Triage nurses' clinical decision making : an observational study of urgency assessment

Background. Researchers have described both the various decision tasks performed by triage nurses using self-report methods and identified time as a factor influencing the quality of triage decisions. However, little is known about the decision tasks performed by triage nurses when making acuity assessments, or the factors influencing triage duration in the real world.

Aims. The aims of this study were to: describe the data triage nurses collect from patients in order to allocate a triage priority using the Australasian Triage Scale (ATS); describe the duration of nurses' decision making for ATS categories 2–5; and to explore the impact of patient and nurse variables on the duration of the triage nurses' decision making in the clinical setting.

Design. A structured observational study was employed to address the research aims. Observational data was collected in one adult emergency department located in metropolitan Melbourne, Australia. A total of 26 triage nurses consented and were observed performing 404 occasions of triage. Data was collected by a single observer using a 20-item instrument that recorded the performance frequencies of a range of decision tasks and a number of observable patient, nurse and environmental variables. Additionally, the nurse–patient interaction was recorded as time in minutes.

Results. It was found that there was limited use of objective physiological data collected by the nurses' in order to decide patient acuity, and large variability in the duration of triage decisions observed. In addition, analysis of variance indicated strong evidence of a true difference between triage duration and a range of nurse, patient and environmental variables.

Conclusion. These findings have implications for the development of practice standards and triage education. In particular, it is argued that practice standards should include routine measurement of physiological parameters in all but the collapsed or obviously unwell patient, where further delay may impede the delivery oftime-critical intervention. Furthermore, the inclusion of arbitrary time frames for triage assessment in practice standards are not an appropriate method of evaluating triage decision making in the real world.

Game situation information in video-based perceptual decision making : the influence of criticality of decisions

This study examined the effects of game situation information, manipulated in terms of time and score, on decisions made in a video-based perceptual test in basketball. The participants were undergraduate university students (n=159) who viewed 21 offensive basketball plays, under two test conditions (low decision criticality; high decision criticality). To manipulate the conditions, prior to each clip, the
participants were presented with a description of the remaining time and score differential. High decision criticality situations were characterised by a remaining time of 60 seconds or less and score differentials of 2 points or less. Low decision criticality situations were characterised by remaining time of 5 minutes or more and score differentials of 5 points or more. The participants indicated their decision (pass, shoot, dribble) after the visual display had been occluded for each clip. The results indicated that decision profiles differed under the low and high decision criticality conditions. More pass decisions were made under high decision criticality situations and more shoot decisions under low decision criticality situations. These variations differed according to the type of main sport played but not for the basketball competition level. It was concluded that game situation information does influence decision making and should be considered in video-based testing and training.

Assumptions of decision-making capacity: the role supporter attitudes play in the realisation of Article 12 for people with severe or profound intellectual disability

The United Nations Convention on the Rights of Persons with Disabilities (UNCRPD) was the first legally binding instrument explicitly focused on how human rights apply to people with disability. Amongst their obligations, consistent with the social model of disability, the Convention requires signatory nations to recognise that “…persons with disabilities enjoy legal capacity on an equal basis with others in all aspects of life” and mandates signatory nations to develop “…appropriate measures to provide access by persons with disability to the support they may require in exercising their legal capacity”. The Convention promotes supported decision-making as one such measure. Although Australia ratified the UNCRPD in 2008, it retains an interpretative declaration in relation to Article 12 (2, 3, 4), allowing for the use of substituted decision-making in situations where a person is assessed as having no or limited decision-making capacity. Such an outcome is common for people with severe or profound intellectual disability because the assessments they are subjected to are focused on their cognition and generally fail to take into account the interdependent nature of human decision-making. This paper argues that Australia’s interpretative declaration is not in the spirit of the Convention nor the social model of disability on which it is based. It starts from the premise that the intention of Article 12 is to be inclusive of all signatory nations’ citizens, including those with severe or profound cognitive disability. From this premise, arises a practical need to understand how supported decision-making can be used with this group. Drawing from evidence from an empirical study with five people with severe or profound intellectual disability, this paper provides a rare glimpse on what supported decision-making can look like for people with severe or profound intellectual disability. Additionally, it describes the importance of supporters having positive assumptions of decision-making capacity as a factor affecting supported decision-making. This commentary aims to give a focus for practice and policy efforts for ensuring people with severe or profound cognitive disability receive appropriate support in decision-making, a clear obligation of signatory nations of the UNCRPD. A focus on changing supporter attitudes rather than placing the onus of change on people with disability is consistent with the social model of disability, a key driver of the UNCRPD.

Rise of the machines: a critical consideration of automated leadership decision making in organizations

Machines are increasingly becoming a substitute for human skills and intelligence in a number of fields where decisions that are crucial to group performance have to be taken under stringent constraints—for example, when an army contingent has to devise battlefield tactics or when a medical team has to diagnose and treat a life-threatening condition or illness. We hypothesize a scenario where similar machine-based intelligent technology is available to support, and even substitute human decision making in an organizational leadership context. We do not engage in any metaphysical debate on the plausibility of such a scenario. Rather, we contend that given what we observe in several other fields of human decision making, such a scenario may very well eventuate in the near future. We argue a number of “positives” that can be expected to emerge out of automated group and organizational leadership decision making. We also posit several anti-theses—“negatives” that can also potentially emerge from the hypothesized scenario and critically consider their implications. We aim to bring leadership and organization theorists, as well as researchers in machine intelligence, together at the discussion table for the first time and postulate that while leadership decision making in a group/organizational context could be effectively delegated to an artificial-intelligence (AI)-based decision system, this would need to be subject to the devising of crucial safeguarding conditions.

Sexual decision making in young women

Research over the last 30 years has examined the way in which young people make decisions about participating in sexual behaviours. This research is limited in that theoretical developments in the area have either not been subjected to empirical scrutiny, or are not consistent with empirical findings. The current study used a modified form of the Theory of Planned Behavior (TPB) as a theoretical position for a longitudinal exploration (over a 6-month period) of sexual decision making in a group of young adult women. One hundred and fifty-six young women aged between 18 and 21 years were involved in the study. Regression analysis were used to evaluate the predictors of intention to engage in six types of sexual behaviours at time 1, as well as experiences of these behaviours at time 2. The study found that intention to engage in sexual behaviour was reasonably well predicted using the constructs of TPB. However, behaviour was not well predicted using the variables in TPB, with the most important predictors of most sexual behaviours being past experience and perceived behavioural control, but not intention to engage in the behaviours. Implications of these findings and directions for future research are discussed.

Parental decision-making surrounding complicated births: the impact on parent-infant and infant-marital relationships

This paper reviews current research regarding the impact of birth complications on parental decisionmaking, and the resulting effects on parent-infant and infant-marital relationships. It discusses the importance of informed decision-making on parental satisfaction of the birthing experience, and the benefits of certain strategies, such as kangaroo care, in the facilitation of greater levels of attachment and improved relationships. The paper concludes with suggestions for future research areas to focus on finding better ways to prepare and support parents in these situations, thus improving the quality of relationships between parents and with their child.

Bushfire incident management team decision making

Large scale bushfire (or wildfire) suppression activities are conducted under the control of an Incident Management Team (IMT) comprising four major functions: Command, Operations, Planning, and Logistics. Four methodologies were used to investigate processes determining the effectiveness of IMT decision making activities: (a) laboratory experiments using the Networked Fire Chief computer simulation program; (b) analyses of reports of significant fires; (c) structured interviews with experienced IMT staff; and, (d) cognitive ethnographic studies of IMTs. Three classes of team processes were found to be important determinants of IMT effectiveness: information sharing and management; matching of the four component function goals to overall IMT goals; and monitoring of the overall IMT situation to detect and correct task disruptive processes. Several non-rational processes with the potential for hindering IMT effectiveness were noted. Team metacognition emerged as a key process for understanding effective IMT decision making.

Decision-making in a social welfare context

This paper presents analysis of the decision-making strategies adopted by respondents when confronted with potential policy options that include changes in both aggregate levels of welfare and equity in distribution. The analysis is based on the results of a choice experiment designed to estimate intergenerational distributional preferences. Non-linear welfare functions are employed within a conventional conditional logit framework. The heuristics employed by respondents in the stated preference context provide valuable insights into the application of welfare principles by respondents in determining trade-offs between the potential changes in the well-being of different generations.

Evaluation of a decision aid for prenatal testing of fetal abnormalities : a cluster randomised trial [ISRCTN22532458]

Background: By providing information on the relative merits and potential harms of the options available and a framework to clarify preferences, decision aids can improve knowledge and realistic expectations and decrease decisional conflict in individuals facing decisions between alternative forms of action. Decision-making about prenatal testing for fetal abnormalities is often confusing and difficult for women and the effectiveness of decision aids in this field has not been established. This study aims to test whether a decision aid for prenatal testing of fetal abnormalities, when compared to a pamphlet, improves women's informed decision-making and decreases decisional conflict.

Methods/design: A cluster designed randomised controlled trial is being conducted in Victoria, Australia. Fifty General Practitioners (GPs) have been randomised to one of two arms: providing women with either a decision aid or a pamphlet. The two primary outcomes will be measured by comparing the difference in percentages of women identified as making an informed choice and the difference in mean decisional conflict scores between the two groups. Data will be collected from women using questionnaires at 14 weeks and 24 weeks gestation.

The sample size of 159 women in both arms of the trial has been calculated to detect a difference of 18% (50 to 68%) in informed choice between the two groups. The required numbers have been adjusted to accommodate the cluster design, miscarriage and participant lost – to – follow up.

Baseline characteristics of women will be summarised for both arms of the trial. Similarly, characteristics of GPs will be compared between arms.

Differences in the primary outcomes will be analysed using 'intention-to-treat' principles. Appropriate regression techniques will adjust for the effects of clustering and include covariates to adjust for the stratifying variable and major potential confounding factors.

Discussion: The findings from this trial will make a significant contribution to improving women's experience of prenatal testing and will have application to a variety of maternity care settings. The evaluation of a tailored decision aid will also have implications for pregnancy care providers by identifying whether or not such a resource will support their role in providing prenatal testing information.

Critical care nurses' haemodynamic decision making

For cardiac surgical patients, the immediate 2-hour recovery period is distinguished by potentially life-threatening haemodynamic instability. To ensure optimum patient outcomes, nurses of varying levels of experience must make rapid and accurate decisions in response to episodes of haemodynamic instability. Decision complexity, nurses’ characteristics, and environmental characteristics, have each been found to influence nurses' decision making in some form. However, the effect of the interplay between these influences on decision outcomes has not been investigated. The aim of the research reported in this thesis was to explore variability in critical care nurses' haemodynamic decision making as a function of interplay between haemodynamic decision complexity, nurses' experience, and specific environmental characteristics by applying a naturalistic decision making design. Thirty-eight nurses were observed recovering patients in the immediate 2-hour period after cardiac surgery. A follow-up semi-structured interview was conducted. A naturalistic decision making approach was used. An organising framework for the goals of therapy related to maintaining haemodynamic stability after cardiac surgery was developed to assist the observation and analysis of practice. The three goals of therapy were the optimisation of cardiovascular performance, the promotion of haemostasia, and the reestablishment of normothermia. The research was conducted in two phases. Phase One explored issues related to observation as method, and identified emergent themes. Phase Two incorporated findings of Phase 1, investigating the variability in nurses' haemodynamic decision making in relation to the three goals of therapy. The findings showed that patients had a high acuity after cardiac surgery and suffered numerous episodes of haemodynamic instability during the immediate 2-hour recovery period. The quality of nurses' decision making in relation to the three goals of therapy was influenced by the experience of the nurse and social interactions with colleagues. Experienced nurses demonstrated decision making that reflected the ability to recognise subtle changes in haemodynamic cues, integrate complex combinations of cues, and respond rapidly to instability. The quality of inexperienced nurses' decision making varied according to the level and form of decision support as well as the complexity of the task. When assistance was provided by nursing colleagues during the reception and recovery of patients, the characteristics of team decision making were observed. Team decision making in this context was categorised as either integrated or non integrated. Team decision making influenced nurses' emotions and actions and decision making practices. Findings revealed nurses' experience affected interactions with other team members and their perceptions of assuming responsibility for complex patients. Interplay between decision complexity, nurses' experience, and the environment in which decisions were made influenced the quality of nurses' decision making and created an environment of team decision making, which, in turn, influenced nurses' emotional responses and practice outcomes. The observed variability in haemodynamic decision making has implications for nurse education, nursing practice, and system processes regarding patient allocation and clinical supervision.

Codes of ethics in large private sector Australian businesses

This thesis deals with codes of ethics in the top 500 companies operating in the private sector in Australia. We seek to answer two questions. First, can businesses adopt codes of ethics in a meaningful way, or are business ethics a contradiction in terms for profit seeking organisations in competitive markets? Second, to what extent do Australia’s top 500 private sector firms show commitment to codes of ethics? A number of ancillary questions are explored to form a picture of the current Australian situation and to compare it to the rest of the world, especially the US and Canada. Chapter 1 discusses these questions and the origins of the author’s interest in business ethics. This chapter develops a focus upon codes of ethics and their role in assisting to establish and maintain an ethical culture. The chapter looks at previous research on codes of ethics and demonstrates a lack of understanding in Australia on the subject and the need for research into it. Also included in Chapter 1 is the plan for the thesis. Chapters 2 to 4 review the literature upon which the thesis is based. In Chapter 2, the meaning of the terms ethics and business ethics are considered. Deontological and teleological approaches are distinguished and a (largely) teleological model of business ethics is developed. This chapter also asks whether business ethics are possible. The contention that ethics may be good for a business’s profit is explored in-depth and the conclusion is reached that ethics should be pursued for its inherent worth regardless of the economic benefit that can be attributed to it. A number of models of ethical decision making are discussed in Chapter 3 starting with Kohlberg and Kramer (1969). This discussion leads to the conclusion that organisations must create an ethical culture for staff if they require them to embrace ethical practices. If this is a correct conclusion, then the role of senior managers becomes critical in the process. Chapter 4 looks further at the role of senior managers, organisational culture and ethical/unethical behaviour in organisations. The conclusion is that senior managers do play an integral part in shaping the culture of an organisation. Their actions, either overtly or covertly, impact upon their staff and highlight behaviour that the organisation is or is not willing to tolerate. Sims (1991) proposed ten ways to foster an ethical culture and these ideas are set out and further explored through the work of other writers on management ethics. Finally, the link between ethics and strategic planning is examined. In Chapter 5 the methods used for empirical data gathering are described and justified. A number of factors that can lead us to consider a company’s ‘commitment’ to ethics are outlined. A survey of Australian companies was the primary means of data collection. Each question in the survey instrument is listed and explained. Also the survey response rate is reported, as are major demographic characteristics of respondents. Chapter 6 provides the research findings from the survey of the top 500 companies operating in the private sector in Australia. The research examines: i) the current Australian usage and implementation of codes of ethics; ii) the measures put in place in organisations in order to support a code; From this analysis conclusions are drawn about the ‘commitment’ of companies operating in Australia to codes of ethics. Australian companies are becoming aware of the potential of code usage. Companies operating in Australia that have codes appear to be good at implementing codes and examining staff performance in relation to codes. However, they lack the procedures that incorporate education and training and the implementation of the support mechanisms necessary to enhance employee understanding of the code. In Chapter 7, Australian codes are compared to American and Canadian codes for similarity and disparity. The assessment found that in all three countries codes are primarily concerned with company continuance. Australian codes do tend to be more socially oriented than in the other two countries and also less legalistic. Chapter 8 looks at 4 companies from the first survey that were asked for more in-depth information in a quest to determine current best practice in Australia. These organisations were chosen because they appeared, from the first survey instrument, to have put in place mechanisms to assist employees to better understand the code. The implication is that companies must make a conscious, positive effort to ensure that employees are considered in the process of ethical development. They should have input into the process, rather than just being directed to follow another management initiative. The final chapter summarises the research findings and looks at answers to the two major questions and the seven subordinate empirical questions posed at the start of the thesis. The conclusion reached is that companies operating in Australia appear to be moving towards establishing codes of ethics. Those who already have codes display a real commitment to them. The movement appears to be gathering momentum as more organisations see the value of incorporating ethical business practices into the every day workings of their individual companies. Generally, most Australian companies lag behind the rest of the world, but the pace-setting companies are defining their own best practice and achieving positive outcomes for themselves, their employees and other stakeholders.

Simulated jury decision making in online focus groups

Purpose – A significant issue in jury research has been the use of individual jurors to analyse jury decision-making. This paper aimed to examine the applicability of computer-mediated communication to a mock jury deliberation study.

Design/methodology/approach – Groups of three to five Australian residents anonymously attended a secure chat room and participated in a semi-structured discussion about a simulated child sexual assault scenario. Deliberation transcripts were analysed thematically using NVivo. A hermeneutic framework was used to analyse the deliberation transcripts.

Findings – Five interrelated themes were revealed, each reflecting the tools online juries used to communicate, create meaning, and arrive at a verdict. Electronic jury deliberation promoted an understanding of how people make sense of child sexual assault cases in Australia today.

Originality/value – This study advanced the understanding of online decision making in a child sexual assault scenario. It demonstrated that knowledge of how juries deliberate and create meaning could improve our understanding of how verdicts are achieved. Electronic mock juries are a valuable adjunct to traditional jury deliberation studies because they are cost effective, time efficient, and offer wider recruitment opportunities.

Decision-Making in Economics: Critical Lessons from Neurobiology

In this chapter, the authors consider some of the issues regarding the rational choice decision framework in neoclassical economics and how it can particularly be found wanting in the absence of due consideration for some of the underlying critical neurobiological factors which govern decision making. They develop a critical decision problem and explore the scenario where the solution predicted by formal economic theory may be in conflict with the decision that actually occurs. Such conflict is especially relevant in the context of economic decision making in emerging markets where there can be a lack of trust in the system by the agents operating within it. Based on logically consistent arguments derived from the extant literature, the authors argue that non-consideration of underlying neurobiological factors is a direct cause of this conflict.

Medico-legal decision making for incapacitated neonates

This thesis finds there is a need for greater transparency and objectivity in end-of-life decision making for extremely premature and critically ill infants. To achieve this objectivity, the allocation of finite public healthcare resources, and corresponding quality of life, should be a principal consideration in treatment decisions.

Shared decision making: what do clinicians need to know and why should they bother?

Shared decision making enables a clinician and patient to participate jointly in making a health decision, having discussed the options and their benefits and harms, and having considered the patient's values, preferences and circumstances. It is not a single step to be added into a consultation, but a process that can be used to guide decisions about screening, investigations and treatments. The benefits of shared decision making include enabling evidence and patients' preferences to be incorporated into a consultation; improving patient knowledge, risk perception accuracy and patient-clinician communication; and reducing decisional conflict, feeling uninformed and inappropriate use of tests and treatments. Various approaches can be used to guide clinicians through the process. We elaborate on five simple questions that can be used: What will happen if the patient waits and watches? What are the test or treatment options? What are the benefits and harms of each option? How do the benefits and harms weigh up for the patient? Does the patient have enough information to make a choice? Although shared decision making can occur without tools, various types of decision support tools now exist to facilitate it. Misconceptions about shared decision making are hampering its implementation. We address the barriers, as perceived by clinicians. Despite numerous international initiatives to advance shared decision making, very little has occurred in Australia. Consequently, we are lagging behind many other countries and should act urgently.