How smart health leaders make intuitive decisions

Abstract

A rational decision-making process enables a leader to process information clearly and logically and thus allows for accurate perception and interpretation of the event. It is believed this process prevents leaders from excessively distorting reality and being impacted by cognitive biases, both of which are possible, particularly under stressful conditions. But what happens when the decision-making environment is rapidly changing and the leader does not have time to deploy a thorough, comprehensive rational decision-making process? In time-compressed decision-making environments, leaders must often make quick, accurate decisions, with incomplete, inaccurate, or rapidly changing information, under extremely stressful conditions. To improve the ability of a leader to make high-stress, time-compressed decisions under rapidly changing conditions, we offer the intuitive decision-making process as an alternative to rational decision-making and discuss five components essential to improve intuitive decision-making outcomes.

Introduction

Conventional decision-making science teaches rational decisions are made when leaders use a purposeful, conscious, fact-gathering process. It is theorized that better leadership decisions are made without emotions being involved because emotions impede good decision-making. The more objective and rigorous the thinking processes are, the better the decisions will be. Historically, scholars and practitioners have agreed that the best decisions were made using a conscious, purposeful, rational process. A rational decision-making method enables leaders to process information clearly and logically and thus allows for an accurate perception and interpretation of the event.^1-3 It has been argued that decision-makers use rational skills to prevent them from excessively distorting reality, a possibility particularly likely under stressful conditions.

But what happens when the leadership decision-making environment is rapidly changing and the decision-maker does not have time to deploy a comprehensive rational decision-making process? As an example, this is often the environment faced by trauma response team leaders where few details may be known about the patient’s mechanism of injury, extent of injuries, medical history, medications, allergies, and so on. The team leader must manage the trauma patient, often in rapid decline, with little time to complete a comprehensive, rational analysis of facts and data.

In time-compressed decision-making environments, a trauma response team leader must often make quick decisions with incomplete, inaccurate, or rapidly changing information, under extremely stressful conditions. The ability to prevent a catastrophic patient outcome depends on knowledgeable and experienced subject matter experts making accurate, effective, and timely decisions.

In order to better understand how rational decision-making impedes and how intuitive decision-making facilitates high-stress, high-consequence, time-compressed leadership decision-making, it is valuable to first understand the traditional (rational) decision-making process. The traditional decision-making process relies on reasoning ability, typically associated with complex problem-solving and consists of gathering information, calling up relevant knowledge (explicit and implied), making calculated observations about the situation, and processing multiple alternative solution options, often weighted to some pre-established criteria.⁴ Rational decision-making employs a standard technique for problem-solving that typically involves a five to seven step linear process.

Trauma response team leaders know when conditions are changing rapidly, there often isn’t enough time to deploy all the steps in a rational decision-making process. Fortunately, there is an alternative to the traditional decision-making process known as naturalistic decision-making where expert-level practitioners can use their recognition of previous training and experiences to help drive intuitive decision-making.

The recognition-primed decision-making model

The basis for making intuitive decisions resides in the ability of the leader to make rapid assessments of conditions and to draw upon their stored knowledge to drive decisions. This model of decision-making, known as the recognition-primed decision-making model, was first uncovered while researching how fireground commanders used their training and experience to make quick decisions on emergency scenes without completing a comprehensive analysis of options for purposes of comparison. The research revealed fireground commanders typically make critical decisions in thirty seconds or less and they rarely compare the merits of alternative actions. Rather, they used their training and experience to identify a workable course of action as the first one they considered. When it was necessary to evaluate several decision options, fireground commanders conducted mental simulations to visualize the outcome of their option prior to making a decision and implementing their action plan.⁵ The researchers argued recognition-primed decision-making was faster than analytical approaches because it relied on memory and recognition of past training and experiences to get an immediate sense of what was happening and the action to be taken.

Trauma response team leaders work in naturalistic decision-making environments where the fast-pace, high-stress, high-consequence, rapidly changing, uncertain conditions drive a need for them to make quick decisions. These conditions are ideal for making recognition-primed decisions. As noted from the research with fireground commanders, it is better for a leader to make a good decision quickly and prepare to execute it well rather than to agonize over a perfect choice that comes too late.⁶ Oftentimes a leader may not know what the best choice was until after the fact, and the quest for an ideal decision option can drive the leader to obsess over inconsequential, incomplete, or missing details.

Five components essential to making effective intuitive decisions

There are five components essential to making effective intuitive decisions: information, situational awareness, self-efficacy, tacit knowledge, and mental modelling.

Information

While operating in time-compressed decision-making environments, it is often impractical for leaders to wait for complete and accurate information prior to making critical decisions. While conditions are changing rapidly, these leaders must be able to quickly process a limited amount of information, draw on their experience, make some reasonable assumptions, rely on their intuition, make a decision, and implement an action. For example, in a trauma response, the difference between life and death for the patient in decline is measured in seconds and minutes, not hours.

When uncertainty abounds, stakes are high and there is a very short time period in which to operate, potential consequences of decisions can be very difficult to fully evaluate prior to making a decision.^1,7,8 Rather, leaders should gather a reasonable amount of data and rely on their experience and intuition to fill in the unknowns. The need to rely on intuitive processes becomes even more important while operating under rapidly changing conditions where uncertainty abounds. For example, United States Marines Corps official doctrine recognizes the importance of using intuition as an important tool on the battleground noting the use of intuition as being vitally important to help officers make decisions in the rapidly changing conditions of war where time compression and the uncertainty of conditions are critical factors.⁹

Situational awareness

Situational awareness is achieved from a leader’s ability to perceive and understand what is happening in their environment while being mindful of the passage of time and the speed in which conditions are changing. Once understanding is achieved, the leader then makes predictions about the outcomes of decision options prior to implementation.¹⁰ If the predicted outcome of the leader’s first option is good, they should implement it. If it’s not, the leader should scrap that decision option, pick another, and start the prediction process again. This may go on for several iterations until a viable option is identified and implemented.

A growing body of research indicates that in real-world environments, experts make decisions using a holistic process involving situation recognition and pattern matching to memory structures to make rapid decisions.^5,6,11 Within this framework, a leader’s situational awareness, and internal conceptualization of the current situation, becomes the driving factor in their decision-making process.¹⁰ Strong situational awareness is the foundation for good decision-making.

Self-efficacy

Self-efficacy is the degree of self-confidence a leader possesses that allows them to believe they can handle the uniqueness of a challenging situation. It is the belief that they know they are doing the right thing that enables the leader to trust their intuition and to act on it. Training and past experience dealing with similar situations helps build the leader’s self-efficacy—their sense of confidence—and their level of comfort acting on an intuition-based decision.¹² Self-efficacy does not focus on the specific job-related skills the leader possesses, but rather the self-judgment of what the leader can do with their knowledge and skills.

Essentially, self-efficacy refers to a sense of mastery and control the leader feels they have over their environment.² A strong sense of efficacy may foster an overall confidence and positive emotional response, resulting in a more effective decision-making process under stress. This is a critical trait of effective leaders.

Without a high level of self-efficacy, not only may the leader question (and possibly delay) critical decisions, but other team members may also pick up cues of wavering confidence which can decrease fellow team members comfort with the decisions being made. Critical decision-making environments are no place for leaders who lack the confidence to be effective. Oftentimes the situation is progressing or degrading at a pace that will not allow the leader to display uncertainty.

Tacit knowledge

Tacit knowledge can be described as the cumulation of a leader’s lifetime of stored training, experiences, and memories, which are filtered through their perspectives, beliefs, and values. The leader’s experiences and values interact with knowledge stores that are called upon implicitly, and often unspoken, during a decision-making situation. All humans have a tacit knowledge inventory; a reservoir of implicit knowledge (gained through training, experience, and memory) that can be accessed, or made explicit, through intuitive thought processing.¹³

Because tacit knowledge depends so much on the stored experiences of the leader, the best intuitive decision-makers are subject matter experts. Ample research exists that demonstrates subject matter experts routinely make decisions based on tacit knowledge grounded in their stored experiences.^12,14-16

The human brain compresses and stores a person’s experiences and allows them to recall, almost instantly, numerous examples and solution options that may relate to the problem at hand.¹⁷ A leader’s tacit knowledge provides a link between their stored experiences and their working memory that allows them to make estimates about what will happen even though the information being fed into their brain may be incomplete.

Mental modelling

As experience is gained, a leader develops internal models of the systems and environments they operate in. These mental models serve to help direct limited attention in efficient ways, providing a means of integrating information without overloading their working memory.¹⁸ The use of mental modelling in decision-making is considered to be dependent on the leader’s ability to match critical cues and clues in their environment with elements in their existing mental models. It is important in training to develop scenarios that allow leader’s to make intuitive decisions, which means experimentation and tolerating mistakes. Experimentation with ideas should be encouraged and leaders should not be penalized for honest mistakes.¹⁹ Some of this learning may also come from observing and imitating instructors, role models, and peers.

In some work settings, post-incident evaluations, critiques, and simulations can be valuable tools whereby leaders can share their intuitive decision-making processes and allow others to learn from their experiences.²⁰ Sharing experiences can help develop the intuitive decision-making abilities of novice leaders as well. In order to be effective, it is essential for leaders to develop, practice, and share mental modelling skills.

Pros and cons for each decision model

The rational decision-making process, while popular and widely taught in leadership development curriculum, is not flawless. One obvious limitation is that it can consume valuable time that is not always available to the leader. The rational decision-making process may be insufficient for making high-stakes decisions under time pressure and uncertainty.²¹ The deliberation needed to transform a continuous stream of complexity into discrete problems, options, and consequences suitable for analysis consumes scarce time and resources. It also takes a fair amount of data. If there are too many gaps in the analysis, the leader can get stuck. In dynamically changing environments, any analysis that is done may become obsolete by the time it is completed.²¹

Oftentimes, reports provided to leaders can be contradictory, false, or uncertain. So, even if a decision is reached through detailed analysis of factors, the soundness of the decision depends on the correctness and completeness of information. Comparing the uncertainty of healthcare leadership decisions to the unpredictability of wartime decisions, it is impossible to weigh all the relevant factors for even the simplest decisions in war and thus, military leaders rely on intuition to ultimately guide them in effective decision-making.¹⁹

A major disadvantage of intuitive decision-making, as with the rational decision-making process, is that the decision can end up being wrong. A fast and wrong decision made by a leader can simply expedite an undesirable outcome. When an intuitive decision turns out poorly, the credibility of the leader can be impacted if they are unable to document the intuitive thought processes they used to make their decision.²² Healthcare leadership decisions are increasingly being subjected to intense scrutiny and criticism by the public, media, and top administration. Decisions not supported by written proof of sound, rational reasoning processes are likely to be viewed as not credible. The competent healthcare leader is expected to be a rational person, devoid of emotions, and a master of analytical techniques. Decision evaluators may also consider the use of intuition as an irrational approach to making an effective healthcare decision.²³ Critics have characterized intuition as a fragile quality that can be easily undermined by stress, unreliable information or the overbearing pressure to make a rapid decision.

All leadership decisions, rational and intuitive, hold the potential to be influenced by any one of more than fifty cognitive biases that can skew a leader’s thinking and information processing. Since the rational decision-making process is grounded on the use of facts and data to drive decisions, it would be logical to conclude bias can be eliminated. However, even when deploying a rational model for decision-making the leader must assign some weight (or preference) to information. In other words, it would be rare that every piece of incoming information holds the same level of critical importance. Thus, there is some subjectivity employed in rational decision-making as well. Even where computer modelling is used, the programmers had to make judgement calls on the weighted importance of the data being inputted into the software. The greatest advantage to machine-driven decisions is the ability to remove emotions from the process, so long as the decision-maker is willing to accept an automated decision that may run counter to their intuition.

And while rational decision-makers can be negatively impacted by an array of cognitive biases, intuitive decision-makers are especially vulnerable to cognitive biases, such as confirmation bias where a leader may, at a subconscious level, give deference to information that supports the decision they want to make. Likewise, a leader can dismiss or discount information that does not support the decision they want to make.²⁴

Recommendations

This review results in several recommendations beneficial to leaders in healthcare who work in fast-paced, high-stress, ever-changing decision-making roles. Training for leaders should include a module that teaches the intuitive decision-making process and explains the five factors essential to making effective intuitive decisions. Classroom, practical modules, and simulations should be designed to blend the best of rational and intuitive decision-making processes.

Expert-level decision-makers should be encouraged to share, in the moment, what they are feeling about their decision options and why they feel more or less favourable toward particular options. To ensure others know the leader is sharing their intuition, the leader should be encouraged to say, out loud, phrases such as “my gut is telling me” and then articulate what they are feeling—sharing their tacit knowledge. It can, however, be difficult for a leader to put into words why they are having a certain feeling that is driving them toward a decision because the knowledge giving rise to the feeling resides in their subconscious. It is not uncommon for leaders to know what the right decision is, but when pressed for an explanation, their only response may be “I just knew.”

The most effective intuitive decision-makers must develop subject matter expertise. While novices can (and likely will) make intuitive decisions, the accuracy of their decision is more vulnerable due to their lack of tacit knowledge and their lack of stored experiences to prime their recognition of the best action to take. As their collection of stored experiences grows, the more data points of knowledge the leader can draw upon to make intuitive decisions.

A word of caution is advised for leaders relying on their intuition. All humans have subconscious biases and those biases are imbedded in every leader’s tacit knowledge. Leadership training should include explanations for common decision biases and tips for how the leader can counter potential biases.

For example, when two members of a leadership team have a different understanding of what is happening and what action is best for the situation, this should cause them to stop and seek to resolve this difference in understanding. This is commonly referred to as team members lacking shared situational awareness or, more colloquially, the two leadership team members are not on the same page. When this occurs, the leaders should openly discuss what they are seeing, hearing, and feeling. They should be cautious not to simply defer to the leader with the highest authority. Rank does not always make a leader the smartest person in the room. It simply makes the leader the most powerful person in the room. Every leader, regardless of experience or rank, is subject to cognitive biases that can skew perception and understanding.

Because it can be difficult, if not impossible, to articulate in words the basis for the feeling of knowledge, it can be risky for leaders, especially newer leaders, to speak up to their peers and superiors when something doesn’t feel right to them. Highly effective teams build intuitive decision-making into their curriculum, encouraging junior leaders to practice making rational and intuitive decisions and then comparing and contrasting the efficacy of each. Team members should always be encouraged to speak up when there is a concern and everyone on the team, including leaders, should adopt a mindset of inquisitiveness and seek to understand when a team member speaks up and articulates they have a gut feeling, a hunch, or when something just does not feel right to them.

During after-action reviews, leaders should openly discuss both the rational and intuitive decisions they made. This should be done for both successful and unsuccessful outcomes. It can be extremely challenging to teach novice leaders how expert leaders make decisions using intuition because the expertise lies within the subconscious memory of the leader. However, the more the expert decision-maker is willing to share about why they felt something was good or bad, the more a novice can learn about the value of expert knowledge.

Conclusion

In healthcare leadership, there is a place for both rational, evidence-based (explicit knowledge) decision-making and intuitive, feeling-based (tacit-knowledge) decision-making. A rational decision-making process is highly effective when a leader has time to gather, process, analyze, calculate, weight priorities, compare and contrast options, and select the best choice among multiple alternatives. However, in decision-making environments that are high-stress, high-consequence, time-compressed, and with rapidly changing conditions, there simply may not be enough time to use the more comprehensive, time-consuming rational decision-making process. Thus, effective leaders should be knowledgeable of the five components essential for making effective intuitive decisions and develop skills in information gathering, situational awareness, self-efficacy, tacit knowledge, and mental modelling.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Ethical approval

Institutional Review Board approval was not required.

ORCID iD

Richard B. Gasaway

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