Characterizing a Naturalistic Decision-Making Phenomenon

Abstract

We describe a phenomenon viewed through the conceptual lens of a naturalistic decision making perspective: a loss of system resilience, due to increased difficulty in performing macrocognition functions, associated with the implementation of new information technology. Examples of the phenomenon collected in a targeted literature review are characterized by stakeholder groups, technology, typical changes in workflow before and after implementation, and potential impacts on macrocognition and patient outcomes for four clinical care environments. The loss of system resilience is due to increased difficulty in performing macrocognition functions: 1) sensemaking due to less effective cognitive warm-up and collaborative framing strategies, 2) detecting events due to missing trends in data and changes to orders, and 3) coordinating due to less clinical knowledge during scheduling and updating information, and less effective cross-checks. Potential impacts to patient safety include an increase in unnecessary care, missed care, delays in diagnoses and treatment, redundant care, inaccurate diagnoses, medication errors, and adverse events. We recommended future conceptually-driven research in other complex, sociotechnical settings order to develop useful metrics and reduce the risk of incurring undesirable and unnecessary impacts on cognitive work associated with new technology.

Beyond Adoption: A New Framework for Theorizing and Evaluating Nonadoption, Abandonment, and Challenges to the Scale-Up, Spread, and Sustainability of Health and Care Technologies

“…One final concept, which appears key to organizational adaptation over time but was not explicitly addressed in any of the previous frameworks, is the notion of resilience, defined as “the intrinsic ability of a system to adjust its functioning prior to, during, or following changes and disturbances so that it can sustain required operations, even after a major mishap or in the presence of continued stress” [ 117 ]. Organizational psychologists emphasize the importance of macrocognition: that is, reflecting collectively and continuously about how the organization is responding to change, including ongoing sense making, detecting critical events, and coordinating adaptive actions [ 118 , 119 ]. Introduction of new health care information technology systems can lead to loss of system resilience, since new technologies intended to automate work and assure safety may have the unintended effect of reducing time for collaborative dialogue, masking key trends in data (perhaps through information overload and loss of overview), making work routines brittle, and bypassing clinical judgment [ 118 , 120 ].…”

“…Organizational psychologists emphasize the importance of macrocognition: that is, reflecting collectively and continuously about how the organization is responding to change, including ongoing sense making, detecting critical events, and coordinating adaptive actions [ 118 , 119 ]. Introduction of new health care information technology systems can lead to loss of system resilience, since new technologies intended to automate work and assure safety may have the unintended effect of reducing time for collaborative dialogue, masking key trends in data (perhaps through information overload and loss of overview), making work routines brittle, and bypassing clinical judgment [ 118 , 120 ]. Cho et al have warned that the study of resilience in relation to new technologies requires multilevel analysis and is fraught with paradoxes (eg, that developing resilience in one part of the system may generate brittleness in another) [ 121 ].…”

“…Question 7B concerns organizational resilience, and particularly what May and Finch called “reflexive monitoring” [ 27 ] and Patterson et al called the “macrocognitive functions” of sense making, including in particular the ability to detect critical events or issues and respond to these through coordinated action [ 118 ].…”

The TRUSTS Work System Resilience Framework: A Foundation for Resilience-Aware Development and Transition

“…Little to no attention is given to how the new technology will interact with system characteristics and capabilities that ensure resilience in high demand and nonroutine conditions. As a result, the technology is introduced, and the host work system bears the burden of coping with its limitations; limitations that can include paralyzing forms of dark debt (e.g., Aaronson et al, 2021;Finkelstein & Dowell, 1996;Patterson et al, 2016;Sherwood et al, 2020).…”

Safety Frameworks for Emerging Technologies

“…With time and shared experience in pursuit of common system goals, the new technology and work system co-evolve to form a joint work system. However, critical missions and stakeholders of high-stakes work systems cannot, in the meantime, afford the risks posed and disruptions caused by the bull in their china shop (e.g., Aaronson et al, 2021;Finkelstein & Dowell, 1996;Patterson, Militello, Su, & Sarkar, 2016;Sherwood, Neville, McLean, Walwanis, & Bolton, 2020;Trist & Bamforth, 1951).…”