A quick guide to decision making
in Obstetrics
All healthcare professionals make decisions every day.
Some of these decisions are easy
such as deciding which arm to take blood from.
Other decisions are more complex, can have significant implications and may seem impossible to make.
It is worth considering how we make decisions.
We may use different techniques to make decisions depending on the circumstances and conditions surrounding the decision
such as if we feel the need to make a decision quickly,
the task is complex,
how feasible the different options are
and importantly the level of resources and support available to us.
There has been notable work by psychologists such as Daniel Kahneman
which explain the psychology and judgement of decision making.
Psychologists tell us that there are four main types of decision making.
These are intuitive, rule-based, analytical and creative.
Intuitive decision making is following your gut feeling.
This type of decision making is quick as it requires little conscious thought
but only works when we are experienced.
The solution for the decision has been stored alongside the memory of a previous event
and so is recalled automatically.
This solution is often good enough to solve the problem
but may not always be the best decision for the team or the patient.
We often use intuition when we are feeling stressed
for example, if you're informed of a fetal bradycardia for nine minutes
intuitive thought tells you this patient needs delivery.
Rule-based decision-making is when we identify a problem using situation assessment
then apply the rule, procedure or evidence for that situation.
This form of thinking is valuable as it requires more cognitive thought.
It is useful for novices who can apply a guideline or rule to a specific situation
and therefore is easy to justify as we are following a protocol.
As we regularly practice these rules and procedures
the information becomes part of our intuitive decision making
however if we are distracted or interrupted, the information is out of date or inaccurate
we may make the incorrect decision for the wrong situation.
Analytical decision making is also known as choice decision making.
When a problem is recognised a range of options are generated and discussed with team members.
The options are therefore analysed and the best one for the particular situation is chosen.
This form of decision making compares alternative courses of action
and therefore can be slow.
It can be highly affected by stress, distractions
and the number of options and information can cognitively overload individuals.
Creative decision making is employed in complex situations
where there is a lack of evidence of experience to guide decisions
as these situations have either not been encountered before
or are rarely encountered.
Creative thinking is often only used as a last resort
when no other options are available, such as in an emergency.
Decision making is susceptible to different forms of cognitive bias.
Cognitive biases are systemic errors in thinking, which affect the judgement and decisions that we make.
Automation bias is when we trust and favour information from an automated source
and ignore or refute conflicting evidence.
We fail to question if the information is incorrect or if there is a fault
for example accepting the automated diagnosis on an ECG.
Fixation bias is when we get fixated on one particular aspect of information.
This can be influenced by the way information is presented to you
or formed from your past experiences, training and culture.
In medicine this may stop us from acknowledging other key information that may change our decision.
Confirmation bias is when we search for and accept information which confirms a prior possibly incorrect belief
and actively disregard or refute conflicting evidence which could prove us wrong.
Decision making can also be influenced by the same factors as situational awareness
such as stress, fatigue, noise and distractions.
In decision making stress can sometimes be useful
to help us focus our attention to the task required and improve our performance;
however when performing a complex or difficult task
acute stress can negatively influence our decision making and subsequently our performance.
Our mind has a limited capacity of working memory
and by adding acute stress we often form tunnel vision
and struggle to access our long-term memory which may help us to make a decision.
When we are sleep-deprived we are more at risk of making poor decisions.
At home this may mean putting the milk in the cupboard instead of the fridge
but at work this may mean incorrectly interpreting a CTG.
When we are tired decision making is impaired and the time to carry out the action is longer too.
Some studies have shown that those who regularly experience fatigue, utilise protective behaviours such as cross checking.
This has been adopted within maternity using a buddy system or fresh eyes
in which another qualified healthcare professional will review fetal monitoring every hour
to ensure the correct interpretation and therefore management decisions have been made.
This in itself is subject to fatigue but is hopefully better than just one person alone.
So how should we try to make decisions?
Question your assumptions you have made about the situation before making a decision.
Identify alternative possibilities in order to try to prevent biases
and remember if you are tired use protective behaviours such as cross checking.