An exploration of clinical decision-making in mental health triage

Mental health (MH) triage is a specialist area of clinical nursing practice that involves complex decision making. The discussion in this article draws on the findings of a Ph.D. study that involved a statewide investigation of the scope of MH triage nursing practice in Victoria, Australia. Although the original Ph.D. study investigated a number of core practices in MH triage, the focus of the discussion in this article is specifically on the findings related to clinical decision making in MH triage, which have not previously been published. The study employed an exploratory descriptive research design that used mixed data collection methods including a survey questionnaire (n = 139) and semistructured interviews (n = 21). The study findings related to decision making revealed a lack of empirically tested evidence-based decision-making frameworks currently in use to support MH triage nursing practice. MH triage clinicians in Australia rely heavily on clinical experience to underpin decision making and have little of knowledge of theoretical models for practice, such as methodologies for rating urgency. A key recommendation arising from the study is the need to develop evidence-based decision-making frameworks such as clinical guidelines to inform and support MH triage clinical decision making.

The influence of medical enduring power of attorney and advance directives on decision making by Australian intensive care doctors

OBJECTIVE: Despite government encouragement for patients to make advance plans for medical treatment, and the increasing numbers of patients who have done this, there is little research that examines how doctors regard these plans.
DESIGN: We surveyed Australian intensive care doctors, using a hypothetical clinical scenario, to evaluate how potential end-of-life treatment decisions might be influenced by advance planning - the appointment of a medical enduring power of attorney (MEPA) or an advance care plan (ACP). Using open-ended questions we sought to explore the reasoning behind the doctors' decisions.
RESULTS: 275 surveys were returned (18.3% response rate). We found that opinions expressed by an MEPA and ACP have some influence on treatment decisions, but that intensive care doctors had major reservations. Most did not follow the request for palliation made by the MEPA in the hypothetical scenario.
CONCLUSIONS: Many intensive care doctors believe end-of-life decisions remain medical decisions, and MEPAs and ACPs need only be respected when they accord with the doctor's treatment decision. This study suggests a need for further education of doctors, particularly those working in intensive care, who are responsible for initiating and maintaining life support treatment.

Decisions, decisions, decisions : an exploration of clinical decision-making in mental health triage

This paper presents the findings of a project that investigated mental health triage/duty/intake practices across the five community mental health agencies of The Alfred Hospital, Melbourne. The overall aim of the project was to work collaboratively with clinicians to further develop the quality and consistency of mental health triage, duty, and intake clinical practice. The project was designed to facilitate the expansion of the mental health triage knowledge base, and thus contribute to the further development of triage clinical practice. One of the unique aspects of the project was its triangulation across the adult triage service (acute), the two Continuing Care Teams, and the specialist psychiatric services such as the Child and Adolescent Mental Health Service, the Homeless and Outreach Psychiatric Service, and the Mobile Aged Psychiatric Service. The project employed focus group method to collect in-depth, qualitative data. A series of nine focus groups were conducted at each site, which concentrated on eliciting data on the core areas of mental health triage practice such as telephone consultation skills, mental status examination, risk assessment, decision-making, negotiation, crisis assessment, secondary consultation, and documentation. The investigation produced a considerable amount of high quality, in-depth data that was analysed using content analysis methods. The focus of this paper is on presenting the data on clinical decision-making that was raised through the project.

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.

Agent-based hybrid framework for decision making on complex problems

Electronic commerce and the Internet have created demand for automated systems that can make complex decisions utilizing information from multiple sources. Because the information is uncertain, dynamic, distributed, and heterogeneous in nature, these systems require a great diversity of intelligent techniques including expert systems, fuzzy logic, neural networks, and genetic algorithms. However, in complex decision making, many different components or sub-tasks are involved, each of which requires different types of processing. Thus multiple such techniques are required resulting in systems called hybrid intelligent systems. That is, hybrid solutions are crucial for complex problem solving and decision making. There is a growing demand for these systems in many areas including financial investment planning, engineering design, medical diagnosis, and cognitive simulation. However, the design and development of these systems is difficult because they have a large number of parts or components that have many interactions. From a multi-agent perspective, agents in multi-agent systems (MAS) are autonomous and can engage in flexible, high-level interactions. MASs are good at complex, dynamic interactions. Thus a multi-agent perspective is suitable for modeling, design, and construction of hybrid intelligent systems. The aim of this thesis is to develop an agent-based framework for constructing hybrid intelligent systems which are mainly used for complex problem solving and decision making. Existing software development techniques (typically, object-oriented) are inadequate for modeling agent-based hybrid intelligent systems. There is a fundamental mismatch between the concepts used by object-oriented developers and the agent-oriented view. Although there are some agent-oriented methodologies such as the Gaia methodology, there is still no specifically tailored methodology available for analyzing and designing agent-based hybrid intelligent systems. To this end, a methodology is proposed, which is specifically tailored to the analysis and design of agent-based hybrid intelligent systems. The methodology consists of six models - role model, interaction model, agent model, skill model, knowledge model, and organizational model. This methodology differs from other agent-oriented methodologies in its skill and knowledge models. As good decisions and problem solutions are mainly based on adequate information, rich knowledge, and appropriate skills to use knowledge and information, these two models are of paramount importance in modeling complex problem solving and decision making. Follow the methodology, an agent-based framework for hybrid intelligent system construction used in complex problem solving and decision making was developed. The framework has several crucial characteristics that differentiate this research from others. Four important issues relating to the framework are also investigated. These cover the building of an ontology for financial investment, matchmaking in middle agents, reasoning in problem solving and decision making, and decision aggregation in MASs. The thesis demonstrates how to build a domain-specific ontology and how to access it in a MAS by building a financial ontology. It is argued that the practical performance of service provider agents has a significant impact on the matchmaking outcomes of middle agents. It is proposed to consider service provider agents' track records in matchmaking. A way to provide initial values for the track records of service provider agents is also suggested. The concept of ‘reasoning with multimedia information’ is introduced, and reasoning with still image information using symbolic projection theory is proposed. How to choose suitable aggregation operations is demonstrated through financial investment application and three approaches are proposed - the stationary agent approach, the token-passing approach, and the mobile agent approach to implementing decision aggregation in MASs. Based on the framework, a prototype was built and applied to financial investment planning. This prototype consists of one serving agent, one interface agent, one decision aggregation agent, one planning agent, four decision making agents, and five service provider agents. Experiments were conducted on the prototype. The experimental results show the framework is flexible, robust, and fully workable. All agents derived from the methodology exhibit their behaviors correctly as specified.

The use of contracting out : a case study of decision-making and organisational learning in local government

One objective of government is to provide services at least cost whilst maintaining or improving service quality. While this may be an important objective, questions are being asked whether services can be provided more efficiently and effectively by the private rather than by the government sector. The shift of service provision from the public to the private sector is known as outsourcing or contracting out. The objective in this study is to critically examine whether the contracting out of services by local government to the private sector is an efficient management practice.

The contracting out of Parks and Grounds Maintenance services for the City of Kingston in the State of Victoria, Australia, is used as an exploratory case study to identify the variables associated with management decision-making in the contracting out process. Factors relevant to the contracting out decision such as the criteria used in selecting a contractor; the evaluation of a contractor’s performance; and any subsequent changes to management practice relating to the contracting out of the services are identified and discussed.

Political forces were found to be an important consideration in the initial contracting out decision, and the selection of a contractor was influenced by the potential to avoid costs. It was also found that under-bidding and associated cost /profit constraints lead to contractors engaging in non-sustainable environmental practices which resulted in the degradation of the local government’s Parks and Gardens assets. A sustainable asset management philosophy as opposed to an avoidable costs approach now underpins the contracting out process to ensure the preservation of such assets. Further, administrative processes have been revised to make tender specifications more prescriptive, critical components of services have been brought back in-house, and management practices have been amended so that a greater degree of control is exercised over contractors’ activities.

The ethics of surrogate decision making in medicine : autonomy, paternalism, or a different approach?

Knowing who to involve in treatment decisions when a patient is incapacitated has been the subject of discussion in bioethical, health law and clinical research. The major issues tend to revolve around the tension between exercising a degree of medical paternalism and respecting patient autonomy. Patients are encouraged to exert their autonomy even when they may not be capable of doing so, by means of surrogate consent or advanced directives. While liberal concepts of autonomy are exemplified in western bioethics and legal systems, clinically these decisions remain difficult, and input from medical professionals is sought, raising the issue of paternalism. A framework of bioethics, which places the patient in a relational context rather than a strictly autonomous one, may be a more helpful way of deliberating these difficult decisions

Security as an element in environmental assessment and decision making

he prominence of global warming as an environmental issue has illustrated the close relationship between natural resources, ecosystems and global security. Whilst environmental decision making often uses techniques such as economic valuation and risk management, the security component is often not considered, at least not from a security analyst’s perspective. Yet environmental security considerations can be global, regional and/or national in impact. Environmental change and policy can effect human health and well being as well as initiating conflict; it can affect the existence of life itself. These aspects are firmly in the domain of the security discipline although the protection of the global ecosystem has not traditionally been considered by those who create security policy. The idea of environmental/ecological security ranges from the eco-centric approach which examines the impact of human activities that impact on the security of the natural systems to the more traditional anthropocentric perspectives that look at varied issues such as conflict caused by natural resource competition and environmental degradation, and the greening of military operations. This paper will assert that the inclusion of the security factor in policy creation and environmental assessments is essential to give richer solutions to these complex socio-economic and ecological situations. Systems theory over the last few decades has emphasised the inclusion of as many perspectives on messy problems as possible to provide truly systemic outcomes. It is posited that the addition of such concepts as threat analyses will produce more effective and sustainable outcomes.

Lawyers and ethics in practice : the impact of clinical and ethics curricula on lawyers’ ethical decision-making

The authors have conducted a longitudinal study exploring the relationships between values and ethical behaviour for early-career legal practitioners. The study comprised a representative Australian cohort of final-year law students and tracked them through their first two years of employment or further study. It examined changes to ethical decision-making by presenting participants with hypothetical scenarios that provided ethical dilemmas. A questionnaire utilising hypothetical situations was presented in 11 scenarios. This chapter examines responses to the scenarios across the three years of the study, particularly exploring changes over time. Of particular interest were the effects of gender and prior ethics education on changing responses. Findings suggested significant differences between males and females in their ethical responses. They also suggested that involvement in clinical practice, in particular during the law degree, may have a positive impact on future willingness to assist access to justice (insofar as such lawyers were more inclined to participate in later pro bono activity).

Enhancing juror decision-making through provision of transcripts

This thesis explored how much evidence jurors remember when instructed to reach a verdict. Results indicated that jurors required to rely on memory recalled significantly less evidence than jurors provided with access to the court transcript and were less confident than aided jurors that they had returned the 'right' verdict. The portfolio explored a possible association between chronic childhood challenging behaviours and later offending behaviour in individuals with intellectual disability. Includes four clinical case studies. The importance of early intervention is illustrated.

The influence of need-for-cognition on ethical decision-making in marketing

The research established that the work-related norms of marketers and their socialisation into the marketing profession are influenced beneficially by their need-for-cognition. The research revealed contradictions between corporate codes of ethics and the values espoused by professional associations. Better ways of managing corporate ethical standards and behaviour are suggested.