Referral to rehabilitation following traumatic brain injury: practitioners and the process of decision-making

The study aimed to examine the factors influencing referral to rehabilitation following traumatic brain injury (TBI) by using social problems theory as a conceptual model to focus on practitioners and the process of decision-making in two Australian hospitals. The research design involved semi-structured interviews with 18 practitioners and observations of 10 team meetings, and was part of a larger study on factors influencing referral to rehabilitation in the same settings. Analysis revealed that referral decisions were influenced primarily by practitioners' selection and their interpretation of clinical and non-clinical patient factors. Further, practitioners generally considered patient factors concurrently during an ongoing process of decision-making, with the combinations and interactions of these factors forming the basis for interpretations of problems and referral justifications. Key patient factors considered in referral decisions included functional and tracheostomy status, time since injury, age, family, place of residence and Indigenous status. However, rate and extent of progress, recovery potential, safety and burden of care, potential for independence and capacity to cope were five interpretative themes, which emerged as the justifications for referral decisions. The subsequent negotiation of referral based on patient factors was in turn shaped by the involvement of practitioners. While multi-disciplinary processes of decision-making were the norm, allied health professionals occupied a central role in referral to rehabilitation, and involvement of medical, nursing and allied health practitioners varied. Finally, the organizational pressures and resource constraints, combined with practitioners' assimilation of the broader efficiency agenda were central factors shaping referral. (C) 2004 Elsevier Ltd. All rights reserved.

Precautionary principles: a jurisdiction-free framework for decision-making under risk

Fundamental principles of precaution are legal maxims that ask for preventive actions, perhaps as contingent interim measures while relevant information about causality and harm remains unavailable, to minimize the societal impact of potentially severe or irreversible outcomes. Such principles do not explain how to make choices or how to identify what is protective when incomplete and inconsistent scientific evidence of causation characterizes the potential hazards. Rather, they entrust lower jurisdictions, such as agencies or authorities, to make current decisions while recognizing that future information can contradict the scientific basis that supported the initial decision. After reviewing and synthesizing national and international legal aspects of precautionary principles, this paper addresses the key question: How can society manage potentially severe, irreversible or serious environmental outcomes when variability, uncertainty, and limited causal knowledge characterize their decision-making? A decision-analytic solution is outlined that focuses on risky decisions and accounts for prior states of information and scientific beliefs that can be updated as subsequent information becomes available. As a practical and established approach to causal reasoning and decision-making under risk, inherent to precautionary decision-making, these (Bayesian) methods help decision-makers and stakeholders because they formally account for probabilistic outcomes, new information, and are consistent and replicable. Rational choice of an action from among various alternatives-defined as a choice that makes preferred consequences more likely-requires accounting for costs, benefits and the change in risks associated with each candidate action. Decisions under any form of the precautionary principle reviewed must account for the contingent nature of scientific information, creating a link to the decision-analytic principle of expected value of information (VOI), to show the relevance of new information, relative to the initial ( and smaller) set of data on which the decision was based. We exemplify this seemingly simple situation using risk management of BSE. As an integral aspect of causal analysis under risk, the methods developed in this paper permit the addition of non-linear, hormetic dose-response models to the current set of regulatory defaults such as the linear, non-threshold models. This increase in the number of defaults is an important improvement because most of the variants of the precautionary principle require cost-benefit balancing. Specifically, increasing the set of causal defaults accounts for beneficial effects at very low doses. We also show and conclude that quantitative risk assessment dominates qualitative risk assessment, supporting the extension of the set of default causal models.

Increasing male involvement in family planning decision making: trial of a social-cognitive intervention in rural Vietnam

We tested a social-cognitive intervention to influence contraceptive practices among men living in rural communes in Vietnam. It was predicted that participants who received a stage-targeted program based on the Transtheoretical Model (TTM) would report positive movement in their stage of motivational readiness for their wife to use an intrauterine device (IUD) compared to those in a control condition. A quasi-experimental design was used, where the primary unit for allocation was villages. Villages were allocated randomly to a control condition or to two rounds of intervention with stage-targeted letters and interpersonal counseling. There were 651 eligible married men in the 12 villages chosen. A significant positive movement in men's stage of readiness for IUD use by their wife occurred in the intervention group, with a decrease in the proportions in the precontemplation stage from 28.6 to 20.2% and an increase in action/maintenance from 59.8 to 74.4% (P < 0.05). There were no significant changes in the control group. Compared to the control group, the intervention group showed higher pros, lower cons and higher self-efficacy for IUD use by their wife as a contraceptive method (P < 0.05). Interventions based on social-cognitive theory can increase men's involvement in IUD use in rural Vietnam and should assist in reducing future rates of unwanted pregnancy.

Information giving and decision-making in patients with advanced cancer: A systematic review

Patients with advanced, non-curable cancer face difficult decisions on further treatment, where a small increase in survival time must be balanced against: the toxicity of the treatment. If patients want to be involved in these decisions, in keeping with current notions of autonomy and empowerment, they also require to be adequately informed both on the treatments proposed and on their own disease status and prognosis. A systematic review was performed on decision-making and information provision in patients with advanced cancer. Studies of interventions to improve information giving and encourage participation in decision-making were reviewed, including both randomised controlled trials and uncontrolled studies. Almost all patients expressed a desire for full information, but only about two-thirds wished to participate actively in decision-making. Higher educational level, younger age and female sex were predictive of a desire to participate in decision-making. Active decision-making was more common in patients with certain cancers (e.g. breast) than others (e.g. prostate). A number of simple interventions including question prompt sheets, audio-taping of consultations and patient decision aids have been shown to facilitate such involvement. (c) 2005 Elsevier Ltd. All rights reserved.

Occupational therapists' decision making in three therapy settings in Australia

Can a work setting with its organizational, cultural, and practical considerations influence the way occupational therapists make decisions regarding client interventions? There is currently a paucity of evidence available to answer this question. This study aimed to investigate the influence of work setting on therapists’ clinical reasoning in the management of clients with cerebral palsy and upper limb hypertonicity. Specifically the study aimed to examine therapists’ objective and stated policies, and their intervention decisions using Social Judgement Theory methodology. Participants were eighteen occupational therapists with more than five years experience with clients with cerebral palsy who were asked to make intervention decisions for clients represented by 90 case vignettes. They worked in three settings, hospitals (5), schools (6), and community (6). The results indicated that therapy settings did influence therapists’ decisions about intervention choices but not their objective and subjective policy decisions.

Collaborative decision-making processes for maintaining biodiversity: Two Australian case studies

There have been many models developed by scientists to assist decision-makers in making socio-economic and environmental decisions. It is now recognised that there is a shift in the dominant paradigm to making decisions with stakeholders, rather than making decisions for stakeholders. Our paper investigates two case studies where group model building has been undertaken for maintaining biodiversity in Australia. The first case study focuses on preservation and management of green spaces and biodiversity in metropolitan Melbourne under the umbrella of the Melbourne 2030 planning strategy. A geographical information system is used to collate a number of spatial datasets encompassing a range of cultural and natural assets data layers including: existing open spaces, waterways, threatened fauna and flora, ecological vegetation covers, registered cultural heritage sites, and existing land parcel zoning. Group model building is incorporated into the study through eliciting weightings and ratings of importance for each datasets from urban planners to formulate different urban green system scenarios. The second case study focuses on modelling ecoregions from spatial datasets for the state of Queensland. The modelling combines collaborative expert knowledge and a vast amount of environmental data to build biogeographical classifications of regions. An information elicitation process is used to capture expert knowledge of ecoregions as geographical descriptions, and to transform this into prior probability distributions that characterise regions in terms of environmental variables. This prior information is combined with measured data on the environmental variables within a Bayesian modelling technique to produce the final classified regions. We describe how linked views between descriptive information, mapping and statistical plots are used to decide upon representative regions that satisfy a number of criteria for biodiversity and conservation. This paper discusses the advantages and problems encountered when undertaking group model building. Future research will extend the group model building approach to include interested individuals and community groups.