For the past week, Cape Town firefighters have relentlessly been battling fires across the city and it appears that every hour on the news there is another fire to manage. It’s been said that every fire is different, so have you ever wondered how firefighters decide on the best course of action with so many variables and very little time to exhaust all the possible options and outcomes?
In the late 70’s Gary Klein explored the above question. One of his first discoveries was that the laboratory models of decision-making were not sufficient for the conditions that firefighters work in. Furthermore during interviews many firefighters were unable to explain how they reached their conclusions and some experienced firefighters stated that they’ve never made any decisions. This led to some fieldwork observing the firefighters and conducting post-incident interviews to explore whether and how firefighters make decisions. The findings and further work on decision-making resulted in the Recognition Primed Decision-making model (RPD), naturalistic decision-making and recently the shadowbox concept.
Initially Klein hypothesized that firefighters narrow their options to two and then choose the best option of these. Findings demonstrated that 80-90% of the firefighters used the same RPD strategy to decide: They would only generate one option based on cues in the environment. Once they’ve selected their option, they would mentally imagine the next step e.g. how the fire are likely to spread, which houses are likely to collapse and then act on that.
Klein discovered that in high-stress, uncertain situations the level of expertise of the decision-maker plays a major role. Decision-making are based on tacit knowledge where the ‘new’ situation contains something familiar or a cue that allows the decision-maker to act on a ‘prototype’ of what worked before. Experienced firefighters can thus rapidly match current situation to past pattern and literally instantaneously and seemingly intuitively know what to do.
As an example, Klein refers to an interview where firefighters had to enter a house that was on fire. Within seconds the commander ordered everyone to leave the house, literally as the last firefighter escaped, the floor collapsed. In retrospect, the commander explained that the fire was too quiet and that was unusual, he also felt that his ears were too hot. The combination of these impressions prompted the reaction. At the time he didn’t know what was wrong, but he knew something was amiss. It turned out that the heart of the fire was not on the first floor where they entered, it was in the basement that they didn’t know about. If the commander didn’t pick up on the subtle cues, the entire team could’ve been killed.
Because fires grow exponentially, the faster the firefighter can react, the more likely it is that the fire can be contained. It was found that in these situations, the decision-maker opts for the first workable idea and not necessarily the best option (satisficing). It should be mentioned that experienced decision-makers are very likely to generate a plausible first option. Laboratory decision models that require comprehensive evaluation and multiple options are simply not feasible as the fire would be out of control by the time a decision has been taken. It’s thus unlikely that reflective deliberation is the key to successful decisions whilst firefighting.
All of the above was described in the Recognition Primed Decision model (RPD). In the RPD model, a suitable reaction is immediately considered and recognized. RDP relies on the intuitive pattern finding, where people use their experience to match the situation to patterns that they have learned. This is followed by conscious analysis in the form of visualizing or mental simulation to ‘test’ the option. Both intuitive pattern finding and conscious analysis are required. According to the RPD model it becomes a cycle where the decision-maker creates a mental picture of what a reasonable solution looks like, the actions required to reach the ideal outcome and then mentally evaluates the effects of the action.
These findings have been replicated in other environments including military command and control, management of offshore oil installations and neonatal critical care nurses. These environments are all dynamic, constantly shifting, outcomes are uncertain and decisions are time-critical.
I think that the RDP model enforces the importance of tacit knowledge in high stress environments. This is knowledge that is deeply rooted, often people are not aware of the extent of their knowledge e.g. firefighters saying that they don’t make decisions. Tacit knowledge is the know-how that is not contained in the procedure manuals or policies. It is what allows people to perform tasks and provide local knowledge without focused attention. There is only one way to obtain tacit knowledge and that is through experience, and preferably this experience should be guided by an experienced mentor. Sadly tacit knowledge is lost when experienced people leave an organization or industry.
Emergency care is an industry in which tacit knowledge is really important. Even just driving an ambulance into some neighborhoods requires tacit and local knowledge. Rapid and effective decisions are required prehospital, during major incidents and in overcrowded emergency centers. In these situations the decision-making density is high; decisions are made amidst constant, dynamic change. The information available to the decision-maker is incomplete, ambiguous or not available. Decisions are often required within seconds rather than minutes.
The RPD has two preconditions namely
1) There needs to be adequate cues in the environment to assist the decision maker
2) The opportunity in an environment to learn from the cues as it takes time to reach the point of expertise to make these decisions
These preconditions can be used as pointers on how to improve decision-making in emergency care situations. The first is building a repertoire of patterns that will assist decision-making. A great method that is used clinically is simulation training; this could and should be extended to operational decisions during crises situations. In the prehospital environment this is already well-established during training.
The other precondition is the one that I think emergency care and greater healthcare industry often disregards: tacit knowledge. It takes time to build adequate experience which allows good decisions. Consider the vast amount of nurses, paramedics and firefighters that has left the industry in the past ten years, I daresay that the industry disregards the expertise that comes with 20 – 30 years of hands-on experience in the field. These experts are not only leaving because of better salaries, but it’s for better work conditions, opportunities, career progression and to feel acknowledged. Tacit knowledge should be aggressively guarded by the industry!
Novices see only what is there; experts can see what is not there – Klein
Read more by searching for any work by Gary Klein including his work on macro cognition; sources of power, gaining insights, naturalistic decision-making and sense-making