1. Lecture 2 Information processing and intuitive decision making theory Carl Thompson

2. Decision making theory Descriptive approaches: how people actually make decisions Descriptive approaches: how people actually make decisions Normative approaches: how people ought to make decisions Normative approaches: how people ought to make decisions NB. Most approaches have elements of both NB. Most approaches have elements of both

3. Information processing Assumptions Assumptions Human reasoning as the interface between short (stimuli) and long-term (semantic/factual knowledge & experiential (episodic knowledge) memory Human reasoning as the interface between short (stimuli) and long-term (semantic/factual knowledge & experiential (episodic knowledge) memory Human reasoning is rational Human reasoning is rational Rationality is bounded Rationality is bounded

4. Information processing: the process Elstein et al. 1978 Elstein et al. 1978 Cue acquisition Cue acquisition H° generation H° generation Cue interpretation Cue interpretation H° evaluation H° evaluation Carnevali et al 1984 Exposure to pre-encounter data Entry to the data search field and shaping data gathering Coalescing cues into chunks Activating possible H° H° directed search of the data field Testing H° Dx

5. he could not take the sleeping tablets as he could not swallow…. the DN said that they might have to put up a syringe driver for the night if he was not settling and could not take anything orally. ……she told her that it would not be long until he died…… his breathing would get shallower, occasionally it would seem as though he would not breathe again…..it showed that he was nearer to dying…… ….. he had a couple of dressings on his bottom and the dressings were intact. The DN decided to leave them and not to move him around too much as he had not slept much that night….. the DN said that the Marie Curie nurses could work for up to 27 hours and she thought that it would be better if they came at night ….. she would return in the afternoon to reassess him

6. Information cues Signs and symptoms Test results Patient preferences Etc. Optimal judgement Nurses’ Judgements Brunswik’s lens model

7. Social judgement approaches to modelling cue use

8. Importance Utility(s.e.) Factor öòø SYSTOLIC systolic BP 4.59 ó ó 3.4298(9.3211) ó - normal õò÷ -2.9035(9.3211) - ó equivocal ó -.5263(8.9352) ó abnormal ó öòòòòòòòòòø PULSE pulse ó 26.80 ó 18.5965(9.3211) ó ---- normal õòòòòòòòòò÷ -18.404(9.3211) ---- ó equivocal ó -.1930(8.9352) ó abnormal ó öòòòòø RESPS resps 13.13 ó ó -5.0702(9.3211) - ó normal õòòòò÷ -6.5274(8.9598) - ó equivocal ó 11.5976(8.9598) ó -- abnormal ó öòòòòø O2 oxygen sats 14.73 ó ó -12.070(9.3211) --- ó normal õòòòò÷ 8.2632(9.3211) ó -- equivocal ó 3.8070(8.9352) ó - abnormal ó öòòòòòòòø URINE urine output ó 21.64 ó 11.6393(8.9598) ó --- normal õòòòòòòò÷ 6.5965(9.3211) ó - equivocal ó -18.236(8.9598) ---- ó abnormal ó öòòòòòòø GCS glasgow coma score ó 19.11 ó -7.5702(9.3211) -- ó normal õòòòòòò÷ -9.4035(9.3211) -- ó equivocal ó 16.9737(8.9352) ó ---- abnormal ó 53.5702(6.5013) CONSTANT Pearson's R =.838 Significance =.0000 Kendall's tau =.570 Significance =.0003 Summary of judgement policy for one clinician faced with the Dx of shock in critical care. Utilities Importance Internal consistency

9. SHARED DECISION MAKING VALUES ROLE CONFLICT, GP WISHES COST NEED FOR VISIBILITY IN DECISION REJECTION OF EXPERTISE PATIENT REJECTION OF EXPERTISE CNS WOUND FORMULARY COST DOWN TO WHAT I’VE USED OVER THE YEARS SEEING IS BELIEVING AND EXPERIMENTATION Investigations: urine, FBC, ESR, urea and electrolytes, blood glucose, swab (if appropriate) Background information History: how and when ulcer started; current treatment; pain… etc General medical condition: diabetic? RA; anaemic?… etc Other health information: smoker? Mobility? Medication?…etc general condition: well? Pulse, BP, weight Leg exam: oedema, temperature; ankle and calf circumference… Ulcer: size, odour, slough, exudates? Doppler ABPI Compliance? ARTICLES PHYSIOLOGY DAILY VISITS PATIENT INFORMATION COLLEAGUE’S ‘EXPERIMENTS’

10. Problems with info processing Role of H° Role of H° Over emphasising positive findings Over emphasising positive findings Excessive data collection Excessive data collection

11. Intuition and expertise Understanding without a rationale (Benner & Tanner 1987 p2) Understanding without a rationale (Benner & Tanner 1987 p2) A perception of possibilities, meanings and relationships by way of insight (Gerrity 1987 p63) A perception of possibilities, meanings and relationships by way of insight (Gerrity 1987 p63) Knowledge of a fact or truth, as a whole; immediate possession of knowledge; and knowledge independent of the linear reasoning process (Rew and Barron 1987 p60) Knowledge of a fact or truth, as a whole; immediate possession of knowledge; and knowledge independent of the linear reasoning process (Rew and Barron 1987 p60) Immediate knowing of something without the conscious use of reason (Schrader and Fischer 1987 p45) Immediate knowing of something without the conscious use of reason (Schrader and Fischer 1987 p45) [A] process whereby the nurse knows something about a patient that cannot be verbalised, that is verbalised with difficulty or for which the source of knowledge cannot be determined (Young 1987 p52) [A] process whereby the nurse knows something about a patient that cannot be verbalised, that is verbalised with difficulty or for which the source of knowledge cannot be determined (Young 1987 p52)

12. Intuition Type of knowledge vs mode of thought Type of knowledge vs mode of thought Lack of visibility Lack of visibility Dubious morality? Dubious morality? Reflective ‘paradox’ and ?black box Reflective ‘paradox’ and ?black box Accurate sometimes (hindsight?) Accurate sometimes (hindsight?) Lack of power Lack of power

13. Novice - expert Dreyfus’ and Benner Dreyfus’ and Benner Novice Novice Advanced beginners Advanced beginners Competent Competent Proficient Proficient Expert Expert

14. performance Whole situation Whole situation Orientation Orientation Decision Decision Situation components Situation components Perception Perception action action

15. Level of organisation Lower……Higher Sub process PerceptionActionOrientationDecision Stage Perceives the elements of the situation Acts on those elements Recognises whole situations Makes decisions and plans to attain goals in the situation NoviceAnalyticalAnalytical Rely on others Advanced beginner IntuitiveAnalytical Rely on others CompetentIntuitiveIntuitiveAnalyticalAnalytical ProficientIntuitiveIntuitiveIntuitiveAnalytical ExpertIntuitiveIntuitiveIntuitiveIntuitive

16. ‘the rules’ Realise that expertise is acquired step-by-step Realise that expertise is acquired step-by-step Avoid trying to think like an expert (intuitively) Avoid trying to think like an expert (intuitively) Practice intensively using the rules and logic that are available Practice intensively using the rules and logic that are available *NB the proponents’ discipline (sociology/naturalistic research) does not demand empirical testing so caution advised *NB the proponents’ discipline (sociology/naturalistic research) does not demand empirical testing so caution advised

17. Points of contact and divergence Communicability Communicability Simplification Simplification Context specificity Context specificity applicability applicability