Shared decision-making in mental health care : a user perspective on decisional needs in community-based services

BACKGROUND: Shared decision-making (SDM) is an emergent research topic in the field of mental health care and is considered to be a central component of a recovery-oriented system. Despite the evidence suggesting the benefits of this change in the power relationship between users and practitioners, the method has not been widely implemented in clinical practice. OBJECTIVE: The objective of this study was to investigate decisional and information needs among users with mental illness as a prerequisite for the development of a decision support tool aimed at supporting SDM in community-based mental health services in Sweden. METHODS: Three semi-structured focus group interviews were conducted with 22 adult users with mental illness. The transcribed interviews were analyzed using a directed content analysis. This method was used to develop an in-depth understanding of the decisional process as well as to validate and conceptually extend Elwyn et al.'s model of SDM. RESULTS: The model Elwyn et al. have created for SDM in somatic care fits well for mental health services, both in terms of process and content. However, the results also suggest an extension of the model because decisions related to mental illness are often complex and involve a number of life domains. Issues related to social context and individual recovery point to the need for a preparation phase focused on establishing cooperation and mutual understanding as well as a clear follow-up phase that allows for feedback and adjustments to the decision-making process. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: The current study contributes to a deeper understanding of decisional and information needs among users of community-based mental health services that may reduce barriers to participation in decision-making. The results also shed light on attitudinal, relationship-based, and cognitive factors that are important to consider in adapting SDM in the mental health system.

Machine Learning Algorithms in Heavy Process Manufacturing

In a global economy, manufacturers mainly compete with cost efficiency of production, as the price of raw materials are similar worldwide. Heavy industry has two big issues to deal with. On the one hand there is lots of data which needs to be analyzed in an effective manner, and on the other hand making big improvements via investments in cooperate structure or new machinery is neither economically nor physically viable. Machine learning offers a promising way for manufacturers to address both these problems as they are in an excellent position to employ learning techniques with their massive resource of historical production data. However, choosing modelling a strategy in this setting is far from trivial and this is the objective of this article. The article investigates characteristics of the most popular classifiers used in industry today. Support Vector Machines, Multilayer Perceptron, Decision Trees, Random Forests, and the meta-algorithms Bagging and Boosting are mainly investigated in this work. Lessons from real-world implementations of these learners are also provided together with future directions when different learners are expected to perform well. The importance of feature selection and relevant selection methods in an industrial setting are further investigated. Performance metrics have also been discussed for the sake of completion.

Shared-decision making in designing new healthcare environments : ready to take off for improved quality

Background Successful implementation of new methods and models of healthcare to achieve better patient outcomes and safe, person-centered care is dependent on the physical environment of the healthcare architecture in which the healthcare is provided. Thus, decisions concerning healthcare architecture are critical because it affects people and work processes for many years and requires a long-term financial commitment from society. In this paper, we describe and suggest several strategies (critical factors) to promote shared-decision making when planning and designing new healthcare environments. Discussion This paper discusses challenges and hindrances observed in the literature and from the authors extensive experiences in the field of planning and designing healthcare environments. An overview is presented of the challenges and new approaches for a process that involves the mutual exchange of knowledge among various stakeholders. Additionally, design approaches that balance the influence of specific and local requirements with general knowledge and evidence that should be encouraged are discussed. Summary We suggest a shared-decision making and collaborative planning and design process between representatives from healthcare, construction sector and architecture based on evidence and end-users’ perspectives. If carefully and systematically applied, this approach will support and develop a framework for creating high quality healthcare environments.

Decision making in health care: limitations of the substituted judgement principle

The substituted judgement principle is often recommended as a means of promoting the self-determination of an incompetent individual when proxy decision makers are faced with having to make decisions about health care. This article represents a critical ethical analysis of this decision-making principle and describes practical impediments that serve to undermine its fundamental purpose. These impediments predominantly stem from the informality associated with the application of the substituted judgement principle. It is recommended that the principles upon which decisions are made about health care for another person should be transparent to all those involved in the process. Furthermore, the substituted judgement principle requires greater rigour in its practical application than currently tends to be the case. It may be that this principle should be subsumed as a component of advance directives in order that it fulfils its aim of serving to respect the self-determination of incompetent individuals.

A field test of the diversity-openness moderator model in newly formed groups: openness to diversity affects group decision effectiveness and interaction patterns

Detrimental effects of diversity in workgroups has frequently been observed but research identifying the factors that lead to negative or positive effects in heterogeneous groups is lacking. The perceived dissimilarity openness moderator model provides one explanation of the process by which diversity influences group affective, behavioral, and cognitive outcomes. Specifically the model identifies individual, group, and organizational openness as moderating the effects of diversity in workgroups. In this paper evidence is provided from a field study that increased openness to perceived dissimilarity leads to better outcomes in newly formed groups. This study also constitutes a significant building block toward the development of theory concerning the moderating variables of the relationship between diversity and group processes, and outcomes of organizations.

Haemodynamic instability after cardiac surgery: nurses` perceptions of clinical decision-making

Background. Cardiac surgical patients are distinguished by their potential for instability in the early postoperative period, highly invasive haemodynamic monitoring technologies and unique clinical presentations as a result of undergoing cardiopulmonary bypass. Little is known about nurses’ perceptions of assuming responsibility for such patients. An nderstanding of nurses’ perceptions may identify areas of practice that can be improved and assist in determining the adequacy of current decision supports.

Aim. The aim of this study was to describe critical care nurses’ perceptions of assuming responsibility for the nursing management of cardiac patients in the initial two-hour postoperative period. Design. An exploratory descriptive study based on naturalistic decision-making.

Methods. Thirty-eight nurses were interviewed immediately following a two-hour observation of their clinical practice. Content analysis and a systematic thematic analysis process called ‘Framework’ were used to analyse the interview transcripts.

Results. Nurses described their perceptions of managing patients in terms of how they felt about making decisions for complex cardiac surgical patients and in terms of how clinical processes unique to the admission phase impacted their decision-making. Nurses felt either daunted or stimulated and challenged when making decisions. Nurses identified handover from anaesthetists, settling in procedures and forms of
collegial assistance as important processes that impacted their decision-making.

Conclusion. Nurses’ previous experiences with similar patients influenced how they felt about making decisions during the initial two-hour postoperative period, but did not alter their views about processes important for patient safety during this time. Relevance to clinical practice. Feelings expressed by nurses in this study highlight the need for clinical supervision and appropriate allocation of resources during the immediate recovery period after cardiac surgery. Nurses identified ways to improve clinical processes that impacted their decision-making during the immediate recovery of cardiac surgical patients.

Impact of internationalisation on business decision-making: the Australian experience

The research considered the impact on the range of decision areas available to strategy setting for organisations internationalising part of their operations to reduce costs. The research utilised qualitative research data collected from interviews with 10 CEOs based on a structured interview guide formulated around the principal issues identified in the literature. Thematic analysis was used to extract evidence in relation to issues identified in the literature as well as new issues not currently identified .It found that internationalisation significantly reduced the range of decision areas available for strategic decision making. This affected the range of inputs to the formulation process, as well as the strategic choice options available. Organisations internationalising operations to reduce costs should increase levels of staff involvement through revolutionary strategy formulation processes, adopted more centralised corporate strategy processes and utilise a clearly differentiated and sequential relationship between corporate and business level strategies. The findings indicate that different strategy formulation processes are required for different levels of internationalisation of operations to reduce operating costs. Research into international strategy must recognize the change in the approach to strategy formulation that occurs as organisations increase their level of international operations. Future research to identify whether the currently generally adopted strategy formulation processes are adequate for all levels of internationalisation of operations should be pursued.

Harm reduction and decision making among recreational ecstasy users

Recent research indicates that 3,4-methylene-dioxymethamphetamine (MDMA), also known as ‘ecstasy’, is becoming increasingly popular as an illicit drug among young people. This study investigated risk and harm reduction practices among recreational ecstasy users. A semi-structured interview with 40 participants was designed to investigate how ecstasy users identify and manage the harms associated with their drug use, and the underlying decision-making process. Overall, the participants identified both positive and negative effects. The reported positive effects predominantly centred around enhanced psychological, physiological and social experiences. However, there were a number of factors that contributed to regulating ecstasy use. These included specific in-group and out-group practices executed within the peer group, preventative harm-reducing practices, shared decision making, and shared responsibility for harm prevention. Recommendations for promoting harm reduction strategies and suggestions for future research are discussed.

Evidence-based clinical policy: case report of a reproducible process to encourage understanding and evaluation of evidence

We report within a case study a reproducible process to facilitate the explicit incorporation of evidence by a multidisciplinary group into clinical policy development. To support the decision-making of a multidisciplinary Intersectoral Advisory Group (IAG) convened by the Royal Australasian College of Physicians Health Policy Unit, a systematic review of randomized controlled trials about environmental tobacco smoke and smoking cessation interventions in paediatric settings was first undertaken. As reported in detail here, IAG members were then formally engaged in a transparent and replicable process to understand and interpret the synthesized evidence and to proffer their independent reactions regarding policy, practice and research. Our intention was to ensure that all IAG members were democratically engaged and made aware of the available evidence. As clinical policy must engage stakeholder representatives from diverse backgrounds, a process to equalize understanding of the evidence and 'democratize' judgment about its implications is needed. Future research must then examine the benefits of such explicit steps when guidelines, in turn, are implemented. We hypothesize that changes to future practice will be more likely if processes undertaken to develop guidelines are transparent to clinicians and other target groups.

Decision-making models used by `graduate nurses` managing patients` medications

Background. Nurses in a graduate programme in Australia are those who are in the first year of clinical practice following completion of a 3-year undergraduate nursing degree. When working in an acute care setting, they need to make complex and ever-changing decisions about patients' medications in a clinical environment affected by multifaceted, contextual issues. It is important that comprehensive information about graduate nurses' decision-making processes and the contextual influences affecting these processes are obtained in order to prepare them to meet patients' needs.
Aim. The purpose of this paper is to report a study that sought to answer the following questions: What are the barriers that impede graduate nurses' clinical judgement in their medication management activities? How do contextual issues impact on graduate nurses' medication management activities? The decision-making models considered were: hypothetico-deductive reasoning, pattern recognition and intuition.
Methods. Twelve graduate nurses who were involved in direct patient care in medical and surgical wards of a metropolitan teaching hospital located in Melbourne, Australia participated in the study. Participant observations were conducted with the graduate nurses during a 2-hour period during the times when medications were being administered to patients. Graduate nurses were also interviewed to elicit further information about how they made decisions about patients' medications.
Results. The most common model used was hypothetico-deductive reasoning, followed by pattern recognition and then intuition. The study showed that graduate nurses had a good understanding of how physical assessment affected whether medications should be administered or not. When negotiating treatment options, graduate nurses readily consulted with more experienced nursing colleagues and doctors.
Study limitations. It is possible that graduate nurses demonstrated a raised awareness of managing patients' medications as a consequence of being observed.
Conclusions. The complexity of the clinical practice setting means that graduate nurses need to adapt rapidly to make sound and appropriate decisions about patient care.

The use of analytic hierarchy process to incorporate stakeholder preferences into regional forest planning

Forest management decisions are often characterised by complexity, irreversibility and uncertainty. Much of the complexity arises from the multiple-use nature of forest goods and services, difficulty in monetary valuation of ecological services and the involvement of numerous stakeholders. Under these circumstances, conventional methods such as cost-benefit analysis are ill-suited to evaluate forest decisions. The Analytic Hierarchy Process (AHP), can be useful in regional forest planing as it can accommodate conflictual, multidimensional, incommensurable and incomparable set of objectives. The objective of this paper is to examine the scope and feasibility of the AHP in incorporating stakeholder preferences into regional forest planning. The Australian Regional Forest Agreement Programme is taken as an illustrative case for the analysis. The results show that the AHP can formalize public participation in decision making and increase the transparency and the credibility of the process.

The group purchasing process : an investigation into the influence of the facilitator in alpine tourism

Group travel is a common feature of all tourism markets and can vary from the familiar peer group/common purpose associations of the football and cricket followers to the non-familiar co-operative travel group of the under 35 year olds bus adventures throughout Europe. This study investigates the nature of social group travel in alpine tourism. It specifically examines the phenomena of the "group facilitator"; the person within the group who takes a major role in the travel decisions and organisation on rehalf of all the other members in the travel party. The specific activities of this "group facilitator" and the role of opinion leadership, information search, organisation process, previous experience, relationship ties between the group members are examined. The 'facilitator' also influences other individuals' decision to participate who delegate selection of destination to this person as well. The 'facilitator' has many of the characteristics of an opinion leader and was recognised by group participants as a major source of information about the destination. The findings of the study have important implications for tourism marketers as they highlight an opportunity to reach many potential travellers by directly targeting one key influencer and decision maker.

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.

Interlink decision making index (IDMI) -- a simple tool/concept to assist decision making for sustainability Part 1: definition of IDMI

There is an apparent gap between the LCA or other assessment's outcomes and its effective application in the decision making process. It is needed to provide to the decision makers a simple, less human interfered mechanism that integrates all the key criteria (environmental, economic, technical and safety etc.). The proposed index: Interlink Decision Making Index (IDMI) has all these features: simple, interlink (all criteria) and automatically and quantified influence of critical criteria (ie. no human weighting needed) and is able to assist the multi-criteria decision making for sustainability based on the outcomes of specific assessments (eg. LCA, ElA etc.). The index represents a pure numerical value and does not necessarily have any physical meanings, but it reflects the total merits of a particular option once the normal decision making criteria and (up to two) critical criteria (CC) have been chosen. Then, without arbitrarily weighting process, the comparison and selection of the best possible option, ie. decision can be made based on the derived IDMI results. Two hypothetical examples are presented in part 2 of the paper to demonstrate the application of the IDMI concept and it's differences with the traditional "tabular method" in the decision making process.

Interlink decision making index (IDMI) : a simple tool/concept to assist decision making for sustainability part 2 : calculation and examples of IDMI

There is an apparent gap between the LCA or other assessment's outcomes and its effective application in the decision making process. It is needed to provide to the decision makers a simple, less human interfered mechanism that integrates all the key criteria (environmental, economic, technical and safety etc.). The proposed index: Interlink Decision Making Index (IDMI) has all these features: simple, interlink (all criteria) and automatically and quantified influence of critical criteria (ie. no human weighting needed) and is able to assist the multi-criteria decision making for sustainability based on the outcomes of specific assessments (eg. LCA, BIA etc.). The index represents a pure numerical value and does not necessarily have any physical meanings, but it reflects the total merits of a particular option once the normal decision making criteria and (up to two) critical criteria (Ce) have been chosen. Then, without arbitrarily weighting process, the comparison and selection of the best possible option, ie. decision can be made based on the derived IDMI results. Two hypothetical examples are presented in the part 2 of the paper to demonstrate the application of the IDMI concept and it's differences with the traditional "tabular method" in the decision making process.