The rational decision making process (sometimes termed the traditional decision making process) is the most commonly taught and practiced formal decision making methodology. While there are some variations, the foundational steps include the following: framing the issue; gathering all of the relevant information needed to make the decision; identifying various decision alternatives; assigning a weighting process to prioritize the decision criteria; selecting the highest ranked decision from the alternatives; implementing the decision; and reviewing the outcome.
Conventional decision making science teaches rational decisions are best made when leaders use this purposeful, conscious, fact-gathering process. It is theorized that better leadership decisions are made without emotions being involved because emotions impede good decision-making. The premise is: the more objective, analytical and rigorous the thinking processes are, the better the decisions will be. A rational decision making method enables leaders to process information clearly and logically, and thus allows for an accurate perception and interpretation of the event. It has been argued that decision makers use rational skills to prevent them from excessively distorting reality with emotions, a possibility particularly likely under stressful conditions.
I served 33 years as a first responder, including 22 years as an administrator (fire chief) and an emergency incident commander. As a fire chief, my job was roughly 80% administrative and 20% emergency responses. In my administrative role, the rational decision making process worked extremely well for me. The process is thorough, comprehensive and, as the name implies, rational.
But what happens when the decision making environment is rapidly changing and the decision maker does not have time to deploy a comprehensive rational decision making process? As an example, this is often the environment faced by trauma response team leaders where few details may be known about the patient’s mechanism of injury, extent of injuries, medical history, medications, allergies, and so on. The team leader must manage the trauma patient, often in rapid decline, with little time to complete a comprehensive, rational analysis of facts and data.
In time-compressed decision making environments, a trauma response team leader must often make quick decisions with incomplete, inaccurate or rapidly changing information, under extremely stressful conditions. The ability to prevent a catastrophic patient outcome depends on knowledgeable and experienced subject matter experts making accurate, effective and extremely time sensitive decisions.
Trauma response team leaders know when conditions are changing rapidly, there often isn’t enough time to deploy all the steps in the rational decision making process. Fortunately, there is an alternative to the rational decision making process known as naturalistic decision making where expert-level practitioners use their recognition of previous training and experiences to help prime intuition-driven decision.
The basis for making intuitive decisions resides in the ability of the leader to make rapid assessments of conditions and to draw upon their stored knowledge to make time-sensitive decisions. This model of decision making, known as the Recognition-Primed Decision Making (RPDM) model, was first uncovered while researching how fireground commanders used their training and experience to make quick decisions on emergency scenes without completing a comprehensive analysis of options for purposes of comparison. The steps of RPDM include the following:
- rapid size-up of the situation;
- focus on a finite number of the most relevant facts;
- compare the current situation to past experiences;
- detect atypical/unusual problems and seek explanations for them;
- run mental options of decision choices in your head;
- make a decision;
- predict the outcome of the decision;
- if the predicted outcome is good, implement the decision. If it is bad, make a different decision until a suitable decision is identified; and
- monitor conditions, compare outcomes to expectations, and adjust as needed.
The research on RPDM had uncovered what I had known (and practiced) at emergency scenes for my entire career. Fireground commanders use the RPDM model and typically make critical decisions in thirty seconds or less and they rarely compare the merits of alternative actions. Rather, they used their training and experience to identify a workable course of action as the first one they considered. When it was necessary to evaluate several decision options, fireground commanders conducted mental simulations to visualize the outcome of their option prior to making a decision and implementing their action plan. Recognition-primed decision making, devoid of lengthy, formal analysis, is much faster than the rational decision making method because it relies on stored memories and recognition of past training and experiences to get an immediate sense of what is happening and the action to be taken.
Trauma response team leaders work in naturalistic decision making environments where the fast-pace, high-stress, high-consequence, rapidly changing, uncertain conditions drive a need for quick decisions. These conditions are ideal for making recognition-primed decisions. Obviously, the more experience the decision maker has with the problem at hand, the more likely they are to craft a fast, accurate decision response. When faced with a patient who is rapidly deteriorating, a good decision made quickly and executed promptly can prove to be much better than agonizing over a perfect choice that comes too late. Oftentimes a leader may not know what the best choice was until after the fact, and the quest for an ideal decision option can drive the leader to obsess over inconsequential, incomplete or missing details that may never be revealed in time.
It is estimated that as much as 95% of a person’s knowledge, training and experience is stored in the subconscious memory – completely outside conscious awareness. When confronted with a problem that needs solved, the individual will gather information (clues and cues) and search their memory database for solutions. This includes a search of the conscious memory database (everything a person can consciously recall), and a search of the subconscious memory database (everything that is stored outside of conscious memory).
The clues and cues are combined to form patterns of similar (or dissimilar) information stored in memory from previous training or experience. The search process is called pattern matching. If there is a match from the subconscious memory stores, it can trigger intuition. Conscious knowledge comes to us as facts, data, proof and evidence – all the things that rational decision makers endear themselves to (and when the conditions are right, it makes sense).
Intuition is our connection to the subconscious memory stores and guides decision making using the “feeling of knowledge.” Trusting intuition can be difficult because there are often no facts, data, proof or evidence the decision makers can point to as the basis for their decision. Rather, they are making a decision based on what feels right and then having to justify the outcome.
Complicating the challenge of trusting decisions made based on feelings is the fact that, while intuitive decisions can be faster, they can also be wrong. However, before you throw out the notion that intuitive decisions are bad because they can be wrong, we need to acknowledge rational decisions can be wrong too. It’s just easier to justify a rational decision because the decision maker can point to all the facts, data, proof and evidence they used to make their decision. Where the only way to justify an intuitive decision is to say it felt like the right thing to do.
Clearly, the best intuitive decisions are made by well-trained, highly experienced individuals with a substantial store of subconscious knowledge to draw upon.
Here are four ways intuitive knowledge may reveal itself to a decision maker:
- your hair standing up on the back of your neck (maybe accompanied by goosebumps on your arms);
- your internal voice (i.e., self-speak) trying to give you good advice about what you should do, or not do;
- you get an impending feeling of doom or sensing a decision would lead to a tragic outcome; and
- you get a gut feeling that something isn’t right.
There are five components essential to making effective intuitive decisions: information, situational awareness, self-efficacy, tacit knowledge, and mental modelling.
Information
While operating in time-compressed decision making environments, it is often impractical for leaders to wait for complete and accurate information prior to making critical decisions. While conditions are changing rapidly, these leaders must be able to quickly process a limited amount of information, draw on their experience, make some reasonable assumptions, rely on their intuition, make a decision and implement an action. For example, in a trauma response, the difference between life and death for the patient in decline is measured in seconds and minutes, not hours.
Situational Awareness
Situational awareness is achieved from a leader’s ability perceive and understand what is happening in their environment while being mindful of the passage of time and the speed in which conditions are changing. Once understanding is achieved, the leader is then able to make predictions about the outcomes of decision options prior to implementation.If the predicted outcome of the leader’s first option is good, they should implement it. If it’s not, the leader should scrap that decision option, pick another, and start the prediction process again. This may go on for several iterations until a viable option is identified, and implemented. Strong situational awareness is the foundation for good decision making.
Self-Efficacy
Self-efficacy is the degree of self-confidence a leader possesses that allows them to believe they can handle the uniqueness of a challenging situation. It is the belief that they know they are doing the right thing that enables the leader to trust their intuition and to act on it. Training and past experience dealing with similar situations helps build the leader’s self-efficacy – their sense of confidence – and their level of comfort acting on an intuition-based decision. Self-efficacy does not focus on the specific job-related skills the leader possesses, but rather the self-judgment of what the leader can do with their knowledge and skills.
Essentially, self-efficacy refers to a sense of mastery and control the leader feels they have over their environment. A strong sense of efficacy may foster an overall confidence and positive emotional response, resulting in a more effective decision-making process under stress. This is a critical trait of effective leaders.
Without a high level of self-efficacy not only may the leader question (and possibly delay) critical decisions, but other team members may also pick up cues of wavering confidence which can decrease fellow team members comfort with the decisions being made. Critical decision making environments are no place for leaders who lack the confidence to be effective. Oftentimes the situation is progressing or degrading at a pace that will not allow the leader to display uncertainty.
Tacit Knowledge
Tacit knowledge can be described as the cumulation of a leader’s lifetime of stored training, experiences, and memories, which are filtered through their perspectives, beliefs, and values. The leader’s experiences and values interact with knowledge stores that are called upon implicitly, and often unspoken, during a decision making situation.All humans have a tacit knowledge inventory; a reservoir of implicit knowledge (gained through training, experience and memory) that can be accessed, or made explicit, through intuitive thought processing.
Because tacit knowledge depends so much on the stored experiences of the leader, the best intuitive decision makers are subject matter experts. Ample research exists that demonstrates subject matter experts routinely make decisions based on tacit knowledge grounded in their stored experiences.
The human brain compresses and stores a person’s experiences and allows them to recall, almost instantly, numerous examples and solution options that may relate to the problem at hand. A leader’s tacit knowledge provides a link between their stored experiences and their working memory that allows them to make estimates about what will happen even though the information being fed into their brain may be incomplete.
Mental Modelling
As experience is gained, a leader develops internal models of the systems and environments they operate in. These mental models serve to help direct limited attention in efficient ways, providing a means of integrating information without overloading their working memory. The use of mental modelling in decision making is considered to be dependent on the leader’s ability to match critical cues and clues in their environment with elements in their existing mental models. It is important in training to develop scenarios that allow leaders to make intuitive decisions, which means experimentation and tolerating mistakes. Experimentation with ideas should be encouraged and leaders should not be penalized for honest mistakes. Some of this learning may also come from observing and imitating instructors, role models and peers.
In some work settings, post-incident evaluations, critiques and simulations can be valuable tools whereby leaders can share their intuitive decision-making processes and allow others to learn from their experiences. Sharing experiences can help develop the intuitive decision-making abilities of novice leaders as well. In order to be effective, it is essential for leaders to develop, practice, and share mental modelling skills.
In healthcare leadership, there is a place for both rational, evidence-based (explicit knowledge) decision making and intuitive, feeling-based (tacit-knowledge) decision making. A rational decision making process is highly effective when a leader has time to gather, process, analyze, calculate, weigh priorities, compare and contrast options and select the best choice among multiple alternatives. However, in decision making environments that are high-stress, high-consequence, time-compressed and with rapidly changing conditions, there simply may not be enough time to use the more comprehensive, time consuming rational decision making process. Thus, effective leaders should be knowledgeable of the five components essential for making effective intuitive decisions and develop skills in information gathering, situational awareness, self-efficacy, tacit knowledge, and mental modelling.
About the Author
Dr. Richard B. Gasaway, PhD, is widely considered a trusted authority on human factors, situational awareness and the high-risk decision making processes used in high-stress, high consequence work environments.
He served 33 years on the front lines as a firefighter, EMT-Paramedic, company officer, training officer, fire chief and emergency incident commander. His doctoral research included the study of cognitive neuroscience to understand how human factors flaw situational awareness and impact high-risk decision making under stress.
As the President of Situational Awareness Matters, Dr. Gasaway leads a team of expert instructors and thought leaders who train and consult worldwide. Dr. Gasaway has authored 7 books on situational awareness and high-risk decision making including “How Smart Workers Use Situational Awareness to Improve Safety.’ His training programs have been delivered to more than 100,000 participants worldwide.
You can read Richard’s article here in the May 2024 edition of Healthcare Management Forum.
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