A qualitative investigation of decision making during help-seeking for adult hearing loss

Objective: The Any Qualified Provider framework in the National Health Service has changed the way adult audiology services are offered in England. Under the new rules, patients are being offered a choice in geographical location and audiology provider. This study aimed to explore how choices in treatment are presented and to identify what information patients need when they are seeking help with hearing loss. Design: This study adopted qualitative methods of ethnographic observations and focus group interviews to identify information needed prior to, and during, help-seeking. Observational data and focus group data were analysed using the constant comparison method of grounded theory. Study sample: Participants were recruited from a community Health and Social Care Trust in the west of England. This service incorporates both an Audiology and a Hearing Therapy service. Twenty seven participants were involved in focus groups or interviews. Results: Participants receive little information beyond the detail of hearing aids. Participants report little information that was not directly related to uptake of hearing aids. Conclusions: Participant preferences were not explored and limited information resulted in decisions that were clinician-led. The gaps in information reflect previous data on clinician communication and highlight the need for consistent information on a range of interventions to manage hearing loss.

The Optimality of Decision Making During Motor Learning

In our daily lives, we often must predict how well we are going to perform in the future based on an evaluation of our current performance and an assessment of how much we will improve with practice. Such predictions can be used to decide whether to invest our time and energy in learning and, if we opt to invest, what rewards we may gain. This thesis investigated whether people are capable of tracking their own learning (i.e. current and future motor ability) and exploiting that information to make decisions related to task reward. In experiment one, participants performed a target aiming task under a visuomotor rotation such that they initially missed the target but gradually improved. After briefly practicing the task, they were asked to select rewards for hits and misses applied to subsequent performance in the task, where selecting a higher reward for hits came at a cost of receiving a lower reward for misses. We found that participants made decisions that were in the direction of optimal and therefore demonstrated knowledge of future task performance. In experiment two, participants learned a novel target aiming task in which they were rewarded for target hits. Every five trials, they could choose a target size which varied inversely with reward value. Although participants’ decisions deviated from optimal, a model suggested that they took into account both past performance, and predicted future performance, when making their decisions. Together, these experiments suggest that people are capable of tracking their own learning and using that information to make sensible decisions related to reward maximization.

Using an end-of-life care pathway in acute stroke: a mixed methods study of decision-making and care experiences

Background: The evidence base on end-of-life care in acute stroke is limited, particularly with regard to recognising dying and related decision-making. There is also limited evidence to support the use of end-of-life care pathways (standardised care plans) for patients who are dying after stroke. Aim: This study aimed to explore the clinical decision-making involved in placing patients on an end-of-life care pathway, evaluate predictors of care pathway use, and investigate the role of families in decision-making. The study also aimed to examine experiences of end-of-life care pathway use for stroke patients, their relatives and the multi-disciplinary health care team. Methods: A mixed methods design was adopted. Data were collected in four Scottish acute stroke units. Case-notes were identified prospectively from 100 consecutive stroke deaths and reviewed. Multivariate analysis was performed on case-note data. Semi-structured interviews were conducted with 17 relatives of stroke decedents and 23 healthcare professionals, using a modified grounded theory approach to collect and analyse data. The VOICES survey tool was also administered to the bereaved relatives and data were analysed using descriptive statistics and thematic analysis of free-text responses. Results: Relatives often played an important role in influencing aspects of end-of-life care, including decisions to use an end-of-life care pathway. Some relatives experienced enduring distress with their perceived responsibility for care decisions. Relatives felt unprepared for and were distressed by prolonged dying processes, which were often associated with severe dysphagia. Pro-active information-giving by staff was reported as supportive by relatives. Healthcare professionals generally avoided discussing place of care with families. Decisions to use an end-of-life care pathway were not predicted by patients’ demographic characteristics; decisions were generally made in consultation with families and the extended health care team, and were made within regular working hours. Conclusion: Distressing stroke-related issues were more prominent in participants’ accounts than concerns with the end-of-life care pathway used. Relatives sometimes perceived themselves as responsible for important clinical decisions. Witnessing prolonged dying processes was difficult for healthcare professionals and families, particularly in relation to the management of persistent major swallowing difficulties.

Impact of a data warehouse model for improved decision-making process in healthcare

The health system is one sector dealing with a deluge of complex data. Many healthcare organisations struggle to utilise these volumes of health data effectively and efficiently. Also, there are many healthcare organisations, which still have stand-alone systems, not integrated for management of information and decision-making. This shows, there is a need for an effective system to capture, collate and distribute this health data. Therefore, implementing the data warehouse concept in healthcare is potentially one of the solutions to integrate health data. Data warehousing has been used to support business intelligence and decision-making in many other sectors such as the engineering, defence and retail sectors. The research problem that is going to be addressed is, "how can data warehousing assist the decision-making process in healthcare". To address this problem the researcher has narrowed an investigation focusing on a cardiac surgery unit. This research used the cardiac surgery unit at the Prince Charles Hospital (TPCH) as the case study. The cardiac surgery unit at TPCH uses a stand-alone database of patient clinical data, which supports clinical audit, service management and research functions. However, much of the time, the interaction between the cardiac surgery unit information system with other units is minimal. There is a limited and basic two-way interaction with other clinical and administrative databases at TPCH which support decision-making processes. The aims of this research are to investigate what decision-making issues are faced by the healthcare professionals with the current information systems and how decision-making might be improved within this healthcare setting by implementing an aligned data warehouse model or models. As a part of the research the researcher will propose and develop a suitable data warehouse prototype based on the cardiac surgery unit needs and integrating the Intensive Care Unit database, Clinical Costing unit database (Transition II) and Quality and Safety unit database [electronic discharge summary (e-DS)]. The goal is to improve the current decision-making processes. The main objectives of this research are to improve access to integrated clinical and financial data, providing potentially better information for decision-making for both improved from the questionnaire and by referring to the literature, the results indicate a centralised data warehouse model for the cardiac surgery unit at this stage. A centralised data warehouse model addresses current needs and can also be upgraded to an enterprise wide warehouse model or federated data warehouse model as discussed in the many consulted publications. The data warehouse prototype was able to be developed using SAS enterprise data integration studio 4.2 and the data was analysed using SAS enterprise edition 4.3. In the final stage, the data warehouse prototype was evaluated by collecting feedback from the end users. This was achieved by using output created from the data warehouse prototype as examples of the data desired and possible in a data warehouse environment. According to the feedback collected from the end users, implementation of a data warehouse was seen to be a useful tool to inform management options, provide a more complete representation of factors related to a decision scenario and potentially reduce information product development time. However, there are many constraints exist in this research. For example the technical issues such as data incompatibilities, integration of the cardiac surgery database and e-DS database servers and also, Queensland Health information restrictions (Queensland Health information related policies, patient data confidentiality and ethics requirements), limited availability of support from IT technical staff and time restrictions. These factors have influenced the process for the warehouse model development, necessitating an incremental approach. This highlights the presence of many practical barriers to data warehousing and integration at the clinical service level. Limitations included the use of a small convenience sample of survey respondents, and a single site case report study design. As mentioned previously, the proposed data warehouse is a prototype and was developed using only four database repositories. Despite this constraint, the research demonstrates that by implementing a data warehouse at the service level, decision-making is supported and data quality issues related to access and availability can be reduced, providing many benefits. Output reports produced from the data warehouse prototype demonstrated usefulness for the improvement of decision-making in the management of clinical services, and quality and safety monitoring for better clinical care. However, in the future, the centralised model selected can be upgraded to an enterprise wide architecture by integrating with additional hospital units’ databases.

Unstructured processes of strategic decision-making

The author aims at developing a better understanding of unstructured strategic decision making processes and the conditions for achieving successful decision outcomes. Specifically he investigates the processes used to make CRE (Corporate Real Estate) decisions. To reveal the fundamental differences between CRE decision-making in practice and the prescriptive ‘best practice’ advocated in the CRE literature, a study of seven leading Italian management consulting firms is undertaken addressing the aspects of content and process of decisions. This research makes its primary contribution by identifying the importance and difficulty of finding the right balance between problem complexity, process richness and cohesion to ensure a decision-making process that is sufficiently rich and yet quick enough to deliver a prompt outcome. While doing so, the study also provides more empirical evidence to some of the most established theories of decision-making, while reinterpreting their mono-dimensional arguments in a multi-dimensional model of successful decision-making.

The governance of inter-organisational decision-making : understanding the impacts of informal networks on formal decision-making regimes in the Brisbane Airport region

Airports and cities inevitably recognise the value that each brings the other; however, the separation in decision-making authority for what to build, where, when and how provides a conundrum for both parties. Airports often want a say in what is developed outside of the airport fence, and cities often want a say in what is developed inside the airport fence. Defining how much of a say airports and cities have in decisions beyond their jurisdictional control is likely to be a topic that continues so long as airports and cities maintain separate formal decision-making processes for what to build, where, when and how. However, the recent Green and White Papers for a new National Aviation Policy have made early inroads to formalising relationships between Australia’s major airports and their host cities. At present, no clear indication (within practice or literature) is evident to the appropriateness of different governance arrangements for decisions to develop in situations that bring together the opposing strategic interests of airports and cities; thus leaving decisions for infrastructure development as complex decision-making spaces that hold airport and city/regional interests at stake. The line of enquiry is motivated by a lack of empirical research on networked decision-making domains outside of the realm of institutional theorists (Agranoff & McGuire, 2001; Provan, Fish & Sydow, 2007). That is, governance literature has remained focused towards abstract conceptualisations of organisation, without focusing on the minutia of how organisation influences action in real-world applications. A recent study by Black (2008) has provided an initial foothold for governance researchers into networked decision-making domains. This study builds upon Black’s (2008) work by aiming to explore and understand the problem space of making decisions subjected to complex jurisdictional and relational interdependencies. That is, the research examines the formal and informal structures, relationships, and forums that operationalise debates and interactions between decision-making actors as they vie for influence over deciding what to build, where, when and how in airport-proximal development projects. The research mobilises a mixture of qualitative and quantitative methods to examine three embedded cases of airport-proximal development from a network governance perspective. Findings from the research provide a new understanding to the ways in which informal actor networks underpin and combine with formal decision-making networks to create new (or realigned) governance spaces that facilitate decision-making during complex phases of development planning. The research is timely, and responds well to Isett, Mergel, LeRoux, Mischen and Rethemeyer’s (2011) recent critique of limitations within current network governance literature, specifically to their noted absence of empirical studies that acknowledge and interrogate the simultaneity of formal and informal network structures within network governance arrangements (Isett et al., 2011, pp. 162-166). The combination of social network analysis (SNA) techniques and thematic enquiry has enabled findings to document and interpret the ways in which decision-making actors organise to overcome complex problems for planning infrastructure. An innovative approach to using association networks has been used to provide insights to the importance of the different ways actors interact with one another, thus providing a simple yet valuable addition to the increasingly popular discipline of SNA. The research also identifies when and how different types of networks (i.e. formal and informal) are able to overcome currently known limitations to network governance (see McGuire & Agranoff, 2011), thus adding depth to the emerging body of network governance literature surrounding limitations to network ways of working (i.e. Rhodes, 1997a; Keast & Brown, 2002; Rethemeyer & Hatmaker, 2008; McGuire & Agranoff, 2011). Contributions are made to practice via the provision of a timely understanding of how horizontal fora between airports and their regions are used, particularly in the context of how they reframe the governance of decision-making for airport-proximal infrastructure development. This new understanding will enable government and industry actors to better understand the structural impacts of governance arrangements before they design or adopt them, particularly for factors such as efficiency of information, oversight, and responsiveness to change.

Analysis and optimisation of the preferences of decision-makers in black-start group decision-making

As the first stage of power system restoration after a blackout, an optimal black-start scheme is very important for speeding up the whole restoration procedure. Up to now, much research work has been done on generating or selecting an optimal black-start scheme by a single round of decision-making. However, less attention has been paid for improving the final decision-making results through a multiple-round decision-making procedure. In the group decision-making environment, decision-making results evaluated by different black-start experts may differ significantly with each other. Thus, the consistency of black-start decision-making results could be deemed as an important indicator in assessing the black-start group decision-making results. Given this background, an intuitionistic fuzzy distance-based method is presented to analyse the consistency of black-start group decision-making results. Moreover, the weights of black-start indices as well as the weights of decision-making experts are modified in order to optimise the consistency of black-start group decision-making results. Finally, an actual example is served for demonstrating the proposed method.

Transforming beyond self: fluidity of parent identity in family decision-making

When a household welcomes a new infant a transformation occurs whereby household routines, values and decisions change. This research explores how decision-making is influenced by fluctuating identity subjectivities. We explore longitudinally, using a family identity framework, how the transitioning between self, couple and family self-identities influences the decisions made regarding social issues, in this case infant feeding. Results indicate that decision-making during a period of transformation is not straightforward, relying on a multiplicity of identities that are constantly renegotiated and dependent on other influences. Decisions made conform to the identity-construct-of-the-moment, but are fluid and subject to change, such that pinpointing causal pathways is inappropriate. Implications for influencing the consumption of social behaviors for consumer researchers are one size does not fit all and require an in-depth understanding of the fluidity of decision-making. Consequently, social marketing strategies need to be tailored to constructed identities and flexible across time to remain influential.

The Reorganisation of Provincial Territories in Light of the Imperial Decision-Making Process : Later Roman Arabia and Tres Palaestinae as Case Studies

The dissertation examines Roman provincial administration and the phenomenon of territorial reorganisations of provinces during the Imperial period with special emphasis on the provinces of Arabia and Palaestina during the Later Roman period, i.e., from Diocletian (r. 284 305) to the accession of Phocas (602), in the light of imperial decision-making. Provinces were the basic unit of Roman rule, for centuries the only level of administration that existed between the emperor and the cities of the Empire. The significance of the territorial reorganisations that the provinces were subjected to during the Imperial period is thus of special interest. The approach to the phenomenon is threefold: firstly, attention is paid to the nature and constraints of the Roman system of provincial administration. Secondly, the phenomenon of territorial reorganisations is analysed on the macro-scale, and thirdly, a case study concerning the reorganisations of the provinces of Arabia and Palaestina is conducted. The study of the mechanisms of decision-making provides a foundation through which the collected data of all known major territorial reorganisations is interpreted. The data concerning reorganisations is also subjected to qualitative comparative analysis that provides a new perspective to the data in the form of statistical analysis that is sensitive to the complexities of individual cases. This analysis of imperial decision-making is based on a timeframe stretching from Augustus (r. 30 BC AD 14) to the accession of Phocas (602). The study identifies five distinct phases in the use of territorial reorganisations of the provinces. From Diocletian s reign there is a clear normative change that made territorial reorganisations a regular tool of administration for the decision-making elite for addressing a wide variety of qualitatively different concerns. From the beginning of the fifth century the use of territorial reorganisations rapidly diminishes. The two primary reasons for the decline in the use of reorganisations were the solidification of ecclesiastical power and interests connected to the extent of provinces, and the decline of the dioceses. The case study of Palaestina and Arabia identifies seven different territorial reorganisations from Diocletian to Phocas. Their existence not only testifies to wider imperial policies, but also shows sensitivity to local conditions and corresponds with the general picture of provincial reorganisations. The territorial reorganisations of the provinces reflect the proactive control of the Roman decision-making elite. The importance of reorganisations should be recognised more clearly as part of the normal imperial administration of the provinces and especially reflecting the functioning of dioceses.

“We have to work within the system!”: Staff perceptions of organizational barriers to decision making for older adults with dementia in Australian aged care facilities

The current study explored the perceptions of direct care staff working in Australian residential aged care facilities (RACFs) regarding the organizational barriers that they believe prevent them from facilitating decision making for individuals with dementia. Normalization process theory (NPT) was used to interpret the findings to understand these barriers in a broader context. The qualitative study involved semi-structured interviews (N = 41) and focus groups (N = 8) with 80 direct care staff members of all levels working in Australian RACFs. Data collection and analysis were conducted in parallel and followed a systematic, inductive approach in line with grounded theory. The perceptions of participants regarding the organizational barriers to facilitating decision making for individuals with dementia can be described by the core category, Working Within the System, and three sub-themes: (a) finding time, (b) competing rights, and (c)not knowing. Examining the views of direct care staff through the lens of NPT allows possible areas for improvement to be identified at an organizational level and the perceived barriers to be understood in the context of promoting normalization of decision making for individuals with dementia.

Changes of mind in decision-making.

A decision is a commitment to a proposition or plan of action based on evidence and the expected costs and benefits associated with the outcome. Progress in a variety of fields has led to a quantitative understanding of the mechanisms that evaluate evidence and reach a decision. Several formalisms propose that a representation of noisy evidence is evaluated against a criterion to produce a decision. Without additional evidence, however, these formalisms fail to explain why a decision-maker would change their mind. Here we extend a model, developed to account for both the timing and the accuracy of the initial decision, to explain subsequent changes of mind. Subjects made decisions about a noisy visual stimulus, which they indicated by moving a handle. Although they received no additional information after initiating their movement, their hand trajectories betrayed a change of mind in some trials. We propose that noisy evidence is accumulated over time until it reaches a criterion level, or bound, which determines the initial decision, and that the brain exploits information that is in the processing pipeline when the initial decision is made to subsequently either reverse or reaffirm the initial decision. The model explains both the frequency of changes of mind as well as their dependence on both task difficulty and whether the initial decision was accurate or erroneous. The theoretical and experimental findings advance the understanding of decision-making to the highly flexible and cognitive acts of vacillation and self-correction.

The Silent Period of Evidence Integration in Fast Decision Making

In a typical experiment on decision making, one out of two possible stimuli is displayed and observers decide which one was presented. Recently, Stanford and colleagues (2010) introduced a new variant of this classical one-stimulus presentation paradigm to investigate the speed of decision making. They found evidence for "perceptual decision making in less than 30 ms". Here, we extended this one-stimulus compelled-response paradigm to a two-stimulus compelled-response paradigm in which a vernier was followed immediately by a second vernier with opposite offset direction. The two verniers and their offsets fuse. Only one vernier is perceived. When observers are asked to indicate the offset direction of the fused vernier, the offset of the second vernier dominates perception. Even for long vernier durations, the second vernier dominates decisions indicating that decision making can take substantial time. In accordance with previous studies, we suggest that our results are best explained with a two-stage model of decision making where a leaky evidence integration stage precedes a race-to-threshold process. © 2013 Rüter et al.

An international comparison of legal frameworks for supported and substitute decision-making in mental health services

There have been important recent developments in law, research, policy and practice relating to supporting people with decision-making impairments, in particular when a person’s wishes and preferences are unclear or inaccessible. A driver in this respect is the United Nations Convention on the Rights of Persons with Disabilities (CRPD); the implications of the CRPD for policy and professional practices are currently debated. This article reviews and compares four legal frameworks for supported and substitute decision-making for people whose decision-making ability is impaired. In particular, it explores how these frameworks may apply to people with mental health problems. The four jurisdictions are: Ontario, Canada; Victoria, Australia; England and Wales, United Kingdom (UK); and Northern Ireland, UK. Comparisons and contrasts are made in the key areas of: the legal framework for supported and substitute decision-making; the criteria for intervention; the assessment process; the safeguards; and issues in practice. Thus Ontario has developed a relatively comprehensive, progressive and influential legal framework over the past thirty years but there remain concerns about the standardisation of decision-making ability assessments and how the laws work together. In Australia, the Victorian Law Reform Commission (2012) has recommended that the six different types of substitute decision-making under the three laws in that jurisdiction, need to be simplified, and integrated into a spectrum that includes supported decision-making. In England and Wales the Mental Capacity Act 2005 has a complex interface with mental health law. In Northern Ireland it is proposed to introduce a new Mental Capacity (Health, Welfare and Finance) Bill that will provide a unified structure for all substitute decision-making. The discussion will consider the key strengths and limitations of the approaches in each jurisdiction and identify possible ways that further progress can be made in law, policy and practice.

A critical narrative analysis of shared decision-making in acute, inpatient mental health care

Shared decision-making (SDM) is a high priority in healthcare policy and is complementary to the recovery philosophy in mental health care. This agenda has been operationalised within the Values-Based Practice (VBP) framework, which offers a theoretical and practical model to promote democratic interprofessional approaches to decision-making. However, these are limited by a lack of recognition of the implications of power implicit within the mental health system. This study considers issues of power within the context of decision-making and examines to what extent decisions about patients? care on acute in-patient wards are perceived to be shared. Focus groups were conducted with 46 mental health professionals, service users, and carers. The data were analysed using the framework of critical narrative analysis (CNA). The findings of the study suggested each group constructed different identity positions, which placed them as inside or outside of the decision-making process. This reflected their view of themselves as best placed to influence a decision on behalf of the service user. In conclusion, the discourse of VBP and SDM needs to take account of how differentials of power and the positioning of speakers affect the context in which decisions take place.

Women's decision making and experience of subsequent pregnancy following stillbirth.

INTRODUCTION: This study sought to increase understanding of women's thoughts and feelings about decision making and the experience of subsequent pregnancy following stillbirth (intrauterine death after 24 weeks' gestation). METHODS: Eleven women were interviewed, 8 of whom were pregnant at the time of the interview. Modified grounded theory was used to guide the research methodology and to analyze the data. RESULTS: A model was developed to illustrate women's experiences of decision making in relation to subsequent pregnancy and of subsequent pregnancy itself. DISCUSSION: The results of the current study have significant implications for women who have experienced stillbirth and the health professionals who work with them. Based on the model, women may find it helpful to discuss their beliefs in relation to healing and health professionals to provide support with this in mind. Women and their partners may also benefit from explanations and support about the potentially conflicting emotions they may experience during this time.