Change language: English Deutsch Español Nederlands Your Results Closed-Minded Open to New Experiences Disorganized Conscientious Introverted Extraverted Disagreeable Agreeable Calm / Relaxed Nervous / High-Strung What aspects of personality does this tell me about? There has been much research on how people describe others, and five major dimensions of human personality have been found. They are often referred to as the OCEAN model of personality, because of the acronym from the names of the five dimensions. Here are your results: Open-Mindedness High scorers tend to be original, creative, curious, complex; Low scorers tend to be conventional, down to earth, narrow interests, uncreative. You enjoy having novel experiences and seeing things in new ways. (Your percentile: 81) Conscientiousness High scorers tend to be reliable, well-organized, self-disciplined, careful; Low scorers tend to be disorganized, undependable, negligent. You are very well-organized, and can be relied upon. (Your percentile: 99) Extraversion High scorers tend to be sociable, friendly, fun loving, talkative; Low scorers tend to be introverted, reserved, inhibited, quiet. You are extremely outgoing, social, and energetic. (Your percentile: 98) Agreeableness High scorers tend to be good natured, sympathetic, forgiving, courteous; Low scorers tend to be critical, rude, harsh, callous. You are good-natured, courteous, and supportive. (Your percentile: 98) Negative Emotionality High scorers tend to be nervous, high-strung, insecure, worrying; Low scorers tend to be calm, relaxed, secure, hardy. You probably remain calm, even in tense situations. (Your percentile: 19) Results Feedback How useful did you find your results? Not at all 1 2 3 4 5 Very Useful What is the “Big Five”? Personality psychologists are interested in what differentiates one person from another and why we behave the way that we do. Personality research, like any science, relies on quantifiable concrete data which can be used to examine what people are like. This is where the Big Five plays an important role. The Big Five was originally derived in the 1970's by two independent research teams -- Paul Costa and Robert McCrae (at the National Institutes of Health), and Warren Norman (at the University of Michigan)/Lewis Goldberg (at the University of Oregon) -- who took slightly different routes at arriving at the same results: most human personality traits can be boiled down to five broad dimensions of personality, regardless of language or culture. These five dimensions were derived by asking thousands of people hundreds of questions and then analyzing the data with a statistical procedure known as factor analysis. It is important to realize that the researchers did not set out to find five dimensions, but that five dimensions emerged from their analyses of the data. I ...

1. Change language: English Deutsch Español Nederlands
Your Results
Closed-Minded Open to New Experiences
Disorganized Conscientious
Introverted Extraverted
Disagreeable Agreeable
Calm / Relaxed Nervous / High-Strung
What aspects of personality does this tell me about?
There has been much research on how people describe others,
and five major dimensions of human personality have been
found. They are often referred to as the
OCEAN model of personality, because of the acronym from the
names of the five dimensions. Here are your results:
Open-Mindedness
High scorers tend to be original, creative, curious,
complex; Low scorers tend to be conventional, down to earth,
narrow interests, uncreative.
You enjoy having novel experiences and seeing things in
new ways. (Your percentile: 81)
Conscientiousness
High scorers tend to be reliable, well-organized, self-
disciplined, careful; Low scorers tend to be disorganized,
undependable, negligent.
You are very well-organized, and can be relied upon.
(Your percentile: 99)

2. Extraversion
High scorers tend to be sociable, friendly, fun loving,
talkative; Low scorers tend to be introverted, reserved,
inhibited, quiet.
You are extremely outgoing, social, and energetic.
(Your percentile: 98)
Agreeableness
High scorers tend to be good natured, sympathetic,
forgiving, courteous; Low scorers tend to be critical, rude,
harsh, callous.
You are good-natured, courteous, and supportive. (Your
percentile: 98)
Negative Emotionality
High scorers tend to be nervous, high-strung, insecure,
worrying; Low scorers tend to be calm, relaxed, secure, hardy.
You probably remain calm, even in tense situations.
(Your percentile: 19)
Results Feedback
How useful did you find your results?
Not at all 1 2 3 4 5 Very Useful
What is the “Big Five”?
Personality psychologists are interested in what differentiates
one person from another and why we behave the way that we do.
Personality research, like any science,
relies on quantifiable concrete data which can be used to
examine what people are like. This is where the Big Five plays
an important role.

3. The Big Five was originally derived in the 1970's by two
independent research teams -- Paul Costa and Robert McCrae
(at the National Institutes of Health), and
Warren Norman (at the University of Michigan)/Lewis Goldberg
(at the University of Oregon) -- who took slightly different
routes at arriving at the same results: most
human personality traits can be boiled down to five broad
dimensions of personality, regardless of language or culture.
These five dimensions were derived by asking
thousands of people hundreds of questions and then analyzing
the data with a statistical procedure known as factor analysis. It
is important to realize that the
researchers did not set out to find five dimensions, but that five
dimensions emerged from their analyses of the data. In
scientific circles, the Big Five is now the most
widely accepted and used model of personality (though of
course many other systems are used in pop psychology and work
contexts; e.g., the MBTI).
What do the scores tell me?
In order to provide you with a meaningful comparison, the
scores you received have been converted to “percentile scores.”
This means that your personality score can
be directly compared to another group of people who have also
taken this personality test. The percentile scores show you
where you score on each personality
dimension relative to other people, taking into account normal
differences in gender and age.
For example, your Extraversion percentile score is 98, which
means that about 98 percent of the people in the comparison
sample are less extraverted than you. In other
words, you are strongly extroverted as compared to them. Keep
in mind that these percentile scores are relative to our particular
sample of people. Thus, your

4. percentile scores may differ if you were compared to another
sample (e.g., elderly British people).
Where can I learn more?
If you'd like to learn more about personality psychology, take a
look at these links to other personality sites on the web. Take a
look at our homepage for more tests!
How do I save my results? How can I share them?
You can bookmark or share the link to this page. The URL for
this page contains only the data needed to show your results and
none of your private responses. Save
this URL now, as you won't be able to get back to this page
after closing it: https://www.outofservice.com/bigfive/results/?
o=63,81,94&c=100,100,100&e=88,100,94&a=100,94,100&n=25
,25,44&y=2000&g=f
For classroom activities: sometimes educators ask students to
use this site for classroom projects and need the “raw” scores.
Your raw scores, normalized 0 to 1: o:
0.79, c: 1.00, e: 0.94, a: 0.98, n: 0.31
1. State four types of emotions that could potentially affect a
DM process in health care.
a. Anger
b. Happiness
c. Fear
d. Trust
2. Describe the emotional factors labeled as:
a. Mood at the time of making decision
i. Anger: Individual could be frustrated or offended which leads
to anger. It can have a negative impact on the decision being
made.

5. ii. Happiness: Being happy while making a decision can lead to
a boost of confidence and can make a decision with conviction.
iii. Fear: Individual is nervous about the decision that needs to
be made. Can lead to a decrease in confidence.
iv. Trust: Being trustworthy of your team whom you are making
the decision. You are trusting that they are giving you the
sufficient and accurate information needed to make the best
decision.
b. Role of regret
i. Anger: The individual may be regretful for being frustrated
and angry at the time of decision making.
ii. Happiness: The individual may feel regretful in being too
confident in their decision they made.
iii. Fear: The individual could feel a sense of regret because
they let their nervousness get the best of them and could result
in a negative outcome.
iv. Trust: The individual may feel a sense of regret when
trusting others to help with making a decision rather than
making the decision on your own.
c. Feelings attached to different choice options.
i. Anger: The individual may feel a sense of guilt for being
angry at the time of decision making and how it could have
clouded their judgment
ii. Happiness: Being happy and confident in the decision you
made can lead to others feeling the same when they are faced
with a decision to make.
iii. Fear: The individual may have some anxiety about the
decision that was made and if it was the right choice.
iv. Trust: The individual may feel a level of confidence for
having a team of individuals to work with and having trust
within each other.
3. Discuss how each of the emotional factors in #2 could affect
decisions made based on the ETHICAL or Shared Decision
Making models of DM.
a. Ethical Decision Making: a tool that can be used by health
care providers to help develop the ability to think through an

6. ethical dilemma and arrive at an ethical decision
i. Mood at time of making decision: Using the ethical model,
the mood at the time of decision-making can be one of
confidence. The individual is working with research and data.
The research is examined and facts are argued. Individual has
all information needed to make a sound and ethical decision
ii. Role of Regret: Individual may feel regretful in the decision
they made. In this model, one has to stick to the facts. Making a
decision based strictly on facts may not be the best decision
iii. Feelings attached to different choice options: individual
could have feelings of confidence. They made a choice based on
the facts presented. There could also be a feeling of
vulnerability and anxious. Although the decision was based on
factual data, was it the best decision to make?
b. Shared Decision Making: Key component in patient centered
care. Physicians and patients work together to make a decision
that will give the best outcome.
i. Mood at time of making decision: Those involved in the
decision making process (physicians and patients) have
collectively come to a decision. All information is presented to
make a sound decision.
ii. Role of Regret: Feeling a sense of regret on a decision that
was made collectively as a group. Although it is important to
have input from both physicians and patients, maybe the final
decision shouldn’t be made as a group but rather by one
individual.
iii. Feelings attached to different choice options: within shared
decision-making, there can be a wide range of feelings. Some
may feel confident while others may be vulnerable and anxious.
Working with individuals with different feelings can affect
decision making.
References:
Beemterber, P. (n.d.). Ethical decision-making models: Ethics
in dentistry: Part iii – ethical decision-making: Ce course.
Retrieved March 14, 2021, from
https://www.dentalcare.com/en-us/professional-education/ce-

7. courses/ce546/ethical-decision-making-
models#:~:text=An%20ethical%20decision%2Dmaking%20mod
el,arrive%20at%20an%20ethical%20decision.&text=These%20
models%20consider%20ethical%20principles%2C%20obligation
s%20and%20values.
Emotional factors. (n.d.). Retrieved March 14, 2021, from
https://www.satpe.co.uk/2019/05/20/emotional-factors/
Shared Decision Making. (2013, December). Retrieved March
14, 2021, from
https://www.healthit.gov/sites/default/files/nlc_shared_decision
_making_fact_sheet.pdf
HCA 574
Decision Making in Healthcare
Reading #1
The Basics of DM Processes
Module 1: March 08 – 21, 2021
*
Important Questions
How are decisions made in HC organizations?
What are the useful DM models?
Which DM model should I apply?
How can the DM process be managed?

8. How do consumers (patients) bear the burden of choice?
What is the influence of technology, culture, and ethics on DM?
How do different viewpoints on DM such as those of patients,
providers or health executives consider important issues such as
cost, quality and access in the DM process?
What causes poor decisions?
*
*
How are Decisions Made in HC Organizations?
DECISION MAKING--Definition:
The process of choosing a course of action for dealing with a
problem or an opportunity.
Or
The process through which alternatives are selected and then
managed through implementation to achieve healthcare
objectives.
What is your definition of DM? Why?
*
*
How are Decisions Made?
Steps in Systematic DM and Analysis Process (DMAP)
Recognize and define the problem or opportunity.
Identify and analyze alternative courses of action, and estimate
their effects on the problem or opportunity.

9. Choose a preferred course of action.
Implement the preferred course of action.
Evaluate the results and follow up as necessary.
*
*
How are Decisions Made?
The systematic decision-making process may not be followed
where substantial change occurs and many new technologies
prevail.
New decision techniques may yield superior performance in
certain situations.
Ethical consequences of decision making must be considered.
All applicable in health care? Why, Why Not?
*
So DM is Important …To come to a decision, a series of events
take place
Resources: Have to be in place, available at the right time
Processes: Have to be determined
DM: Has to be executed
Strategy: Has to be in place
Implementation: Can it work in all situations?
Returns: What are patient/organizational benefits? DM has to be
part of strategic position for healthcare organizations

10. *
*
How are Decisions Made?
DECISION ENVIRONMENTS INCLUDE:
Certain environments.
Risk environments.
Uncertain environments.
What’s the most dominant environment in health care? Why?
*
*
How are Decisions Made?
CERTAIN ENVIRONMENTS
Exist when information is sufficient to predict the results of
each alternative in advance of implementation.
Certainty is the ideal problem solving and decision making
environment.
Examples in health care?
Whose perspective should take precedence in this environment?
Why?
*

11. *
How are Decisions Made?
RISK ENVIRONMENTS
Exist when decision makers lack complete certainty regarding
the outcomes of various courses of action, but they can assign
probabilities of occurrence.
Probabilities can be assigned through objective statistical
procedures or personal intuition.
Give two examples in health care.
Whose perspective should take precedence in this environment?
Why?
*
*
How are Decisions Made?
UNCERTAIN EVIRONMENTS
Exist when there is so little information that one cannot even
assign probabilities to various alternatives and possible
outcomes.
Uncertainty forces decision makers to rely on individual and
group creativity to succeed in problem solving.
Examples in health care?
Whose perspective should take precedence in this environment?
Why?
*

12. *
Uncertain Environments …2
Also characterized by rapidly changing:
External conditions.
Information technology requirements.
Personnel influencing problem and choice definitions.
These rapid changes are also called organized anarchy.
*
*
How are Decisions Made?
TYPES OF DECISIONS
Planned Decisions
Involve routine problems that arise regularly and can be
addressed through standard responses.
Non-planned Decisions
Involve abnormal problems that require solutions specifically
tailored to the situation at hand
*
*
Decision Making Models
Classical Decision Theory (CDT)
Views the decision maker as acting in a world of complete
certainty.
Behavioral Decision Theory (BDT)

13. Accepts a world with bounded rationality and views the
decision maker as acting only in terms of what he/she perceives
about a given situation.
*
*
CDT vs. BDT
CDT
The classical decision maker:
Faces a clearly defined problem.
Knows all possible action alternatives and their consequences.
Chooses the optimum alternative.
Is often used as a model of how managers should make
decisions.
*
*
CDT vs. BDT …2
BDT
Recognizes that human beings operate with:
Cognitive limitations.
Bounded rationality.
The behavioral decision maker:
Faces a problem that is not clearly defined.
Has limited knowledge of possible action alternatives and their
consequences.

14. Chooses a satisfactory alternative.
*
*
CDT vs. BDT …3
CDT
May not fit well in a chaotic world.
Can be used toward the bottom of many firms, even most high-
tech firms.
BDT
Fits with a chaotic world of uncertain conditions and limited
information.
Encourages satisficing decision making.
*
*
Decision Making Models
The Garbage Can Model (GCM)
A model of decision making that views problems, solutions,
participants, and choice situations as mixed together in the
“garbage can” of the organization.
In stable settings, behavioral decision theory may be more
appropriate.
In dynamic settings, the garbage model may be more
appropriate.

15. *
*
Decision Making Models
Implications of GCM
Choice making and implementation may be done by different
individuals.
Because of interpretation, there is a risk that the actual
implementation does not exactly match the choice.
Many problems go unsolved.
Think of an example in the US HC System which may represent
a problem that has never been solved due to poor DM/poor
alternative choices.
*
*
Decision Making Models: A.D.P.I.E.The Assessment,
Diagnosis, Planning, Implementation Evaluation (ADPIE)
Model
Assessment
Evaluate
Diagnose

16. Planning
Implementation
On-going Assessment
On-going Diagnosis
On-going Planning
On-going Implementation
On-going Evaluation
*
This model was developed as an on-going evaluation tool. The
strategic plan is an ongoing living process. As soon as the
organization initiates the assessment process and, therefore,
determines the needs of the organization (diagnosis), it is time
to move on to the planning phase where the stake holders
determine (plan) the strategies to meet the needs of fixing or
addressing the problems within the organization (diagnosis).
After this phase is completed, it is time to put into action the
plans (implement) determined by the organization’s stake
holders. It is then imperative to see if the organization has met
the goals of the plans and programs that were implemented
(evaluate). Upon finishing the evaluation and discovering the
success and failures of the implemented plans, (take note
already a new organization is emerging), it is time to begin
assessing the new organization with it’s new strengths and
weaknesses that are a net result of implementing the initial
ADPIE process. To do this effectively, it is necessary to
initiate the ADPIE process again. At the end of this next
ADPIE process, the result will again be a new organization with
its new strengths and weaknesses that are a net result of
implementing the second ADPIE process. ADPIE then starts
again, and so on and so on…. This process is ongoing through
out the life of the organization. This helps to prevent inertia,

17. stagnation, and non-growth which is inherent in many
organizations who have not put in place an on-going evaluation
processes to use as a metric for the on-going outcomes
measurements needed for the on-going success of the
organization.
ADPIE …2Ongoing DM/Evaluation toolPhase by phase through
A.D.P.I.EState the cycle after completing the initial
ADPIEOngoing throughout the life of HC organization
*
Shared Decision Making ModelSDM MODEL
Collaborative model—providers & patients/family
Applies the SHARE Approach (AHRQ)
Applies clinical evidence
Applies the principle of patient centeredness
What are the likely challenges in SDM?
Where/What is the place/role of healthcare executive in SDM?
*
E.T.H.I.C.A.L. ModelApplied in Ethical DM
Examine the ethical dilemma
Thoroughly comprehend the possible alternatives
Hypothesize ethical arguments
Investigate, compare, and evaluate the arguments for each
alternative
Choose the alternative you would recommend
Act on your chosen alternative

18. Look at the ethical dilemma and examine the outcomes while
reflecting on the ethical decisionUse to arrive at rational and
justifiable decisions
*
Intuitive DM ModelHow the Intuitive Model Works
Consciously recalling gained knowledge
Based on formal/informal education and experience
Inexperienced: Take time to make decisions—step by step from
assessment to implementation
Experienced: “Leap” from information gathering to
implementation.
Good idea? Why? Why Not?
*
DM Tools & StrategiesSWOT AnalysisDecision MatrixDecision
TreePareto DiagramCost-Benefit AnalysisDiscuss tools used by
your organization in its DM processes.
*
*
DM Realities
Decision makers face complex choice processes.
DM information may not be available
Bounded rationality and cognitive limitations affect the way
DM parties define problems, identify alternatives, and choose
preferred solutions
Most DM goes beyond step-by-step rational choice
Most DM falls between the highly rational and the highly
chaotic

19. Decisions must be made under risk and uncertainty
*
*
DM Realities …2
Decisions must be made to solve non-routine issues
Decisions must be made under time pressures
Decisions must be made under information limitations
Decisions should be ethical
What’s your pick as the best DM Model in health care
environment in general? Why?
What’s your pick as the best DM Model in health care
environment under the COVID-19 situation? Why?
*
*
How to Manage DM Processes
CHOOSING PROBLEMS TO ADDRESS
Ask and answer the following questions:
Is the problem easy to deal with?
Might the problem resolve itself?
Is this my decision to make?
Is this a solvable problem within the context of the

20. organization?
Apply to a specific health care problem
*
*
How to Manage a DM Process …2
Reasons for DM Failure
Decision makers tend to copy others’ choices and apply them in
their situation
Decision makers tend to emphasize problems and solutions
rather than successful implementation
Decision makers use participation too infrequently
Any other reasons? Apply your HC experience.
*
*
How to Manage a DM Process …3
WHO SHOULD PARTICIPATE IN DM?
Authoritative Decisions.
Made by authority without involving other parties and by using
information on hand
Consultative Decisions
Made by one individual after seeking input from others
Group Decisions

21. Made by all affected/concerned parties collectively
*
*
Influence of Culture, Technology and Ethics on DM
Information Technology and DM
Cultural Factors and DM
US culture stresses decisiveness, speed, and the individual
selection of alternatives.
Other cultures place less emphasis on individual choice than on
developing implementations that work.
Ethical Issues and DM
Ethical dilemmas: ethical/legal/right/beneficial decisions?
Watch the movie “John Q”
https://www.youtube.com/watch?v=_l693tZkCio
Discuss the importance of cultural, technological and ethical
factors in DM processes. Use views from your group
perspective
*
See discussions, stats, and author profiles for this publication
at: https://www.researchgate.net/publication/29456185

22. Theories of clinical judgment and decision-making: A review of
the
theoretical literature
Article in Journal of Emergency Primary Health Care · January
2005
DOI: 10.33151/ajp.3.1.308 · Source: OAI
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University of Sydney and Western Sydney Local Health District
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Author(s): Ramon Shaban
ISSN 1447-4999
STUDENT CONTRIBUTION

25. Theories of clinical judgment and decision-making: A review of
the theoretical literature
Article No. 990114
Ramon Z. Shaban BSc(Med) BN PGDipPH&TM
ADipAppSc(Amb) GCertInfecCon
MCHPrac(Hons) MEd RN
School of Nursing, Griffith University.
ABSTRACT
This paper provides a survey of the terrain of theories of human
judgment and decision-
making (JDM). It provides an introduction, overview, and some
insight into the
understanding of some conceptual theories, frameworks, and the
literature of JDM. This
paper is in no way an exhaustive meta-analysis of the literature
on JDM, nor is it intended to
be. It does not seek to categorise and compare existi ng theories
of judgment and decision-
making or critically evaluate each in terms of others, nor does it
seek to reclassify existing
categories. Indeed much of the debate in the literature is about
that very issue—how
researchers and theorists view, characterise, categorise and
apply existing theory of JDM in
existing philosophies, ‘schools-of-thought’, and professional
domains. The problematic,
controversial, and, in the view of some researchers,
inappropriate attempts to do so are well-
documented [1-4]. This paper will provide an overview of the
competing accounts that
various theories and philosophies place on judgment and

26. decision-making.
INTRODUCTION
There is a well-developed and growing body on judgment and
decision-making (JDM).
Considerable debate exists about the constructs and definitions
of judgment and decision-
making. Much work has been done in an attempt to define the
constructs of human clinical
judgment [3, 5-10]. Several authors have sought to describe
JDM using a number of different
expressions and constructs essentially to describe the same
phenomena [1]. There is no one
universal or ‘true’ definition of JDM, with descriptions of JDM
varying considerably across
disciplines, professions and philosophies. Other representations
of the constructs of
judgment and decision-making include clinical decision-making
[1, 11-13], clinical
judgement [1, 5, 6, 14, 15], clinical inference [16], clinical
reasoning [17, 18], and diagnostic
reasoning [19, 20].
In a professional clinical context, judgment is viewed as a
“professional choice rather than
tasks: real life practice rather than imagined activities of those
who see professional status as
a good in its own right rather than a means to a desirable,
namely the higher quality care and
treatment of patients” [1, p. 7]. Dowie [21] defines judgment as
‘the assessment of the
alternative’, the ‘choosing between alternatives’, and argues
that judgments are always in
some way an assessment of the future. In proposing this, Dowie
argues that if a decision is to

27. be considered sensible then surely some knowledge of what the
future might look like after
the decision is made is required. Individuals predict the future
when making decisions all the
time; otherwise choices would be made with no thought as to
the likely consequences of the
decision. When making choices, individuals draw on a variety
of sources of information:
Journal of Emergency Primary Health Care (JEPHC), Vol.3,
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Author(s): Ramon Shaban
experience, the ‘first principles’ of stored knowledge or facts,
the expertise of others, and
occasionally the experiences of tens, hundreds, even thousands,
of others in the form of
research evidence [1]. Decisions are not always made with
‘complete’ or ‘true’ objectivity,
and indeed many wage an argument that complete and objective
judgment providing the
‘truth’ is always, on some level, biased. Sadler [22] and others
argue that no consideration
of the nature of qualitative judgments proceeds far before the
matters of subjectivity and
objectivity are raised. Others insist that the notion of
uncertainty is an underestimated
component of JDM processes, particularly in stressful
circumstances and contexts [10, 23].
Hammond [10] suggests there exists a level of irreducible
uncertainty in all JDM, particularly
in the context of social policy, and argues that all judgments

28. and decisions are flawed and
fallible on some level. Thompson and Dowding [1] claim that
individuals’ experiences are
commonly distorted with hindsight, and people can be selective
in providing the information
they think is needed where first principles often have to be
recast as new knowledge replaces
old.
‘CLASSICAL’ DECISION-MAKING PARADIGM
In a broad context, theories of human judgment and decision-
making may be viewed from a
number of different positions and philosophies. Decision-
making, as a scientific inquiry, was
first established in the early 1950s by Edwards [24] and
Hammond [25]. This work was
continued and through the work of Tversky, Kahneman and
others, it has flourished. One of
the original paradigms of JDM, referred to as ‘classical
decision-making’ (CDM), views the
decision maker as acting in a world of complete certainty [3].
The classical decision maker
faces a clearly defined problem, knows all possible action
alternatives and their
consequences, and chooses the optimum alternative. Often used
in management, CDM
theory has been applied in multiple contexts in the health
professions, although Chapman [3]
and others note that CDM may not fit well in chaotic worlds,
uncontrolled environments, or
critical situations. CDM models are often used in controlled
settings and environments in
purely theoretical and non-applied constructs. Most
predominantly found in laboratory
settings, CDM models and theories seek to prescribe the correct

29. way to make a decision in an
ideal situation, environment or world.
‘NATURALISTIC’ DECISION-MAKING PARADIGM
During the mid-1980s, growing criticism of CDM led to a
reframing of thinking on JDM
theory. A new philosophical paradigm referred to as
‘naturalistic (or behavioural) decision-
making’ (NDM) was developed [26]. NDM recognises that
human beings operate with
cognitive limitations in bounded rationality. Orasanu and
Connolly [27] describe
characteristics of decision-making in naturalistic environments
as those presenting with ill-
structured problems in uncertain, dynamic environments with
shifting, ill-defined, and
competing goals. In these ecologies, time constraint is a
significant factor, requiring
assessment, interpretation and assimilation of multiple data
from multiple sources, often in
high stakes settings. Organisational norms, goals, and
expectations are often balanced
against the decision maker’s personal choice. The naturalistic
decision maker faces a
problem that is not clearly defined, has limited knowledge of
possible action alternatives and
their consequences, and chooses a satisfactory alternative [26].
It assumes that the decision
maker acts only in terms of what they perceive about a given
situation. This model of
decision-making is more appropriate in the contexts of chaotic
environments with uncertain
conditions and limited information. Individuals rely primarily
on their experience in making
naturalistic decisions [28].

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DESCRIPTIVE THEORIES
Descriptive theories, naturalistic and behavioural in nature,
originate from the philosophies
and professions of psychology and behavioural science [2].
Specifically, descriptive theories
are interested in understanding how individuals actually do
make judgments and decisions.
Descriptive theories place no restriction on whether the
individual is rational and logical or
irrational and illogical, and seek to understand how individuals
make judgments and
decisions in the real world, focusing on the actual conditions,
contexts, ecologies, and
environments in which they are made [1]. Irrationality in this
context refers to instances
where individuals have not given any thought to the process of
judgment or decision-making,
and, even if they have, are unable to implement the desired
process [2]. These theories seek
to understand the learning and cognitive capabilities of
‘ordinary people’ and aim to
determine if their behaviour is consistent ‘rational’ [2].
Context, interactions, and ecology
are central to the interpretation and study of descriptive JDM
theory.

31. Arguably the most influential and frequently used descriptive
theory or model used in nursing
and the midwifery is that of ‘information processing theory’
(IPT) [29]. Information
processing theory, also referred to as ’hypothetico-deductive
approach’, suggests that human
judgment and the reality of reasoning are ‘bounded’ and limited
to the capacity of the human
memory [29]. IPT suggests that individuals, in making
decisions, go through a number of
stages that are guided predominately by the acquisition of cues
from the environment [1].
Many authors have proposed variations of essentially the same
phenomena with this theory
[20, 30-32]. Descriptive models and theories of JDM place
significant emphasis on
investigating, heuristics, uncertainty, biases, and error in JDM.
Heuristics are simplifying
strategies or ’rules of thumb’ used to make decisions, and make
it easier to deal with
uncertainty and limited information. Thompson and Dowding
[1] describe a number of
categories of heuristics. ‘Availability heuristics’ base decisions
on recent events that relate to
the situation at hand. ‘Representativeness heuristics’ base a
decision on similarities between
the situation at hand and stereotypes of similar occurrences
[26]. ‘Anchoring and adjustment
heuristics’ base a decision on incremental adjustments to an
initial value determined by
historical precedent or some reference point. Although useful
when dealing with uncertainty,
heuristics often lead to systematic errors that affect the quality
and/or ethics of decisions [1].
Descriptive theories as methods of inquiry have been applied to

32. multiple professions for
nearly half a decade. Large bodies of descriptive theory
research have been conducted,
particularly in the nursing profession [1, 33]. A distinct feature
of descriptive theories is that
they are not concerned with the quality of the judgment or the
outcome of the decision in any
qualitative way. How the individuals arrive at a judgment or
decision, regardless of how
good or bad it may be, is paramount. Evaluation of judgments
and decisions within this
philosophy is based on the empirical validity or extent to which
the model observed
corresponds to the observed choices in the judgment or
decision.
NORMATIVE THEORIES
Normative theories of JDM, classical and positivist in nature,
were born from the statistical,
mathematical, and economic philosophies [2]. In this domain,
researchers (often referred to
as decision theorists) seek to propose rational procedur es for
decision-making that are logical
and may be theorised. The focus of normative theory is to
discover how rational people
make decisions with the aim of determining how decisions
should be made in an ideal or
optimal world, where decisions are based on logical and known
conclusions supported by
clear or probable evidence. Normative theories, often based on
statistics and probabilities
within the positivist domain, propose to evaluate how good
judgments should be made and
how good outcomes should be achieved [1]. Normative theories
give little or no
consideration to how judgments are made by ‘ordinary people’

33. in reality and everyday
Journal of Emergency Primary Health Care (JEPHC), Vol.3,
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Author(s): Ramon Shaban
practice, and place little or no emphasis on the context or
ecology of the judgment [2]. They
are concerned only with optimal conditions and environments,
and assume that decision
makers are ‘superrational’ [34], with little or no emphasis on
how JDM occurs in the ‘real’
world.
‘Expected utility theory’ (EU) and ‘subjective expected utility
theory’ (SEU) are the
normative approaches of choice, often referred to as the gold
standard for optimal decision-
making. Subjective expected utility theory is a normative
approach that takes into account
the decision-makers values or beliefs in a ‘rational’ context and
calculates the probability of
various outcomes occurring before identifying the optimum
decision for that individual [3].
‘Multi-attribute utility theory’ is the normative theory of
decision-making with multiple
goals. A common normative approach to JDM is ‘Bayes
Theorem for Judgments’. A central
tenant of normative theories is the assessment and explication
of risk. In order to determine
how judgments and decisions should be made, comprehensive
risk analysis must be

34. undertaken and all possible risks are explicated and weighted
[1]. Decision analysis is the
direct implementation of these theories to specific decisions.
Decision analysis and the use of
decision trees based on the predicability of event probability
and statistics occurrence is
commonly used to assist in JDM in medicine [1]. Clinical
decision analysis uses techniques
to make the decision-making process explicit by breaking it
down into processes and
components so the effect of different observations, actions,
probabilities, and utilities can be
analysed [21]. Decision trees work by breaking down problems
into smaller decisions and
choices and adding numerical values such as the probability of
the events to each part of the
decision. Once each choice has been assigned a probability,
based on the assumption that
this is possible, the option with the highest utility for the
decision maker can be calculated
[1]. Often referred to as ‘expected utility theory’, the model
attempts to quantify the
probability of the most likely and most desirable event in an
attempt to assist the individual or
group in making that judgment or decision by making it known.
Decision analysis has been
applied in multiple settings [1]: assisting women to make
decisions to continue with a
pregnancy with risk of Down’s Syndrome in childbirth [1, 35],
and deciding on the types of
intervention that should be used for psychiatric patients with
violent tendencies [36].
Chapman and Sonnenberg [3] criticise the use of decision
analysis in instances where
probabilities are based on cultural or societal norms from areas
and locations outside of the

35. use area.
Judgment and decision-making in the context of uncertainty,
stress, and social policy has
been the focus of much of the work of Hammond [10, 23] and
many others. Large bodies of
statistical and probabilistic theory, such as Bayes Theorem,
seek to manage or redress this
uncertainty and stress in judgment making. Reason [37]and
Vincent [38] have examined
errors and slips in JDM, proposing that human error is based on
one or more of, or a
combination of, skills-based failure, rule-based failure, and
failure at knowledge-based level.
They and others have examined the use of rule-applications
processes in an attempt to limit
bias and error in JDM [39, 40]. Risks assessments, tools,
scales, and measurements have
been in use in medicine for years and are prolific in the
medical, psychological and scientific
literature [1]. Such instruments seek to quantify risk and, in
doing so, aim to make all risks
known.
A major criticism of normative theoretical approaches is that
they fail to capture the reality of
most decision situations in heath-care, particularly in nursing,
that are characterised by
incomplete knowledge of all available alternatives, a lack of
reliable probabilistic data of the
consequences of these alternatives, and few readily acceptable
techniques for reliably
gauging patient utility [41]. Normative theories rely on the
quantification of risk in complete
and known ways, which many have argued is not possible [1, 3].
Hastie and Dawes [42]

36. Journal of Emergency Primary Health Care (JEPHC), Vol.3,
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suggest that good decisions are those in which the process
follows the laws of logic and
probability theory. Others have argued that it is not possible to
identify, assign relative
probabilistic weight to, and account for all aspects of risk,
particularly in medicine and health
care [10, 23, 25]. Attempts to do so provide an analysis that is
only valid for one point in
time with significant, unrepresented, and unaccounted bias.
PRESCRIPTIVE THEORIES
In 1982, Bell, Raiffa, and Tversky [2] challenged the dichotomy
of normative and descriptive
theories. A growing group of individuals had expressed
discontent and opposition to the
notion of a dichotomy in the theorising and understanding of
JDM. Rather than forcing JDM
into diametrically opposed philosophies, this group proposed
the need for theories to improve
the quality of decisions and judgments in practice. In
challenging the existing dichotomy,
Bell et al. [2] suggested that in fact the central purpose for
examining JDM is to help
individuals make better decisions. A number of researchers
were concerned with devising
methods that incorporate the insights gained from normative
theories in ways that recognised

37. the cognitive limitation of individuals. Others were concerned
with explaining rational
models in a manner that would appeal to ordinary people. Bell
et al [2] established a third
philosophical stance, known as ‘prescriptive theory’, thereby
creating a trichotomy. This third
philosophy is often used in operational research and the
management sciences in an attempt
to help people to make good decisions and train them to make
better decisions.
Prescriptive theories set out to ‘improve’ the judgments and
decisions of individuals by
investigating how people make decisions [1, 2]. The focus of
prescriptive theories is to
‘help’ or ‘improve’ individual’s judgments. In evaluating the
application of prescriptive
models and theories that attempt to aid in the JDM process, the
central question asked is
pragmatic—did it make the judgment any better? Prescriptive
theories have been applied in
multiple settings and contexts. Decision analysis and decision
trees (normative techniques
described earlier) are used commonly in prescriptive modelling
in medicine to improve
clinician JDM [1]. A recently introduced but now common
prescriptive model for assisting
JDM in clinical settings is the use of clinical guidelines and
clinical policies. Clinical
guidelines are prescriptive tools used to assist practitioner and
patient decisions about
appropriate health-care for specific circumstances [1]. They are
largely guidelines that
outline operational information, procedures, and guidelines with
options, and are often
referred to as ‘protocols’. Primarily aimed at improving the

38. quality of care or standardising
care, guidelines are mechanisms for reducing variations in
clinical practice and discouraging
practices that are not based on sufficient evidence [1]. While
they have been found to
provide improvements in the quality of care [43], the effects of
their application are
significantly variable and the extent to which they are routinely
applied is not clear [44].
Woolf et al. [45] argue that clinical guidelines clearly benefit
users and patients, although
their use is reported to be overtly problematic [46], particularly
given that they can contribute
to an illusion of a single answer for a complex problem [1, 47].
Guidelines themselves are
supposed to, but may not, contain the best available research
evidence, and may lead to
judgments that may not have otherwise been made because of
the absence of a more suitable
options. Thompson and Dowding [1] argue that decisions do
not occur in a vacuum, and that
individuals operate in complex environments having to assess
and weigh multiple data on
multiple levels at multiple times. Schon [48] argues that
clinical guidelines should never
(and should never claim to) aim to cover all aspects and
possibilities of the JDM process.
Computer-assisted decision-making has also recently been
applied to assist with JDM,
particularly in the operational areas of industry, science,
aviation, and medical and
emergency call centres [1]. Computer-assisted decision-making
software such as Medical

39. Journal of Emergency Primary Health Care (JEPHC), Vol.3,
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Priority Dispatch System (MPDS) has been implemented in a
number of emergency services
nationally and internationally, including in Australia. Farrand
et al [49] examined the
introduction of a computerised dispatch system into an EMS
call centre traditionally staffed
with nurses. The study found that while attempting to formalise
nurse decision processes
using artificial intelligence the complexities of the decision
processes were revealed. An
assessment of the accuracy of the decision process, using an
expert panel review of 1,006
calls, found almost perfect sensitivity with telephone triage and
decision whether to send an
EMS resource or not. In this instance, the study demonstrated
that nurses JDM processes in
this setting were sophisticated [1]. Other studies have reported
similar findings [50, 51].
SOCIAL JUDGMENT THEORY
An alternative way of looking at judgment is by comparing the
‘quality of the judgment’ and
the ‘judgment process’. Accuracy, as a measure of the quality
of JDM, is popular across a
broad spectrum of disciplines and philosophies. One theoretical
framework that provides a
mechanism to measure the accuracy of judgment is ‘social

40. judgment theory’ (SJT). The
central assumption of SJT is that an individual’s judgment
relates to the reality of their social
environment and that the environment can be represented by a
series of lenses [7].
A central SJT theoretical approach for the study human
judgment, proposing scope and
theoretical framework constructs for judgment analysis is the
‘Lens Model’. Social judgment
approaches use the relationship between the information and the
outcomes of interest as the
basis for establishing the criterion. The ‘Lens Model’ is an
alternative approach for the study
of human judgment, proposing scope and theoretical framework
constructs for judgment
analysis. According to Hammond [2, p.167] “an organism is
depicted as a lens; that is, it
‘collects’ the information from the many cues that emanate from
an object and refocuses
them within the cognitive system of the organism in the form of
a judgment about the
object”. Cooksey [1] presents a number of variations in ‘Lens
Model’ analytic assessment
systems, each placing different emphasis on the different
aspects, types, and contexts of
judgment. The characteristics and application of the ‘Lens
Model’ is described in
considerable detail elsewhere by Shaban, Wyatt-Smith &
Cumming [52].
INTUITION
A popular alterative method for explaining how health-care
workers such as nurses and
midwives make judgments and decisions has been the notion of

41. intuition [1]. Intuition has
been defined in the literature in many ways [1], such as
‘understanding without a
rationale’[6] or an ‘immediate knowing of something without
the conscious use of reason’
[53],‘knowledge of a fact or truth, as a whole, with immediate
possession of knowledge and
an independence from linear reasoning process’ [54]. Although
there is no agreement in the
literature as to a universal definition of intuition, there is a
common assumption about its
contextual meaning. A common theme throughout all the
definitions of intuition is the notion
that the judgment and reasoning process just happens, cannot be
explained, and is not rational
[1]. Benner [5, 6, 14] first examined the notion of ‘nurse
intuition’, establishing that expert
nurses display intuitive judgment that is not found in novices.
In Benner’s interpretation, the
ability to make judgments intuitively characteristically
distinguishes experts from novices
and, in doing so, expert nurses are no longer reliant on analytic
principles to connect their
understanding of a situation to an appropriate decision and
action [1].
One strength of the intuition is that is acknowledges the ability
of individuals to know or
readily and quickly recognise the possible outcomes of a given
situation—a key element of
decision-making in situations of risk and uncertainty [1].
However, this theory has attracted
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intense criticism over the last decade, particularly in that
experts who rely heavily on
intuition demonstrate knowledge constructs that are ‘context
nature specific’, and therefore
the nature and applicability of their knowledge is largely
limited to narrow, specific contexts
[55]. For example, Dowding [7] argues that a major criticism of
‘nurse intuition’ is that the
expertise and ‘intuition’ is grounded around a specific context
and is of a specific nature, and
that nurses cannot take their ‘intuition’, knowledge, or skills
and apply them out of that
context. Further the notion of intuition has been criticised
when contextualised against ‘truth’
or ‘knowing of the truth’, in that it disregards the positivist
paradigms in which much of
medicine and health-care is grounded. Thompson & Dowding
[1] argue that expertise is
almost entirely connected to a more extensive knowledge base,
because experience itself is
knowledge.
EXPERT-NOVICE THEORY
Expertise, as a theory for JDM, was first promulgated in the
late-1960s largely due to
attempts to develop artificial intelligence systems [56]. The
definition of ‘expertise’ is as
problematic and controversial as that of judgment. Chi et al.
[56], in characterising this
expert-novice phenomenon, suggest that experts excel mainly in

43. their own domain/s in which
they perceive possess large meaningful patterns of knowledge.
Experts are fast; they are
faster than novices at performing skills of their domain and they
quickly solve problems with
little error, demonstrating that experts have superior short-tem
and long-term memory.
Experts see and represent a problem in their domain at a deeper
level than novices; novices
tend to represent a problem at a superficial level. Experts spend
a great deal of time analysing
a problem qualitatively and have strong self-monitoring skills.
The expert–novice theory has been widely applied to multiple
professions and contexts [14,
56, 57]. Experts achieve better clinical results, where reasoning
is based on accurate and
technical competence, although Higgs and Jones [58] argue that
other outcome dimensions,
particularly from that of the patient’s perspective, may be
lacking in peer-judged contexts.
Alexander and Judy [59] argue that individuals who monitor and
regulate their cognitive
processing during task performance demonstrate expertise. This
concept, known as
metacognition, is essential to high quality human performance.
Experts demonstrate the
ability to manage their intellectual resources and possess a
wealth of domain-specific
knowledge, including propositional knowledge, craft
knowledge, and personal knowledge
[59]. Expert theories and its immediate extension, expert-
novice theory, are theories used
widely across multiple disciplines and contexts, particularly in
health, education, and the
humanities [1].

44. COGNITIVE CONTINUUM
A number of researchers and theorists suggest that clinical
reasoning practices are based on a
combination of IPT stages and intuition. This theory, referred
to as ‘cognitive continuum’,
suggests that reasoning is neither purely intuitive nor purely
analytical, and that it is located
somewhere in between [1]. Cognitive continuum is described as
a prescriptive model, as it
aims to help people improve their judgments [1]. In order to
ascertain what cognitive mode
is in use, three factors must be known: the structure of the task,
the number of information
cues, and the time available to make the judgment or decision.
Intuition, in this
interpretation, is viewed as the most appropriate form of
cognition in instances where a task
is poorly structured, multiple information cues available, and
there is little time for judgment
or decision-making to occur. Conversely, if the task is largely
structured, with few
information cues available, and much time available for JDM,
then an analytical approach is
appropriate. Thompson and Dowding [1] suggest that most
medical JDM falls between the
Journal of Emergency Primary Health Care (JEPHC), Vol.3,
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45. two extremes, and therefore suggests that the most appropriate
form of cognition for
practitioners to use is that of system-aided judgments.
SIGNIFICANCE AND LIMITATIONS OF THE THEORETICAL
LITERATURE ON
JUDGMENT AND DECISION-MAKING
The literature and theories on judgment and decision-making are
as extensive as they are
controversial. The fragmented nature of studies to date within
the general health disciplines
addressing aspects of clinical judgment process has not yet
resulted in a comprehensive
understanding of the phenomena [1] or a suitable universal
model or theoretical framework .
Studies have traditionally followed or engaged one particular
JDM paradigm or philosophy
exclusively. Few, if any, have sought to view or examine JDM
in more than one paradigm,
which is a recent and growing criticism of the current body of
research [1]. Much of the
work to date has applied descriptive approaches, such as
information processing theories to
judgment processes, in an attempt to contribute greater
understanding of how judgments are
made. In doing so, these studies, in the main, have provided
greater insight into the cognitive
process involved, particularly with respect to assessment
practices. However, the ecological
validity of many of these studies has been questioned [32, 60,
61], particularly with the
criticism that they have focused on the representativeness of the
judgment tasks presented [1].
Many JDM studies have occurred in contexts and ecologies

46. away from the clinical setting
and therefore do not induce the same cognitive strain and
commensurate effect on accuracy
[1, 60]. Conversely, some studies have focused primarily or
exclusively on the accuracy or
quality of the judgment or judgment process. To date, these
studies have focused on
judgment error in particular disciplines, largely the operations
and management sciences [38].
A major criticism of these studies, that are normative in nature,
is that they negate to value of
context, ecology and interaction in examining the JDM
processes [1, 62, 63]. Other authors
have criticised the methods by which risk, uncertainty, and
stress have been quantified,
arguing that no matter how quantified, the full effect of such
factors can never fully be
understood outside the context of the individual [10, 23].
Sources of judgment errors in other
contexts and disciplines need to be examined and explored.
The use of prescriptive approaches, which attempt to improve
JDM and help individuals to
make better judgments, has also been criticised as a single
paradigm of inquiry [1, 62]. Used
considerably in teaching or instruction contexts and intervention
studies, prescriptive models
has been used to help individuals make better judgments and
improve the quality the JDM
process. The use of only prescriptive theoretical approaches
significantly limits that ability to
interpret findings in other contexts and paradigms, such as
descriptive theory [64]. Further, a
number of studies have attempted to improve JDM in the
absence of any normative or
descriptive data or constructs and have failed because of a lack

47. of understanding of the
judgment process or the quality of a good judgments [1, 62].
CONCLUSION
The study of JDM has been a focus of psychologists, scientists,
and others for more than half
a century [1]. Considerable research exists in the literature
proposing a variety of theories of
JDM. Theories of JDM have long and extensive philosophical
foundations, often emanating
from specific professions or disciplines. The literature and
theories of JDM are as extensive
and comprehensive as they are controversial. There is no single
way to organise the research
and literature on JDM. It is clear that there are differing and
competing accounts of JDM in
the literature and in research. There exists a dearth of the
judgment research in paramedic
practice [52]. Much of the research conducted to date carries
with it considerable
Journal of Emergency Primary Health Care (JEPHC), Vol.3,
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Author(s): Ramon Shaban
controversy and conflict even when considered within its own
paradigm or context. Many of
the studies demonstrate poor ecological validity and a
significant potential for
overgeneralisation. Thompson and Dowding [1] suggest it is
time to consider new

48. approaches to existing knowledge and research on JDM that will
make lasting contributions.
Additional research, new approaches and rethinking about
existing judgment and decision-
making and they ways in which they may be applied to
professional work is required.
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Other papers in this series:
Paper One - Mental health and mental illness in paramedic
practice: A warrant for research
and inquiry into accounts of paramedic clinical judgment and
decision-making
http://www.jephc.com/full_article.cfm?content_id=170
Acknowledgments
The author would like to acknowledge and thank Associate
Professor Claire Wyatt-Smith and
Professor Joy Cumming for their supervision and support, and
Mr Jason Emmett for his
editorial review of this manuscript.

56. http://www.jephc.com/full_article.cfm?content_id=170
Journal of Emergency Primary Health Care (JEPHC), Vol.3,
Issue 1-2, 2005
Author(s): Ramon Shaban
Author Disclosure
The author has no financial, personal or honorary affiliations
with any commercial
organization directly involved or discussed in this study.
This Article was peer reviewed for the Journal of Emergency
Primary Health Care Vol.3, Issue 1-2, 2005
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https://www.researchgate.net/publication/29456185‘CLASSICA
L’ DECISION-MAKING PARADIGM‘NATURALISTIC’
DECISION-MAKING PARADIGMDESCRIPTIVE
THEORIESINTUITIONEXPERT-NOVICE
THEORYCOGNITIVE CONTINUUMSIGNIFICANCE AND
LIMITATIONS OF THE THEORETICAL LITERATURE
OCONCLUSIONPaper One - Mental health and mental illness
in paramedic p