time. A prototype system is described and trialled comparing conventional practices surrounding note-taking and report writing with the use of location-based photography. The results show little difference in time spent patrolling under the two conditions but significant improvement in reporting under the location-based photography condition. One explanation of these differences relate to the manner in which note taking provides support for sense-making but could interfere with RPDM (through the need to analyze the situation in sufficient detail to make notes), whereas imaging can be performed as part of the RPDM activity. Tagged images change the nature in which the reports are written in that sense-making is performed largely post hoc, which allows flexibility in interpretation and analysis.

Recognition primed decision making and the organisational response to accidents: Überlingen and the challenges of safety improvement in European air traffic management

The pioneering work of Rasmussen, Reason and their colleagues has greatly improved our understanding of the longer term causes of adverse events in safety-critical systems. Far less attention has been paid to the organisational decision making that characterises the response to accidents and incidents. Therefore, this paper examines the interventions by national and international agencies after one of the most serious accidents in European Air Traffic Management. Insights from Naturalistic Decision Making (NDM) and Recognition Primed Decision Making (RPDM) are used to explain the complex ways in which technical, organisational and political constraints shape and support the decisions and actions taken by different agencies. These constraints affect national and international safety organisations in the aftermath of major accidents. In particular, this paper uses NDM and RPDM to assess the interventions made by Swiss Federal agencies and by the Air Navigation Service provider (ANSP) following the Überlingen mid-air collision in July 1st 2002. Later sections show that there are strong similarities between the technical, organisational and political constraints that informed their decisions and the factors that directed the work of the European Organisation for the Safety of Air Navigation (EUROCONTROL). Some of EUROCONTROL’s safety responsibilities (i.e. the safety regulation elements) will in the future pass to the European Aviation Safety Agency (EASA), an Agency of the European Commission. This transfer of responsibilities has the potential to increase the powers available to ensure the implementation of recommendations following future accidents. At the same time there is a danger that key aspects of existing safety and regulatory activities may be overlooked. It is critical, therefore, that the same level of audit and monitoring be conducted on the European agencies during the transition period as is proposed for service providers and national regulatory agencies. It is important to ensure that these changes do not inadvertently lead to the loss of insights from previous adverse events.

Instructional design for advanced learners: training recognition skills to hasten expertise

Expertise in domains ranging from sports to surgery involves a process of recognition-primed decision-making (RPD) in which experts make rapid, intuitive decisions based on recognizing critical features of dynamic performance situations. While the development of expert RPD is assumed to require years of domain experience, the transition from competence to expertise may potentially be hastened by training that specifically targets the recognition aspect of RPD. This article describes a recognition training approach that is based on expertise theories, research findings, and laboratory measurement techniques. This approach repurposes laboratory research tasks as deliberate practice training tasks. Although pioneered in sports expertise research, this approach is appropriate for pre-service and in-service professionals in a wide range of domains that involve rapid, recognition-primed decision-making.

The effectiveness of groups recognizing patterns

An experiment was conducted in which groups made resource allocation decisions while physically dispersed and supported with a shared virtual work surface (What You See Is What I See—WYSIWIS). The task required groups to recognize patterns of information and collaborate to allocate their resources appropriately. The experimental treatment involved the use of a tool specifically designed to minimize the cognitive effort required to recognize and share patterns among group members. Dependent measures included outcome quality, time-to-decision, consensus of pattern recognition, and the number of resource allocation moves required to reach consensus. All groups received significant financial rewards in direct proportion to their outcome quality. Groups supported with the patternsharing tool had significantly higher outcome quality and significantly less resource movements. These results extend the theory of Recognition-Primed Decision-Making by applying it to groups.

The Role of Prepriming in Recognition-Primed Decisionmaking

Klein's (1989a) Recognition-primed Decision model proposes that the experienced decisionmaker, on encountering an incident requiring complex time-pressured decisions, first categorizes the situation as a variant of a familiar type of problem and subsequently simulates mentally the likely consequences of acting on the basis of the categorization. Drawing on data obtained in two studies, the first with Australian Football League umpires and the second with experienced firefighters, this paper suggests that Klein's model be extended to take into account the active mental processing that occurs immediately prior to the incident. In both studies, participants reported engaging in active simulations, based on the limited information available prior to exposure to the actual decisional incident. This suggests that in many time-pressured naturalistic decision settings, the experienced decisionmaker enters the situation with a number of most-likely prototype situations already activated in memory (preprimed) and that situational assessments and possibilities for action are first made from among this reduced set of preprimed prototypes.