Affective and cognitive influences on decision making in healthcare

Diagnostic error makes a substantial contribution to harmful or potentially harmful events in emergency care. While there is knowledge about some of the cognitive thought processes involved in diagnostic decision making, little is known about the role that affect plays in diagnostic judgements, despite research outside healthcare suggesting that decisions involving risk and uncertainty are sometimes driven by affect-based, rather than cognitive-based (rational thinking) features. The aim of this research was to identify some of the affective influences in the diagnostic decision making process and to explore the role that affect played in diagnostic judgement. The narrative review in Chapter 2 uses psychological dual process theories as a theoretical framework to bring together literatures from within and outside healthcare to explain the potential role of affect in diagnostic decision making. The review provides examples of how theory and empirical evidence is relevant to diagnostic decision making and highlights the current gaps in knowledge. The epistemological underpinnings of methodological approaches adopted in the empirical studies, definition of key concepts and justification of research methods and measures are discussed in the following chapter. Studies 1 - 3 present the results of online experimental studies (two pilot studies with doctors and medical students and one main study with 77 doctors across two NHS Hospital Trusts). These drew upon the distinct diagnostic stage of information gathering in order to try and identify whether types (mood, anticipatory affect, anticipated affect) and positive and negative sources (patient factors, team factors, previous experience) of affect influenced clinicians’ decision-making for diagnosis. Findings suggested that affect may influence thoroughness and order of information gathered for diagnosis. Team factors appeared to evoke the most intense affective reactions and specific emotions were identified as being potentially important in diagnostic decision making. Study 4 used clinical simulation to explore differences in perceptions of affect and whether affect played a role in the perceptions of factors critical for effective clinical decision making during critical incidents in 54 healthcare professionals (27 junior doctors and 27 nurses or allied health professions). Findings indicated that both individual and social affect were associated with perceptions of clinical performance and suggested that the two groups of healthcare professionals focused on different affective cues. Cooperation was an important predictor of perceptions of individual and team communication behaviour and team effectiveness for both professional groups. Sixteen semi-structured interviews with doctors working in Accident and Emergency or Anaesthetic departments in two NHS Hospital were conducted in Study 5. Critical Decision Method and the analytic strategy of Framework Approach were used to interrogate the affective features in diagnostic and case management decision making during incidents in emergency care. Eight sources and 5 types of affect were identified and both positive and negative emotions featured in diagnostic and case management decisions. Doctors discussed how affect informed and motivated decisions and also how the intensity of affect, the lack of affect as a conscious process and the rational processes involved in clinical decision making meant that it was not always perceived to play a role. The thesis identified sources and types of affect that feature in diagnostic decision making and findings suggest that affect does influence diagnostic judgements. The thesis concludes by discussing the implications and recommendations for clinical practice and future research.