Cognitive and implicit biases in nurses' judgment and decision-making: A scoping review

BACKGROUND

Cognitive and implicit biases of healthcare providers can lead to adverse events in healthcare and have been identified as a patient safety concern. Most research on the impact of these systematic errors in judgment has been focused on diagnostic decision-making, primarily by physicians. As the largest component of the workforce, nurses make numerous decisions that affect patient outcomes; however, literature on nurses' clinical judgment often overlooks the potential impact of bias on these decisions. The aim of this study was to map the evidence and key concepts related to bias in nurses' judgment and decision-making, including interventions to correct or overcome these biases.

METHODS

We conducted a scoping review using Joanna Briggs methodology. In November 2020 we searched CINAHL, PsychInfo, and PubMed databases to identify relevant literature. Inclusion criteria were primary research about nurses' bias; evidence of a nursing decision or action; and English language. No date or geographic limitations were set.

RESULTS

We found 77 items that met the inclusion criteria. Over half of these items were published in the last 12 years. Most research focused on implicit biases related to racial/ethnic identity, obesity, and gender; other articles examined confirmation, attribution, anchoring, and hindsight biases. Some articles examined heuristics and were included if they described the process of, and the problems with, nurse decision-making. Only 5 studies tested interventions to overcome or correct biases. 61 of the studies relied on vignettes, surveys, or recall methods, rather than examining real-world nursing practice. This could be a serious oversight because contextual factors such as cognitive load, which have a significant impact on judgment and decision-making, are not necessarily captured with vignette or survey studies. Furthermore, survey and vignette studies make it difficult to quantify the impact of these biases in the healthcare system.

CONCLUSIONS

Given the serious effects that bias has on nurses' clinical judgment, and thereby patient outcomes, a concerted, systematic effort to identify and test debiasing strategies in real-world nursing settings is needed.

TWEETABLE ABSTRACT

Bias affects nurses' clinical judgment - we need to know how to fix it.

Thinking in Black and White: Conscious thought increases racially biased judgments through biased face memory

It is a common research finding that conscious thought helps people to avoid racial discrimination. These three experiments, however, illustrate that conscious thought may increase biased face memory, which leads to increased judgment bias (i.e., preferring White to Black individuals). In Experiments 1 and 2, university students formed impressions of Black and White housemate candidates. They judged the candidates either immediately (immediate decision condition), thought about their judgments for a few minutes (conscious thought condition), or performed an unrelated task for a few minutes (unconscious thought condition). Conscious thinkers and immediate decision-makers showed a stronger face memory bias than unconscious thinkers, and this mediated increased judgment bias, although not all results were significant. Experiment 3 used a new, different paradigm and showed that a Black male was remembered as darker after a period of conscious thought than after a period of unconscious thought. Implications for racial prejudice are discussed.

Cognitive bias in workplace investigation: Problems, perspectives and proposed solutions

Psychological research demonstrates how our perceptions and cognitions are affected by context, motivation, expectation, and experience. A mounting body of research has revealed the many sources of bias that affect the judgments of experts as they execute their work. Professionals in such fields as forensic science, intelligence analysis, criminal investigation, medical and judicial decision-making find themselves at an inflection point where past professional practices are being questioned and new approaches developed. Workplace investigation is a professional domain that is in many ways analogous to the aforementioned decision-making environments. Yet, workplace investigation is also unique, as the sources, magnitude, and direction of bias are specific to workplace environments. The workplace investigation literature does not comprehensively address the many ways that the workings of honest investigators' minds may be biased when collecting evidence and/or rendering judgments; nor does the literature offer a set of strategies to address such happenings. The current paper is the first to offer a comprehensive overview of the important issue of cognitive bias in workplace investigation. In it I discuss the abilities and limitations of human cognition, provide a framework of sources of bias, as well as, offer suggestions for bias mitigation in the investigation process.

Adolescent and adult drivers' mobile phone use while driving with different interlocutors

PURPOSE

We examined the frequency of adolescents' and their parents' mobile phone use while driving (MPUWD) in the context of their peer and parent-child interlocutors (i.e., communication partners), considering individual differences in perceived risk and symptoms of technology addiction.

METHODS

Ninety-four participants (47 parent-adolescent dyads) completed a survey battery measuring their symptoms of technology addiction, perceived risk of MPUWD, and MPUWD with family members and with their peers as assessed via the proportion of trips when drivers used a mobile phone to communicate.

RESULTS

For both adolescents and their parents across both types of interlocutors (parent-child, peer), stronger risk perceptions were associated with less MPUWD, and stronger symptoms of technology addiction were associated with more MPUWD. A three-way interaction among technology addiction, interlocutor (parent-child, peer), and driver (parent, adolescent) was observed. For adolescents, the association between technology addiction and MPUWD was significantly stronger for MPUWD with their peers than it was for their MPUWD with their parents; this association was not observed for parents. Parents engaged in MPUWD with their children as frequently as adolescents engaged in MPUWD with their peers.

CONCLUSIONS

Symptoms of technology addiction play a stronger role for adolescents' MPUWD with their peers than it does for adolescents' MPUWD with their parents. These and other driver-by-interlocutor interactions should be considered in future research on distracted driving and in prevention efforts.

People's perspectives about COVID-19 vaccination certificate: Findings from a representative Italian sample

In Italy, like in other countries, issues still exist regarding how to reach high vaccine coverage and several countries have considered policies to increase vaccine uptake. In the present study, we focused on people who have a favorable attitude towards vaccination. In March-April 2021, we asked a representative sample of Italian participants (N = 1,530) to assess to what extent they would support the adoption of a COVID-19 vaccination certificate, excluding unvaccinated people from participating in public and cultural events. Furthermore, as the vaccination coverage increases, severe forms of COVID-19 requiring hospitalization more likely involve unvaccinated individuals, who might be perceived as those who don't contribute to ending the pandemic and who constitute a significant health cost for society. We then asked participants to assess to what extent they would favor the idea of requiring people who refuse the vaccine to pay for their own medical expenses in case of hospitalization. We hypothesized that support for the adoption of the vaccination certificate would be predicted by the COVID-19 vaccination status (received, booked, high-, medium-, low-willingness to be vaccinated, or refused) and by the same factors that are known to affect the willingness to get vaccinated. These factors were also tested in a model aimed at investigating if a vaccinated person would favor a measure requiring the unvaccinated individuals to pay for medical expenses. Results confirmed that the support towards the vaccination certificate policy was strongly predicted by the vaccination status and by factors known to affect the willingness to get vaccinated. Interestingly (and surprisingly), a similar pattern was observed for the support of the policy about medical expenses. In conclusion, support for a COVID-19 vaccination certificate was high among the Italian population in the early phases of the vaccination rollout. The findings are discussed considering potential policies to tackle the pandemic.

Social Cognitive Processes Underlying Normative Misperception of Sexual Judgments

Acquaintance-initiated sexually aggressive behavior (SAB) is a widespread problem on college campuses, and intervention strategies thus far have not produced sustained reductions in SAB. Peer-related social norms and cognitive processes underlying sexual decision-making have separately been implicated in SAB. The present study integrates this work by examining the effect of perspective (self vs. typical college male referent) on college men's judgments of the justifiability of unwanted sexual advances, determining the cognitive processes underlying men's misperceptions, and evaluating rape-supportive attitudes (RSA) as a correlate of the implicated processes. College men attracted to women (n = 217) completed the Heterosocial Perception Survey-Revised, in which they judged the justifiability of a man's increasingly intimate sexual advances as a woman responds increasingly negatively. Participants completed the Heterosocial Perception Survey-Revised from their own perspective and from the typical college male perspective. Participants also completed questionnaires assessing RSA and demographics. Undergraduate men, and particularly those endorsing more RSA, greatly overestimated how much the typical college male perceives increasingly nonconsensual behavior as justified. Three cognitive processes were strongly implicated in this misperception. When responding from the self-perspective, RSA correlated significantly with all cognitive processes. These findings illustrate the utility of integrating work on social norms and cognitive processing to document the global effect of perspective on average justifiability ratings and the perspective effect on cognitive processes underlying the ratings. Future work should evaluate personalized normative feedback and cognitive-training approaches to target misperceptions of peers' sexual judgments, given the well-established relation between sexual misperception and SAB risk.

Blinded by our sight: Understanding the prominence of visual information in judgments of competence and performance

Visual information often quickly dominates people's judgments of others' competence and performance, including in the selection of leaders and decision makers. Reviewing recent research on static and dynamic visual cues, we discuss how people extrapolate judgments of competence and performance from visual information. We highlight how these two streams of research contribute to understanding performance perceptions and offer future avenues for research integrating the consideration of both static and dynamic visual cues.

Informal versus formal judgment of statistical models: The case of normality assumptions

Researchers sometimes use informal judgment for statistical model diagnostics and assumption checking. Informal judgment might seem more desirable than formal judgment because of a paradox: Formal hypothesis tests of assumptions appear to become less useful as sample size increases. We suggest that this paradox can be resolved by evaluating both formal and informal statistical judgment via a simplified signal detection framework. In 4 studies, we used this approach to compare informal judgments of normality diagnostic graphs (histograms, Q-Q plots, and P-P plots) to the performance of several formal tests (Shapiro-Wilk test, Kolmogorov-Smirnov test, etc.). Participants judged whether or not graphs of sample data came from a normal population (Experiments 1-2) or whether or not from a population close enough to normal for a parametric test to be more powerful than a nonparametric one (Experiments 3-4). Across all experiments, participants' informal judgments showed lower discriminability than did formal hypothesis tests. This pattern occurred even after participants were given 400 training trials with feedback, a financial incentive, and ecologically valid distribution shapes. The discriminability advantage of formal normality tests led to slightly more powerful follow-up tests (parametric vs. nonparametric). Overall, the framework used here suggests that formal model diagnostics may be more desirable than informal ones.

Estimation of factorial expressions and its improvement through calibration: A replication and extension of Tversky and Kahneman (1973)

Fifty years ago, Tversky and Kahneman (Cognitive Psychology, 5[2], 207-232, 1973) reported that people's speeded estimations of 8 × 7 × 6 × 5 × 4 × 3 × 2 × 1 were notably higher than their estimations for the equivalent expression in the opposite order, 1 × 2 × 3 × 4 × 5 × 6 × 7 × 8 (Median = 2,250 vs. 512, respectively). On top of this order effect, both groups grossly underestimated the correct value (40,320). The differential effect of the two orders on estimation has become famous as an early demonstration of the anchoring effect, where people's judgments under uncertainty are unduly influenced by an initial reference point (or "anchor"). Despite this fame, to the best of our knowledge, this effect has never been replicated. In a sample of 253 U.S. adults, the current study provides the first replication of this foundational example of anchoring. It extends this effect for the first time to a within-participants design, revealing its relative robustness even among participants who see the descending order first. Drawing on procedures from the mathematical cognition literature, it shows how the anchoring effect can be mitigated: calibrating to the correct value of 6! reduces this effect, and calibrating to 10! eliminates it altogether. An individual differences analysis measures the arithmetic fluency of participants and their accuracy on a new estimation assessment, and finds that higher estimation ability may be a "protective factor" against some anchoring effects. These findings affirm the anchoring effect of Tversky and Kahneman (1973, Study 6) while suggesting that calibration may be an effective strategy for helping to improve people's estimation of superlinear functions that are important in real-life contexts.

The less-is-better effect: a developmental perspective

The less-is-better effect emerges when an option of lesser quantitative value is preferred or overvalued relative to a quantitively greater alternative (e.g., 24-piece dinnerware set > 24-piece dinnerware set with 16 additional broken dishes; Hsee, 1998, Journal of Behavioral Decision Making, 11, 107-121). This decisional bias emerges when the option of lesser quantitative value is perceived as qualitatively better (e.g., smaller set of intact dishes > larger set of partially broken dishes). Interestingly, this effect emerges for adult humans when options are evaluated separately but dissipates when options are considered simultaneously. The less-is-better bias has been attributed to the evaluability hypothesis: individuals judge objects on the basis of easy-to-evaluate attributes when judged in isolation, such as the brokenness of items within a set, yet shift to quantitative information when evaluated jointly, such as the overall number of dishes. This bias emerges for adult humans and chimpanzees in a variety of experimental settings but has not yet been evaluated among children. In the current study, we presented a joint evaluation task (larger yet qualitatively inferior option vs. smaller yet qualitatively superior option) to children aged 3 to 9 years old to better understand the developmental trajectory of the less-is-better effect. Children demonstrated the bias across all choice trials, preferring an objectively smaller set relative to a larger yet qualitatively poorer alternative. These developmental findings suggest that young children rely upon salient features of a set to guide decision-making under joint evaluation versus more objective attributes such as quantity/value.

Individual Differences in Judgment and Decision-Making: Novel Predictors of Counterproductive Work Behavior

The current paper proposed individual differences in judgment and decision-making (JDM)-namely, the skill associated with recognizing social norms, decision-making styles, and risk-benefit perceptions-as a novel set of predictors of counterproductive work behavior (CWB). We hypothesized that the skill associated with recognizing social norms, rational decision-making style, and perceived riskiness of unethical behavior would be related negatively to CWB, whereas the avoidant decision-making style, spontaneous decision-making style, and perceived benefits of unethical behavior would be related positively to CWB. Moreover, we hypothesized that JDM-focused individual differences would exhibit incremental validity above and beyond the traditional individual difference predictors of CWB (personality, trait affect, and cognitive ability). Results from three independent samples provided strong support for the hypotheses. The strongest predictor of CWB was individual differences in perceived benefits of unethical behavior (meta-analytic correlation across the three samples = .487). This result suggests a simple insight, yet one almost completely missing from the existing CWB literature: People who believe unethical behavior is likely to benefit them will tend to enact more CWB than those who do not. Additionally, across the three samples, the novel JDM-focused individual difference predictors performed well in comparison to the traditional individual difference predictors, suggesting their usefulness to research and practice. We therefore suggest several avenues for future research on JDM-focused individual differences as predictors of CWB. Additionally, vis-à-vis practical implications, we discuss the possibility of using JDM-focused individual differences in employee selection and organizational intervention contexts with the aim of reducing CWB.