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Liddy Shriver Sarcoma Initiative

From a Nurse's Perspective

Decision Making: Complexities and Variables

An ESUN Article

Marianne Griffin RN, BA
Clinical Coordinator of the Victorian Sarcoma Service
Peter Mac Callum Cancer Centre/St. Vincent's Hospital
Melbourne, Australia

I have said it thrice: What I tell you three times is true.
– Lewis Carroll

Today, we receive information in many and varied ways. The greater utilisation of multimedia, both written and visual, means that the average person will begin at a starting point with preconceived ideas of what to expect, even if that information may not be accurate.

A person undergoing cancer treatment undertakes many decisions, ranging from when and how to attend an appointment to making complex choices about treatment options, including participating in a research study. Communication issues that affect the decision making process include the volume and complexity of information being communicated and the way that the information is conveyed, as well as the patient's anxiety level, physical state of well being and ablity to understand the language being spoken.

According to Wikipedia, "Decision making can be regarded as an outcome of mental (cognitive) processes leading to the selection of a course of action among several alternatives. Every decision making process produces a final choice: This can be an action or opinion of choice." [1]

Decision making is a complex process. Individuals make decisions within a personal context, allowing for individual preferences and including predetermined sets of values. The process may be continuous, interacting with the environment (cognitive), or it may be logical and rational (normative). At another level decision making can be viewed by some as a problem solving exercise that ends in a satisfactory end point. This process may be rational, irrational, emotional, logical, or based upon tacit or explicit assumptions. Some of the decision making techniques that are used include:

• Listing advantages and disadvantages (Decision Making Tree)
• Flipping a coin (Random Choice)
• Accepting the first option that seems as though it will lead to the desired end point
• Prayer,  astrology (Forms of Divination)
• Taking advice from a person in authority (Acquiesce to an expert)
• Choosing the option with the highest probability (Decision Analysis)

Behavioural psychologist, Isabel Briggs Meyers, developed a set of four bi-polar dimensions called the Myer- Briggs Type Indicator to demonstrate that a person’s decision making process depends on their cognitive style. [1,2]  The four corners of these dimensions are: thinking/feeling, extroversion/introversion, judgement/perception and sensing/intuition.  Depending upon points scored would indicate a person’s decision style, for example those who scored near thinking, extroversion, sensing and judgement would tend to have a decision making style that was logical, analytical, objective, critical and empirical. [2]

How does this information help health care workers in aiding patients make important decisions?  One may say that by having knowledge of the complexities of the process will allow for difference. It enables health care workers to present information to individual patients in a variety of ways that will allow them the greatest ability to make choices for their own bodies and treatment, even if that choice is to have no treatment.  It also recognises that within family and peer support groups, each member may have a different decision making style, which may lead to conflict.

When many people are asked to make a decision based upon the same information, individual bias will be a factor, leading to a variety of answers, including:

• Selective search for evidence [3]
• Premature termination of search for evidence
• Inertia
• Selective perception (Prejudice) [4]
• Wishful thinking
• Repetition bias (Illusion of Truth)
• Group thinking (Peer group pressure)
• Source credibility bias (we do not like the person/group from which the information has come: prejudice)
• Role fulfilment
• Illusion of control

Emotions also play a part in the decision making process, which can lead to benefit or harm.

These points highlight the individual nature of choice. Moons et al (2009) purport that repeated statements are perceived as more valid, presumably because repetition imbues the statement with familiarity. [5]  This concept is termed the Illusion of Truth and was first developed by Hasher et al. [6]  Increased familiarity consistently provides a positive signal that increases agreement, with the component variables being a person’s motivation and ability to process information, the degree of repetition and the quality of the argument presented.  As a result of the Illusion of Truth, novel arguments and information are much more likely to be rejected.

The above points highlight some, but not all, of the variable factors that are part of the decision making process.  An enhanced knowledge in this area is of benefit to any health care worker in an endeavour to support all patients as individuals in their complex and time-imperative choices.

Keep moving forward.
- Walt Disney

References

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