decision making under stress strategies for becoming a better decision maker in emergencies...

Decision Making Under Stress

Strategies for

Becoming a Better Decision Maker

inEmergencies

Developed byDC John Tippett

City of Charleston Fire DepartmentCarlos Alfaro, MCFRS

Synopsis

Given that attendees have already been introduced to the principles of Crew Resource Management (CRM), this session will focus on the element of

decision making in an effort to improve that skill.

Learning Objectives

• Review principles of Crew Resource Management to refresh attendees’ memories.

• Discuss, describe and dispense information on decision making to improve that skill in attendees.

Credits

The following presentation borrows, with permission, from the work of Chief Richard B. Gasaway (Ph.D), Roseville

Fire Department (MN)rich.gasaway@ci.roseville.mn.us

651-792-7304.

The works of Gary Klein and Malcolm Gladwell were also used in the preparation of this presentation.

Why are we here?

Robert Evans, MCFRS

Decisions we make have impact

• http://www.youtube.com/watch?v=G3uoVOOlT2s

• http://www.youtube.com/watch?v=Bqh5h17bmC4&feature=related

Error Management

• Contemporary thinking acknowledges that error is a way of life.

– given the acceptance that human error may occur, the focus has become “How does one effectively manage error?”

– proper error management greatly enhances safety

CRM Review

• What: The conscious and deliberate use of all resources in a non-threatening, non-punitive environment. Employing principles of CRM in every aspect of performance helps avoid, trap, and mitigate the impact of errors.

• Goal: To achieve optimal performance

from a team executing multiple, complex tasks.

Crew Resource Management (CRM) is a tool created to

optimize human performance by reducing the

effect of human error through the use of all

resources.

6 Principles

• Communication

• Task Allocation

• Situational Awareness

• Teamwork

• Decision Making

• Debrief”*

Communication

Task Allocation

Situational Awareness

Teamwork

Decision Making

Decisions: Choices made from among two or more alternatives.

Is decision making an art or a science?

TraditionalDecision-Making Process

• Define the problem.

• Identify decision criteria.

• Allocate weights to the criteria.

• Develop the alternatives.

• Evaluate the alternatives.

• Select the best alternative.

• Evaluate effectiveness of the action.

Subject Matter Experts useNaturalistic Decision Making

Dr. Gary Klein, PhD (Klein & Associates) www.decisionmaking.com

Studies included: fireground

and battleground commanders.

Hypothesis: Fireground

commanders use cognitive

decision making processes.

What were the results of Klein’s research?

Fireground commanders did not use cognitive decision-making processes.

In many cases, the IC didn’t even go as far as coming up with two plans of action to compare.

They picked the first thing that came to mind and played it out in their mind.

What were the results of Klein’s studies?

If the mental model played out ok, they went with that decision.

If it didn’t, they scrapped it and used the same process with the next solution that came to their mind.

Why is This Important to Us?

How can we as decision makers do this?

• Recognition-Primed Decision Making– Situational Awareness– Tacit Knowledge– Mental Modeling– Self-Efficacy (confidence)

Exercise 1

RPDM(20 minutes)

Exercise Instructions

• You will be shown a series of incident scenes.

• Incident scene will be displayed for 5 seconds.

• Ask students following questions:– Have you run an incident like this before?– What did you do?– Did your actions result in a successful

outcome?

• Have you run an incident like this before?• What did you do?• Did your actions result

in a successful outcome?

Scenario 1

• Have you run an incident like this before?• What did you do?• Did your actions result

in a successful outcome?

Scenario 2

Scenario 3

• Have you run an incident like this before?• What did you do?• Did your actions result

in a successful outcome?

Scenario 4

• Have you run an incident like this before?• What did you do?• Did your actions result

in a successful outcome?

Scenario 5

• Have you run an incident like this before?• What did you do?• Did your actions result

in a successful outcome?

Common Characteristics of Command & Control

Decision-Making

• High ambiguity with unknown cause and effect.

• Low probability of frequent occurrence.

• Unusual and unfamiliar circumstances.

• Requires rapid action.

• Can pose serious threat to survival.

• Dilemma necessitates a decision be made.

Naturalistic Decision Making (NDM)

NDM (Intuitive) Process

• Size-up situation quickly.• Recognize “typical” ways of reacting.• Mentally game out the options.• Focus on most relevant information.• Form expectations.• Detect anomalies and problems.• Seek explanations for unusual

events.• Make a decision and run with it.

Decision Making Setting

Stable v. Unstable

Decision-Maker

Novice

v.

Subject Matter Expert

Decision-Making Focus

Narrow v. Broad

Decision-Making Time

Ample time to decide

v.

Limited time to decide

Decision-Making working conditions

Stable

v.

Unstable

Decision-MakingGoals

Clearly stated

v.

Unclear/ambiguous

Decision-Making Information

Quality– Precise– Degrading

Quantity– Not enough– Too much

Decision-Making Inputs

Clear inputs

v.

Subtle cues and patterns

Decision-Making Consequences

Low stakes

v.

High stakes

Qualities of effective decision-makers

Flexible Quick thinker Resilient Adaptive Risk taker Accurate

Decisions can triggerstress reactions

• Heart rate increases.• Respirations increase.• Pupils dilate.• Glucose released for instant energy.• Endorphins are released.• Blood supply to the kidneys and digestive tract is

restricted.• The bowels and bladder may release their contents.• Attention is focused in immediate, highly structured

tasks. More important & complex tasks are avoided.• Natural judgment systems shut down and more primitive

instincts take over.

Stress triggers “Primitive Instincts” and tells you to use your

Intuition

Physiology of Decision Making

• Left Brain

• “Logical” thinkers

• Right Brain

• “Intuitive” Thinkers

Physiology of decision making

Left BrainLeft Brain

Logical

Sequential

Rational

Analytical

Objective

Looks at parts

Right BrainRight Brain

Random

Intuitive

Holistic

Synthesizing

Subjective

Looks at wholes

Primary Personality Traits

C. G. JungAnalytical Psychologist

– Extrovert or Introvert– Sensing or Intuitive– Thinking or Feeling– Perceiving or Judging

Examples of primary traits

Reserved v. OutgoingSubmissive v. AggressiveSerious v. Happy-go-luckyTimid v. VenturesomeTough-minded v. SensitiveTrusting v. SuspiciousPractical v. ImaginativeSelf-Assured v. ApprehensiveConservative v. ExperimentalGroup dependent v. Self-sufficientUncontrolled v. ControlledRelaxed v. Tense

Emergency SceneDecision-Making Environment

• Conditions: Uncontrolled and continually changing• Time: Constrained• Information: Degrading, too much, not enough• Ambiguity: High, with unknown cause and effect• Frequency of event: Low• Situation: Unusual and unfamiliar• Action: Rapid and necessary• Risk: High

3 Levels of Situation Awareness (SA)

Level 1 Capturing the elements of the current situation• Paying Attention• “What’s going on right now?”Level 2: Comprehending the current situation• Sense Making• “What does this mean?”Level 3: Predicting the future situation• Story Building• “Where is this going?”

How do you develop Naturalistic Decision-Making skills?

• Must become a competent

subject matter expert.• Progression of Competency in SA

– Unconscious Incompetence

“I didn’t even see that.”– Conscious Incompetence

“I saw it, but I didn’t know what it meant.”– Conscious Competence

“I saw it, and I knew what it meant.”– Unconscious Competence

“Something inside told me that was important.”

What’s the problem?

• Experience:– (novice EMTs, commanders, firefighting teams)

• Communications:– (lack of, too much, confusion, incomplete)

• Situation Awareness:– (all 3 levels: capturing, comprehending, predicting)

• Sense Making:– (figuring it out)

• Story Building:– (predicting where it’s going)

• Task Overload:– (being overwhelmed)

What’s the problem?

• Multi-Tasking:– (doing too many things at once)

• Distractions:– (interruptions, setting things aside that need done)

• Staffing:– (experience, training, understaffing)

• Error Creep:– (doing things wrong and getting away with it)

• Conflicting goals:– (multiple goals, freelancing)

• Human factors:– (personality, ego, fatigue, culture, complacency, invulnerability)

• Commander location:– (In the street? In a command vehicle?)

Becoming a better emergency scene decision maker

• Training for NDM – Reading and comprehending cues– Developing situation awareness– Forming mental models and forecasting– Training commanders “in context”

• Practice commanding in NDM environment (not the classroom)

Becoming a better emergency scene decision maker

• Acceleration of experience– Commanders-in-training

• Commanding actual incidents – No substitute for the lived experience.

• Post-incident evaluations (learn from mistakes - avoid error creep).

– Simulations – A safe way to make mistakes.• Computer-based• Pencil & Paper• “Chalk Talks”

– Case studies – Other people’s lived experiences.• Near-Miss Reports• N.I.O.S.H. Reports• Firefighter Close Calls Reports• “On The Job” narratives that include lessons learned

TADMUS*

*Team Decision Making Under Stress

• U.S. Army study on team decision making.

• Best performers under stress were adaptive.

• Adapatability was trainable.

Making TADMUS work

• Team must have a common mental model.

• Leader routinely gives assessment.– Facilitates information sharing.– Allows others to cue base or NDM.

• Team develops common language.

• Develop anticipatory behavior.– Communicate– Train together

Team Decision Making Exercise

• Form into teams as indicated by instructor.

• You will be presented with a series of scenarios that will require you to make decisions in an increasingly time sensitive environment.

Case Study

• www.firefighternearmiss.com• Report # 05-147

Event Narrative

I responded as part of an ALS crew for a heart attack. We arrived on the scene and were greeted by a group of small children standing on the front porch flagging us down and flashing the porch light. The PMIC commented that it looked like "grandpa must be having the big one." The two medics grabbed gear and headed into the house. I grabbed the portable radio and followed behind. When I walked in the house I observed the charge medic seated across from a man about 30 years old, sweating profusely and breathing heavily. I excused myself as I walked by and took a position in the corner of the kitchen. I set the portable on a chest freezer and turned around. As I scanned the room I noticed for the first time that the table area and kitchen had been trashed. The "victim" started breathing more heavily and started chanting "I don't want to hurt anybody, I don't want to hurt anybody," over and over, getting louder and louder. He then stood up abruptly, started yelling and kicked his chair. The children screamed and ran down the hallway to their bedrooms. The charge medic said, "Ok, that's it, we're outta here." He and the other medic headed for the door. I grabbed the portable but was cut off by the victim. He squared off facing me…

What’s Next?

Event Narrative• …and prevented me from getting past. I was able to get over to his wife. She whispered to me

that if he could only find a job, everything would be alright. I told her we needed to get the hell out of here. He started coming at us breathing heavily and grunting. I pushed her into the dining room out of the sight of her husband. We could hear him pulling the drawers out and throwing silverware and utensils around. I told the wife to head for the living room so we could exit by the main hall.

• I could hear the charge medic calling for police help, stating there was a firefighter trapped in the house with a violent mental patient. As the wife and I came down the front hall, the patient stepped into the hall and cut off our escape. We retreated back into the living room and he returned to the kitchen and started throwing silverware around again. I saw the charge medic coming toward the front door. I told the wife to stay in the hallway and I moved up to the intersection of the bedroom hallway and front hallway. The charge medic opened the front door and we both called for the kids to come out of their bedrooms. As they came down the hall, I passed them to the charge medic and he took them outside. The patient continued to tear the kitchen apart. As the last child was passed, the patient came back into the hallway. I backed up and he went back into the kitchen. Everything got very quiet so I walked down the hallway with the wife in tow. As we got to the intersection of the kitchen and hallway, the patient came at us. I pushed the wife out the front door and retreated down the front hall again. I could hear him chanting again and throwing things around the kitchen and decided I could make it out of the house. As I reached the hallway intersection again, he came out of the kitchen and threw a punch. His fist hit the wall and stopped his momentum. I took the opportunity to make my escape and ran out the front door. The police arrived a short time later and took the patient into protective custody.

People live and die by the decisions we make

“If we are to learn to improve the quality of the decisions we make, we need to

accept the mysterious nature of our snap judgments.”-- Malcolm Gladwell

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