Making decisions is something that everyone does all day, every day: what to wear when going out, how to travel when going on holiday or what to have for lunch all require decision making. Decisions are also made in practice, but involve owners, opinions of colleagues and clinical evidence. Some decisions will be made instantly; others may take more time. In both situations, it is important to understand how those decisions are made.
When working with patients, you are continuously deciding on how to treat and care for them. You need to consider the clinical presentation, the way they respond to treatment, the evidence base, practice protocols, possible side effects and costs — to name a few factors — but it is important to stop and think about how you make those decisions. Clinical decisions may be based on practice protocol, the latest evidence, or personal experience. Where protocols or standard operating procedures (SOPs) are implemented, there needs to be an awareness of how these were developed. There needs to be an awareness amongst the end users of the decision making process that was applied to develop those protocols. Clarity and transparency of the methodology, training for the people sitting on such review panels and any conflicts of interest need to be acknowledged to ensure that all decisions are based on valid, reliable and current information.
When completing a nursing care plan, decisions need to be made about the care that will be given. It may be that there is only one possible option, or there may be many different possibilities to consider. Think about how you make those decisions: some decisions allow you to exercise autonomy, but there will be times when the care of a patient is controlled by other people in your team. The owners' wishes also need to be considered.
The theory of clinical decision making has, in recent years, received more attention from policy makers, particularly in the field of human medicine. Members of the public are more willing to question the advice given by both human and veterinary health professionals and want to be more involved in the decision-making process (NHS England, 2019). Therefore, both from an educational perspective and in terms of the day-to-day approach taken in practice, it is important to review how decisions are made and if they are best for each individual patient.
Quality improvement, clinical audit and significant event reviews involve reflection on the care given, and decision making will be influenced by the outcome of such quality improvement events (Mosedale, 2018; 2019; Royal College Of Veterinary Surgeons (RCVS), 2019). Reflective practice is central to the process of learning from previous experiences (Fontaine, 2018) and this will influence future decision making.
Theory of decision making
The decision-making process can be divided simply into two different groups (Kahneman, 2011):
- Decisions that are made quickly without little thought are known as System 1 decisions
- Decisions that involve time and conscious processes, evaluating the different choices, are known as System 2 decisions.
System 1 decision making
From a psychological perspective, System 1 decisions involve past experiences and rely on gut instinct or pattern recognition. You might know that an individual dog has in the past chewed out their stitches, so the next time they are recovering from surgery you will put a buster collar on them to prevent the problems encountered before. Gut instinct is regarded by some to be useful in human and veterinary consultation (van den Bruel et al, 2012; Brown, 2015; Iqbal et al, 2015), allowing clinicians to respond to the concerns of patients (human medicine), or owners, thus leading to specific actions such as a more in-depth work up or further tests.
Heuristics describes the process by which people implement System 1 decisions and take shortcuts to make decisions: using past experiences or familiarity with a problem on which to base those decisions (Kahneman, 2011). So, for example, if you have had a group of cases that managed to pull out their intravenous catheter when receiving fluids, you might put in place extra measures to ensure that the next case does not do this, irrespective of the individual characteristics of that case, thus making use of past experience in the decision-making process.
System 1 decisions are, however, prone to problems including bias, misplaced confidence or a lack of information (McKay, 2011). While our experiences are valid and cannot be argued with, they may not be representative of the general population as a whole. Therefore, it is important to think about the factors that influence any decision, to ensure that the final decision is based on best evidence and is appropriate for that individual case.
System 2 decision making
The System 2 decision-making process takes into account these influencing factors. Making a System 2 decision takes more time, as it involves a conscious evaluation of the different options available, considering current evidence or best practice. System 2 decisions are more systematic and involve all options, considering the possible outcomes of each. They still rely on experience but also draw on a wider knowledge of the subject. However, within veterinary practice, there may not be enough evidence available, and so decisions often have to be made without the reliability of complete data sets (May, 2013). This is the daily challenge that faces veterinary teams.
The process of decision making
Three main methods of decision making have been recognised within human and veterinary medicine (Charles et al, 1999: Cornell and Kopcha, 2007):
- Paternalistic or guardian
- Consultant or teacher
- Shared or collaborator.
As the name suggests, the paternalistic approach is similar to that which exists between a parent and child, where the owner relies on the guidance and decision making of the veterinary professional. In human nursing, three models of decision making have been described by Banning (2008):
- Information processing
- Intuitive humanist model
- Clinical decision-making model.
Within veterinary practice, a consultant or teacher approach allows the veterinary team to inform and guide the decision making of the owner, but not make the decision for them. The owner is still responsible for the final decision, having had a chance to find out more information about each of the available options.
Shared decision making probably best describes the care given in veterinary practice. Within human medicine, the delivery of shared decision making is still developing, since the implementation of shared decision-making practices has been slow in the NHS (Joseph-Williams et al, 2017). This contrasts with the situation in veterinary practice where patients come with owners who need to pay for the treatment; those owners often therefore want to be involved in the decision-making process. It is unlikely that an owner would say: ‘Do what you want,’ and leave the veterinary team to deliver all care, without any discussion. In emergency medicine, where owners are stressed or worried about their animal, they may feel less able to make decisions and may therefore follow the guidance of the veterinary team. However, these very situations can lead to problems later on when owners have had time to reflect and may not agree with the course of action taken.
Financial concerns, consent, compliance, home care and owner wishes are all involved in the process of decision making to some degree, as shown in Figure 1; however, the degree to which they influence the outcome will vary between owners. Some owners will come to the practice with a list of information gathered from ‘Dr Google’ and their mind already set on what the best options are for their pet. Others will see the veterinary team as the experts and expect them to decide on the best care for their pet.
Most owners, however, fall somewhere in between: they wish to be presented with the options, given all information about possible outcomes, informed about costs, told what might be expected of them with regard to home care, and also told how their pet might respond to any form of treatment. How long will it take for them to get better? What are the chances of them making a full recovery? Will there be any side effects from the medication? Will they need to stay in the hospital for a long time? What will happen to them while they are hospitalised?
Everitt (2011) identified that veterinary consultations were very much shared decisions taking account of both the owner and animal circumstances. Reasons for this included the status of the animal, the value placed on an animal by the owner, payment for veterinary services as opposed to ‘free’ NHS treatment, owner resources, the acceptability of euthanasia as a treatment option and the circumstances of the consultation. Client-associated factors will influence any consultation and the decision-making process. The age, gender, educational background and the type of consultation are all considered relevant (Cornell and Kopcha, 2007). This explains the need for excellent communication skills whenever discussing care with an owner. All cases and owners are different with distinctive expectations.
For more complicated cases, a lot of information may need to be discussed with an owner, and many different options may be available. Within the veterinary team, it is possible that there are different views about the best care for a particular patient. Veterinary medicine includes euthanasia as a treatment option, which can make decision making even more difficult. Past experience of euthanasia may influence how an owner approaches this option with another animal. The veterinary team needs to consider these feelings when supporting owners to make the best decisions for their animal.
Care of the individual animal and owner is central to the concept of shared decision making — the process should be inclusive, allowing patients (or owners of animals) to express their concerns and play a part in the care that is delivered. Work by Kanji et al (2012) observed that use of a relationship-centred care approach, developing a partnership between client and veterinary surgeon, had positive implications for client compliance. The same can be applied to veterinary nursing consultations. Good communication skills, listening, understanding and acting on owner concerns build trust in a relationship-centred care approach.
Work by Kuper and Merle (2019) demonstrated that partnership-centred and empathic communication decreased the need for owners to consult alternative healthcare providers or seek information from online sources. Making decisions about the care of inpatients also needs to encompass owner wishes, which should be noted and clearly visible on the records. Where any doubt exists, it is important that the practice environment allows for professional discussions between veterinary surgeons and nurses about individual cases.
Work by various authors in human medicine (Hall and Dornan, 1988; Levinson, 1994; Stewart, 1995; Levinson et al, 1997) has demonstrated that shared decision making, and relationship-centred interactions promoted improved patient outcomes and fewer malpractice claims. Indeed, shared decision making builds good relationships and trust between professional and owner (VetSet2Go Project, 2018). Shared decision making can be more time-consuming but the reduction in problems or dealing with complaints may be worth the time costs (Levinson et al, 1997).
Coe et al (2008) demonstrated that owners expect veterinary surgeons to educate them and provide reliable information; give them a range of options with the advantages and disadvantages of each being explained; listen to them; and that a partnership would be formed to care for their pets. While no research has been carried out to evaluate the opinions of owners regarding veterinary nursing consultations, it is fair to assume that owners would also wish veterinary nurses to listen, educate, provide information and options to them during the process of building a patient caring partnership.
Factors influencing decision making
All decisions can be affected by bias, where there is a tendency towards or prejudice against a specific outcome based on individual beliefs or experiences. It is important that any risk of bias is recognised in the decision-making process, so that any effects can be removed or minimised.
Cognitive bias is a fault in memory or expectations of what will happen and can lead to an increased rate of errors in decision making (McKenzie, 2014). Cognitive bias includes factors such as availability bias (judging the probability of a diagnosis with the ease with which it comes to mind); omission bias (do no harm is better than carrying out an intervention with risk); or confirmation bias (seeking to prove a hypothesis rather than disprove).
Various methods have been suggested to minimise cognitive errors (Arkes, 1981; Fischhoff, 1982: Croskerry, 2003) including the use of checklists (Gawande, 2003; Treadwell et al, 2014), using evidence-based practice guidelines and algorithms. Within veterinary practice, using checklists has been shown to improve patient care and is central to quality improvement (Oxtoby and Mossop, 2016). The development of guidelines within emergency medicine has led to the development of the RECOVER initiative which is now regarded as gold standard for the delivery of cardiopulmonary resuscitation (CPR) (Recover, 2019) from both veterinary nurses and veterinary surgeons. These guidelines remove the time needed for decision making from all parties, carrying out CPR through the provision of algorithms.
While bioethics require that all medical professionals do no harm, the risk-benefit assessment implies that all interventions incorporate a degree of risk. However, this needs to be balanced with the risk of doing nothing. The risk assessment will vary between case and practice. In the emergency clinic, if the patient is about to die, any treatment may be perceived to be of less risk than doing nothing. Within a practice setting, discussions between veterinary nurses, veterinary surgeons and owners need to take place to decide on the way forward in these situations.
Morals, ethics, culture and emotions of owners and veterinary staff also need to be considered when any decision is made. Veterinary staff do have to make and implement decisions that they may not agree with. In these cases, good communication skills are vital, both between owner and staff and within the team itself to avoid any build-up of resentment or tension.
Using frameworks
In order to consolidate these options, Decision Making Frameworks have been developed for more common conditions in human medicine (Sox et al, 2013; General Medical Council, 2019) and some aspects of veterinary medicine (International Renal Interest Society, 2017; Recover, 2019). These can involve qualitative or quantitative information. Algorithms using probability are used in human medicine, but less so in veterinary medicine (Sox et al, 2013). Applying frameworks and algorithms can be helpful if they incorporate current evidence, but they lose sight of the individual. They are unlikely to accommodate the needs of animals with comorbidities and may only be helpful in more straightforward cases. Therefore, in veterinary medicine, there is an argument both for and against the use of algorithms.
It could be argued that the use of frameworks, algorithms or SOPs can allow for a level of consistency to be applied across a practice. However, they rely on the evidence being available and then evaluated accurately. Within human medicine, frameworks are continuously re-evaluated and updated (Cochrane Library, 2019). What is defined as the best care for a patient one year, may not be the best a year later. Within veterinary nursing, evidence is gradually becoming increasingly available (Dean et al, 2015; Veterinary Evidence, 2019) through publications such as The Veterinary Nurse. However, historically, clinical research depended on large sample size and a reliance on p values. In recent years, this has been challenged with the claim that a p value only focuses on the statistically significant differences between the groups being studied and does not focus on the clinical importance of the results (Jeffery, 2015). This needs to be taken into consideration when reviewing literature to form an evidence base for practice.
The Royal College of Veterinary Surgeons (RCVS) (2018) Practice Standards Scheme requires that SOPs are put in place when working with more common conditions, and also that all staff within the practice are aware of them. However, the way in which these SOPs are developed is up to the practice and therefore may be different from one clinic to the next. Within human medicine, SOPs are commonplace but are developed on a national scale (National Institute for Health and Care Excellence (NICE), 2019). Corporate practice will allow more consistency across the country but there will still be differences in approach between practices. It is important within veterinary practice that the development of SOPs relies on clearly defined decision-making processes, making use of all available evidence, and that there is an awareness of the problems of bias, heuristics and emotions that can influence final decisions.
Conclusion
Decision making is influenced by many different factors (Figure 2). Making decisions about care is an important aspect of veterinary nursing; the ways in which decisions are made about any case should be thoroughly evaluated in order to make use of best evidence and avoid bias, and it is important that enough time is allowed to consider them all.
KEY POINTS
- Decision making can be divided into System 1 and System 2 processes.
- System 1 decisions involve experience and emotions and are made quickly.
- System 2 decisions take time and involve consideration of all influencing factors.
- The decision-making process can be described as paternalistic, guardian or shared.
- Decisions can be affected by bias, emotions, morals and ethics.
- Evidence-based nursing should be implemented when making decisions.