1. Decision Making Under Stress Strategies for Becoming a Better Decision Maker in Emergencies Developed by DC John Tippett City of Charleston Fire Department Carlos Alfaro, MCFRS

2. Synopsis Given that attendees have already been introduced to the principles of Crew Resource Management (CRM), this session will focus on the element of decision making in an effort to improve that skill.

3. Learning Objectives Review principles of Crew Resource Management to refresh attendees memories. Discuss, describe and dispense information on decision making to improve that skill in attendees.

4. Credits The following presentation borrows, with permission, from the work of Chief Richard B. Gasaway (Ph.D), Roseville Fire Department (MN) rich.gasaway@ci.roseville.mn.us 651-792-7304. The works of Gary Klein and Malcolm Gladwell were also used in the preparation of this presentation.

5. Why are we here? Robert Evans, MCFRS

6. Decisions we make have impact http://www.youtube.com/watch?v=G3uoV OOlT2shttp://www.youtube.com/watch?v=G3uoV OOlT2s http://www.youtube.com/watch?v=Bqh5h1 7bmC4&feature=relatedhttp://www.youtube.com/watch?v=Bqh5h1 7bmC4&feature=related

8. Error Management Contemporary thinking acknowledges that error is a way of life. –given the acceptance that human error may occur, the focus has become How does one effectively manage error? –proper error management greatly enhances safety

9. CRM Review What: The conscious and deliberate use of all resources in a non-threatening, non-punitive environment. Employing principles of CRM in every aspect of performance helps avoid, trap, and mitigate the impact of errors. Goal: To achieve optimal performance from a team executing multiple, complex tasks.

10. Crew Resource Management (CRM) is a tool created to optimize human performance by reducing the effect of human error through the use of all resources.

11. 6 Principles Communication Task Allocation Situational Awareness Teamwork Decision Making Debrief*

12. Communication

13. Task Allocation

14. Situational Awareness

15. Teamwork

16. Decision Making

17. Decisions: Choices made from among two or more alternatives.

18. Is decision making a n art or a science?

19. Traditional Decision-Making Process Define the problem. Identify decision criteria. Allocate weights to the criteria. Develop the alternatives. Evaluate the alternatives. Select the best alternative. Evaluate effectiveness of the action.

20. Subject Matter Experts use Naturalistic Decision Making Dr. Gary Klein, PhD (Klein & Associates) www.decisionmaking.com Studies included: fireground and battleground commanders. Hypothesis: Fireground commanders use cognitive decision making processes.

21. What were the results of Kleins research? Fireground commanders did not use cognitive decision- making processes. In many cases, the IC didnt even go as far as coming up with two plans of action to compare. They picked the first thing that came to mind and played it out in their mind.

22. What were the results of Kleins studies? If the mental model played out ok, they went with that decision. If it didnt, they scrapped it and used the same process with the next solution that came to their mind.

23. Why is This Important to Us?

24. How can we as decision makers do this? Recognition-Primed Decision Making –Situational Awareness –Tacit Knowledge –Mental Modeling –Self-Efficacy (confidence)

25. Exercise 1 RPDM (20 minutes)

26. Exercise Instructions You will be shown a series of incident scenes. Incident scene will be displayed for 5 seconds. Ask students following questions: –Have you run an incident like this before? –What did you do? –Did your actions result in a successful outcome?

27. Have you run an incident like this before? What did you do? Did your actions result in a successful outcome? Scenario 1

28. Have you run an incident like this before? What did you do? Did your actions result in a successful outcome? Scenario 2

29. Scenario 3 Have you run an incident like this before? What did you do? Did your actions result in a successful outcome?

30. Scenario 4 Have you run an incident like this before? What did you do? Did your actions result in a successful outcome?

31. Scenario 5 Have you run an incident like this before? What did you do? Did your actions result in a successful outcome?

32. Common Characteristics of Command & Control Decision-Making

33. High ambiguity with unknown cause and effect. Low probability of frequent occurrence. Unusual and unfamiliar circumstances. Requires rapid action. Can pose serious threat to survival. Dilemma necessitates a decision be made.

34. Naturalistic Decision Making (NDM)

35. NDM (Intuitive) Process Size-up situation quickly. Recognize typical ways of reacting. Mentally game out the options. Focus on most relevant information. Form expectations. Detect anomalies and problems. Seek explanations for unusual events. Make a decision and run with it.

36. Decision Making Setting Stable v. Unstable

37. Decision-Maker Novice v. Subject Matter Expert

38. Decision-Making Focus Narrow v. Broad

39. Decision-Making Time Ample time to decide v. Limited time to decide

40. Decision-Making working conditions Stable v. Unstable

41. Decision-Making Goals Clearly stated v. Unclear/ambiguous

42. Decision-Making Information Quality –Precise –Degrading Quantity –Not enough –Too much

43. Decision-Making Inputs Clear inputs v. Subtle cues and patterns

44. Decision-Making Consequences Low stakes v. High stakes

45. Qualities of effective decision-makers Flexible Quick thinker Resilient Adaptive Risk taker Accurate

46. Decisions can trigger stress reactions Heart rate increases. Respirations increase. Pupils dilate. Glucose released for instant energy. Endorphins are released. Blood supply to the kidneys and digestive tract is restricted. The bowels and bladder may release their contents. Attention is focused in immediate, highly structured tasks. More important & complex tasks are avoided. Natural judgment systems shut down and more primitive instincts take over.

47. Stress triggers Primitive Instincts and tells you to use your Intuition

48. Physiology of Decision Making Left Brain Logical thinkers Right Brain Intuitive Thinkers

49. Physiology of decision making Left Brain Logical Sequential Rational Analytical Objective Looks at parts Right Brain Random Intuitive Holistic Synthesizing Subjective Looks at wholes

50. Primary Personality Traits C. G. Jung Analytical Psychologist –Extrovert or Introvert –Sensing or Intuitive –Thinking or Feeling –Perceiving or Judging

51. Examples of primary traits Reservedv.Outgoing Submissivev.Aggressive Seriousv.Happy-go-lucky Timidv.Venturesome Tough-mindedv.Sensitive Trustingv.Suspicious Practicalv. Imaginative Self-Assuredv.Apprehensive Conservativev.Experimental Group dependentv.Self-sufficient Uncontrolledv.Controlled Relaxedv.Tense

52. Emergency Scene Decision-Making Environment Conditions: Uncontrolled and continually changing Time: Constrained Information: Degrading, too much, not enough Ambiguity: High, with unknown cause and effect Frequency of event: Low Situation: Unusual and unfamiliar Action: Rapid and necessary Risk: High

53. 3 Levels of Situation Awareness (SA) Level 1 Capturing the elements of the current situation Paying Attention Whats going on right now? Level 2: Comprehending the current situation Sense Making What does this mean? Level 3: Predicting the future situation Story Building Where is this going?

54. How do you develop Naturalistic Decision-Making skills? Must become a competent subject matter expert. Progression of Competency in SA –Unconscious Incompetence I didnt even see that. –Conscious Incompetence I saw it, but I didnt know what it meant. –Conscious Competence I saw it, and I knew what it meant. –Unconscious Competence Something inside told me that was important.

55. Whats the problem? Experience: –(novice EMTs, commanders, firefighting teams) Communications: –(lack of, too much, confusion, incomplete) Situation Awareness: –(all 3 levels: capturing, comprehending, predicting) Sense Making: –(figuring it out) Story Building: –(predicting where its going) Task Overload: –(being overwhelmed)

56. Whats the problem? Multi-Tasking: –(doing too many things at once) Distractions: –(interruptions, setting things aside that need done) Staffing: –(experience, training, understaffing) Error Creep: –(doing things wrong and getting away with it) Conflicting goals: –(multiple goals, freelancing) Human factors: –(personality, ego, fatigue, culture, complacency, invulnerability) Commander location: –(In the street? In a command vehicle?)

57. Becoming a better emergency scene decision maker Training for NDM –Reading and comprehending cues –Developing situation awareness –Forming mental models and forecasting –Training commanders in context Practice commanding in NDM environment (not the classroom)

58. Becoming a better emergency scene decision maker Acceleration of experience –Commanders-in-training Commanding actual incidents – No substitute for the lived experience. Post-incident evaluations (learn from mistakes - avoid error creep). –Simulations – A safe way to make mistakes. Computer-based Pencil & Paper Chalk Talks –Case studies – Other peoples lived experiences. Near-Miss Reports N.I.O.S.H. Reports Firefighter Close Calls Reports On The Job narratives that include lessons learned

59. TADMUS* *Team Decision Making Under Stress U.S. Army study on team decision making. Best performers under stress were adaptive. Adapatability was trainable.

60. Making TADMUS work Team must have a common mental model. Leader routinely gives assessment. –Facilitates information sharing. –Allows others to cue base or NDM. Team develops common language. Develop anticipatory behavior. –Communicate –Train together

61. Team Decision Making Exercise Form into teams as indicated by instructor. You will be presented with a series of scenarios that will require you to make decisions in an increasingly time sensitive environment.

62. Case Study www.firefighternearmiss.com Report # 05-147

63. Event Narrative I responded as part of an ALS crew for a heart attack. We arrived on the scene and were greeted by a group of small children standing on the front porch flagging us down and flashing the porch light. The PMIC commented that it looked like "grandpa must be having the big one." The two medics grabbed gear and headed into the house. I grabbed the portable radio and followed behind. When I walked in the house I observed the charge medic seated across from a man about 30 years old, sweating profusely and breathing heavily. I excused myself as I walked by and took a position in the corner of the kitchen. I set the portable on a chest freezer and turned around. As I scanned the room I noticed for the first time that the table area and kitchen had been trashed. The "victim" started breathing more heavily and started chanting "I don't want to hurt anybody, I don't want to hurt anybody," over and over, getting louder and louder. He then stood up abruptly, started yelling and kicked his chair. The children screamed and ran down the hallway to their bedrooms. The charge medic said, "Ok, that's it, we're outta here." He and the other medic headed for the door. I grabbed the portable but was cut off by the victim. He squared off facing me…

64. Whats Next?

65. Event Narrative …and prevented me from getting past. I was able to get over to his wife. She whispered to me that if he could only find a job, everything would be alright. I told her we needed to get the hell out of here. He started coming at us breathing heavily and grunting. I pushed her into the dining room out of the sight of her husband. We could hear him pulling the drawers out and throwing silverware and utensils around. I told the wife to head for the living room so we could exit by the main hall. I could hear the charge medic calling for police help, stating there was a firefighter trapped in the house with a violent mental patient. As the wife and I came down the front hall, the patient stepped into the hall and cut off our escape. We retreated back into the living room and he returned to the kitchen and started throwing silverware around again. I saw the charge medic coming toward the front door. I told the wife to stay in the hallway and I moved up to the intersection of the bedroom hallway and front hallway. The charge medic opened the front door and we both called for the kids to come out of their bedrooms. As they came down the hall, I passed them to the charge medic and he took them outside. The patient continued to tear the kitchen apart. As the last child was passed, the patient came back into the hallway. I backed up and he went back into the kitchen. Everything got very quiet so I walked down the hallway with the wife in tow. As we got to the intersection of the kitchen and hallway, the patient came at us. I pushed the wife out the front door and retreated down the front hall again. I could hear him chanting again and throwing things around the kitchen and decided I could make it out of the house. As I reached the hallway intersection again, he came out of the kitchen and threw a punch. His fist hit the wall and stopped his momentum. I took the opportunity to make my escape and ran out the front door. The police arrived a short time later and took the patient into protective custody.

66. People live and die by the decisions we make If we are to learn to improve the quality of the decisions we make, we need to accept the mysterious nature of our snap judgments. -- Malcolm Gladwell

67. References Gladwell, M. (2005).The power of thinking without thinking. New York: Little, Brown & Company. Jensen, R. S. (1997). The boundaries of aviation psychology, human factors, aeronautical decision making, situation awareness, and crew resource management. The International Journal of Aviation Psychology, 7(4), 259-267. Kass, S. J., Herschler, D. A., & Companion, M. A. (1991). Training situational awareness through pattern recognition in a battlefield environment. Military Psychology, 3(2), 105-112. Klein, G. (1998). Sources of power. Cambridge, MA: The MIT Press. Klein, G. (2003). The power of intuition. New York: Doubleday. Klein, G. A., Calderwood, R., & Clinton-Cirocco, A. (1986). Rapid decision making on the fire ground. Proceedings of the 30th Annual Meeting of the Human Factors Society. Dayton, OH, pp. 576-580. Klein, G., Weick, K. E. (June, 2000) Decisions. Across the Board, 37(6). Retrieved on January 10, 2004 from EBSCOhost Research Database. Morrison, J. G., Kelly, R. T., Moore, R. A., & Hutchins, S. G. (2000). Implications of decision-making research for decision support and displays. In J. A. Cannon-Bowers, & E. Salas (Eds.). Decision Making Under Stress: Implications for Training and Simulation, (pp. 375-406). Washington, DC: American Psychological Association. Rubin, D. L. (2001). Crew resource management, Part 6: Critical decision making. Firehouse, 27(7), 118-125. Sadler-Smith, E., & Shefy, E. (2004). The intuitive executive: Understanding and applying gut feel in decision- making. Academy of Management Executive, 18(4), 76-91. Sayegh, L., Anthony, W. P., Perrewe, P. L. (2004). Managerial decision-making under crisis: The role of emotion in an intuitive decision process. Human Resource Management Review, 14, 179-199. Smitherman, M. W. (2000). British styles of incident safety: Command decisionmaking and team knowledge. Fire Department Integrated Risk Analysis and Management Symposium. Fairfax, VA: Public Entity Risk Institute.