Libertad religiosa en las Fuerzas y Cuerpos de Seguridad del Estado

Decision errors are thought to be evident when short cuts are made in the process and when factors such as underlying bias and limitations are influential (Ward, 1999). Ward argued that humans have difficulty using all the available information and that there are limits as to the number of pieces of information our brains can consider at any one time, this view was supported by Elstein et.al (1990) and Bowers, Regehr, Baalthazard and Parker (1990). It is in these situations that an informational short cut or heuristic is used. However, not all heuristics lead to error, Ward cited Dumont (1993) argued that when the problems are poorly structured and there is uncertainty heuristics are used to close the gaps. Experts in an area are more able to reduce heuristic error. There are many arguments as to why this occurs including that experts have a wide range of experience and are able to predict if a heuristic will produce the desired outcome.

Siegert (1999) further explored the issue of decision error. He cited Schwartz (1994) who defines two types of heuristic; availability heuristic as one that is based in personal experience and representative heuristic as the probability of an event being estimated by the degree to which it fits an existing cognitive stereotype. These types of heuristics have been used to explain decision error successfully but Siegert argued that this is simplistic and that there are other processes occurring simultaneously. He put forward the concepts of anchoring and adjustment, overconfidence and

discounting as further explanations for error.

Anchoring and adjustment are based in the concept that when making a decision the starting point, or anchor, is fixed and that it is adjusted according to the value accord deemed to meet the specific features of the particular situation. In clinical situations this may mean that the clinician may begin with an assumption of the probability of a diagnosis and adjust the probability according to the data. As Siegert identified in this heuristic the initial placement of the anchor exerts an influence over the decision outcome. The problem here is if the anchor was erroneous the end decision will also be erroneous.

This problem may be reduced depending on the model of decision-making used. The emergency nurses use the hypothetico-deductive method of decision-making in which the anchor is not fixed at one point (Lyneham, 1999). A problem would exist if after testing the initial diagnostic hypotheses the wrong provisional diagnosis was made. The provisional diagnosis can be seen as a stronger anchor point and if this were invalid then the management plan would also be flawed. Interestingly decision- error has not been studied in nursing.

Emergency clinicians in all areas of health care are often asked to make decisions or given an opinion without having a thorough knowledge of the facts or worse

uncertainty. Dumont (1993) and Schwartz (1994) found that this resulted in errors caused by overconfidence.

Discounting may be an issue in health care. This is when the clinician stops

searching for an alternate diagnosis once a plausible cause has been found (Siegert, 1999). Schwartz (1994) refers to this as diagnostic over shadowing. The evidence for this is seen in the litigation of medicos by their patients. It would be a distressing discussion to examine the number of situations where a simple diagnosis was given without consideration of a more sinister diagnosis based on gender, age or previous history.

In my experience as an emergency practitioner this discounting is frequently seen to the detriment of patient care. There have been two recent outstanding situations: A young man was brought to the emergency department from a psychiatric hospital for scheduling (forced admission) and transfer to a secure hospital. The history given by the accompanying staff was of psychotic/ neurotic behaviour. Refusing food or drink, claiming inability to swallow, faking fever by putting a thermometer in hot drinks (but this was not witnessed) and agitated behaviour. I asked if anyone had looked at his throat, the response was why? I looked and saw two massive peri tonsillar abscesses and gave the diagnosis of possible quinsy. His psychiatric history was the primary anchor and as a result discounting occurred when physical symptoms were seen as only as behavioural changes.

The second incident was more complex; a non-English speaking elderly woman was brought in by her daughter with increasing weakness and fatigue. I was told that she had been to her doctor that day and was diagnosed as a viral illness. I thought she looked shocked and I considered sepsis. I gave her an urgent priority and sent her to the acute area. She was shocked, but not septic she had had a massive myocardial infarction and resultant cardiogenic shock. She died an hour later. The coroner

commented that the doctor discounted her presenting problem, her vague symptoms were not adequately addressed and preconceptions about her age were a contributing factor to the initial misdiagnosis by the general practitioner.

Decision error can have devastating effects. Unfortunately Siegert (1999) does not provide any suggestions to reduce heuristic error. Ward (1999) offers a solution in that he advises that actuarial models and methods be employed. He is not alone in that Sadler-Smith (1999a&b), Lipshitz and Strauss (1997) and Bower (1998), contend that statistical methods are usually more accurate.

What is clear is that decisions are made where uncertainty exists; Lipshitz and Strauss (1997) examined the issue of uncertainty. Lipshitz and Strauss analysed the literature on uncertainty and put forward a number of propositions so that they could study how uncertainty in decision-making could be managed. The three propositions were; uncertainty in the context of action is a sense of doubt that blocks or delays action (p150), the uncertainty with which decision makers must cope depends on the decision-making style which they employ and finally different types of uncertainty can be classified according to their issue (outcomes, situation and alternatives) and source (incomplete information, inadequate understanding and undifferentiated alternatives) (p151).

Lipshitz and Strauss (1997) identified three basic strategies of coping with uncertainty; reducing, acknowledging and suppressing. To reduce error statistical methods may be used to predict outcomes, experience is utilised to fill the gaps and additional information is sort. By acknowledging uncertainty one selects a course of action with the knowledge that there are potential risks. Finally suppressing

uncertainty is often called the Pollyanna effect. It utilises the tactic of rationalisation. Johnson and Daumer (1993) support the view that in times of uncertainty intuitive

decisions/ heuristics may work best, however, this is not acknowledged by Lipshitz and Strauss (1997) or Seigert (1999) and Ward (1999).

Bowers, Regehr, Baalthazard and Parker (1990) argued that the research on

uncertainty supports the belief that intuitive judgments are often misguided because they are over determined by various cognitive heuristics, this [the authors say] clearly implies that intuition is frequently if not typically a systemic source of error in human judgment (p73). The authors criticise previous literature of this nature by saying that there has been an exploitation of the ignorance of experimental subjects, rather than taking advantage of their [the subjects] knowledge and experience. Their criticism is not entirely erroneous as the research into intuition has a number of serious methodological problems. However, it is unwise to make such a sweeping generalisation that intuition is the source of error in decision-making until such times when appropriate methodologies have been utilised and the results analysed.

One interesting model of decision-making is the naturalist framework; this framework is based in the real world. Lipshitz (1993) reviewed nine models of naturalistic decision making and assesses them for similarities / identified six common themes [diversity of form; situation assessment; use of mental imagery; context dependence; dynamics processes; description-based prescription] Klein (1997) used these themes and explored this model as an alternative model for expert decision-making. The premise for this model is that real world experts are able to cognitively process available information, identify hidden cues and use heuristics in situations of uncertainty. His approach is a cognitive task analysis and is informed by the recognition-primed decision-making model. This is a view of decision-making in the real world. The question that Klein tried to answer is how the fire captain knows when to evacuate a building moments prior to its collapse (Bower, 1998). Klein’s question raises the issue of experience as a factor in decision-making.

There is no evidence in the literature that supports the rejection of decision-making on the basis of the error involved in traditional models. However decision error is used to support the rejection of an intuitive style of decision-making. Emergency nurses, although shown to use a known rational model also use an intuitive model of decision-making. This has not been adequately investigated. Whatever decision framework is used and in whatever context the decision is made there is an underlying assumption that practice sic experience influenced the process and at times the outcomes.