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Decision making

Pharmacists have to make professional decisions that often have profound effects on others. This article looks at tools that can aid decision making

Identify gaps in your knowledge
  • Do  you feel confident about making decisions?
  • Why are wrong decisions made?
  • Name two decision making tools
This article relates to the Royal Pharmaceutical Society’s core competencies of “management” and “decision making” (see “Medicines, ethics and practice — a guide for pharmacists”, number 26, July 2002, pp105–6). You should consider how it will be of value to your practice.

No matter which sector of pharmacy you work in, you have to make decisions. As a community pharmacist, you might be faced with a situation where a young woman is making regular purchases of a laxative and you suspect that she is misusing them to lose weight. You have several options, including not taking any action, but deciding which option is best may be difficult. For example, will you not sell the young woman any more laxatives? And is that a decision you want to enforce by yourself or will you expect pharmacy assistants to refuse future requests? Or would it be easier not to stock those laxatives in your pharmacy? And should you refer the young woman to another professional for help?

As a hospital pharmacist, you might have to decide whether to supply a patient with repeat medicines that are not on your formulary or to substitute them with drugs that are. At some point in your professional career, you could be faced with having to decide whether a doctor has made a prescribing error and how to handle this. Clinical pharmacists will to some extent soon have to make their own prescribing decisions.

As an industrial pharmacist you might have to decide whether or not it is worth continuing with a clinical trial programme, whether or not a product will have a competitive edge or if a marketing strategy concords with the Association of the British Pharmaceutical Industry’s code of conduct.

As a pharmacy proprietor, you will be faced with other decisions that could have serious consequences on your business or even your lifestyle. For example, should you introduce a new service to your pharmacy?

By definition, a decision involves choice and therein lies the difficulty — making the right choice. Faced with choices and being unclear about which to make can be stressful. Indecisiveness can be detrimental because it leads to inaction and, moreover, vulnerability to other people’s decisions; neither is over-analysing options the answer because that leads to a syndrome known as “paralysis by analysis” — inaction caused by too much thinking. The ideal situation is somewhere between the two extremes: not being too quick to make a decision and investing some thought into which option will produce the best possible outcome.

Decision types, risks and uncertainty

Most decisions will involve more than two possible outcomes with different levels of importance, value and risk, but they can be classified into two basic types: selective and creative. Selective decisions are perhaps easier to make because solutions already exist and the decision involves selecting one from a choice of many. Creative decisions require more effort because the solutions have yet to be generated. Sound decisions are those based on information gathered, received and analysed. In contrast, decisions based on intuition or emotion are high risk and often lead to disastrous consequences. Wrong decisions are made because they are often:

  • Made in haste
  • Made without consultation
  • Over-analysed
  • Based on past experiences rather than new situations
  • Based on other people’s decisions

Good decision making involves:

  • Defining the issue
  • Gathering information
  • Generating choices
  • Identifying and evaluating alternatives
  • Choosing the best alternative

Decision making inevitably involves risk because, frequently, outcomes cannot be guaranteed. It is often the unknown consequences of a decision that create stress and, sometimes, panic. If you are feeling pressured to make a decision, inaction can be avoided by first setting a deadline for making the decision and sticking to it. Uncertainty can be minimised by considering as many outcomes as possible in the available time, analysing the consequences of different decisions and gathering relevant information. If it emerges that one option yields an unacceptable degree of uncertainty, rule that option out.

Risk analysis can be undertaken using complex mathematical tools but many pharmacists will not have the time to implement structured mathematical strategies. However, at the very least, some acknowledgement of risk will prompt decision makers to make contingency plans.

Stakeholders

When decisions involve serious risks you should always identify the stakeholders who will be affected. If possible, you need to find out whether or not your decision will be acceptable to them and consider how you can involve them in the decision-making process. For example a decision over whether to expand your business might involve stakeholders such as your staff, patients, suppliers, local prescribers and your primary care trust.

Persuasive communication can be used to involve stakeholders in decision making, communicate sensitivity to their views, outline the benefits of your choice for them and, if resistance occurs, to convince them that their views have been taken into consideration.

Decision-making tools

When you are faced with a complex decision or a decision that involves high risk or serious implications for others, you may find it useful to use decision-making tools. As mentioned before, there are various mathematical and computerised tools you can use, but here are a few paper-based tools that many professionals regularly use with success.

Plus/minus/interesting Edward de Bono enhanced the pros and cons technique often used in decision making by developing the “plus/minus/interesting” tool. The pros and cons technique is basically a two column list of reasons for (“pros”) and against (“cons”) a particular decision. The idea is that once you have listed all the pros and cons you make the decision with the most pros.

The plus/minus/interesting technique involves using three columns: plus, minus and interesting to make the decision. In the “plus” column you list benefits or anything you feel positive about. In the “minus” column you list all the negatives and in the “interesting” column anything that is “neutral” (ie, not necessarily a positive or a negative). For fairly simple situations, once you have filled the columns, the positives and negatives should be clear and you should be able to make a decision. However, for more complex decisions attach a positive or negative score to each item listed in the columns as appropriate. Then simply add up all the scores. The scores you attach are purely subjective and based on what you consider to be the degree of benefit or detriment posed by each item.

Take the case of a newly qualified pharmacist based in Yorkshire faced with a decision over whether or not he should take up a new post in London. Figure 1 shows how the plus/minus/interesting chart for his decision might look. Totalling the score, the pharmacist is left with a negative score (–12) which strongly suggests that he should not move to London.

Figure 1: Example of using the plus/minus/interesting tool
Take up a new post in London?
Plus Minus Interesting 
Better social life

+5

Have to sell house -6Better promotion opportunities+2
Change of scenery+4More pollution -5Meet more people+2

Higher salary

+4

Higher cost of living-6Less disposable income_3
  Can only afford flat not house-4  
  Further away from friends and family-5  
Total score: +13 -26 +1 = -12     

SWOT analysis A SWOT analysis is a useful tool for analysing a business issue from different perspectives. You can use the tool to look at the strengths, weaknesses, opportunities and threats of an option. This ensures that you consider an issue fully rather than being too optimistic or pessimistic. Take the case of a community pharmacist thinking about introducing a new weight management service to her pharmacy. Figure 2 shows how her SWOT analysis might look.

Figure 2: Example of making a SWOT analysis
Introduce a weight management programme? 

STRENGTHS

WEAKNESSES

Obesity is a national problem
Weight management service topical and relevant
Slimming clubs in area—obvious interest in weight
Time needed for additional training— already under pressure meeting current need
More administrative work Increased workload all round

Opportunities

Threats

Increase revenue
Good public relations tool
Meet objectives of local community health strategy
Might not attract sufficient interest
Might not be able to fulfil customerdemands
Competition from slimming clubs
Initial financial outlay required

Six thinking hats “Six thinking hats” is another tool developed by Edward de Bono. This tool forces you to apply six different perspectives (“hats”) to a decision. The thinking hats tool works particularly well when teams are involved in making a decision because each team member can “wear” a different hat and look at a decision from a given perspective. It allows for reason, creativity and emotion to contribute to the decision.

Wearing an analytical (white) hat means looking at factual information (eg, statistics, data) and drawing conclusions from it by looking for patterns or trends. You might find that you lack sufficient data and need to do further research in order to come up with a more accurate picture. Going back to our weight management service example, the wearer of the white hat would look at trends for  uptake of weight loss programmes in the area and cost-benefit analyses.

The red hat is the emotionally intelligent hat, useful for trying to feel your way around a decision and taking an emotional perspective. Wearing the red hat could involve looking at weight management from the perspective of an overweight person and understanding what the possible responses to the service could be.

The wearer of the black hat is forced to play devil’s advocate and look at all the negative aspects: why the service might not work, what the problems might be and who might oppose it. This is a useful hat to wear because it allows you to think of a strategy for overcoming opposition or weaknesses.

In contrast to the black hat, the yellow hat is the positive hat, which helps you to see the opportunities and benefits to a particular decision. For example, a weight management service might promote your standing within the community.

The green hat is the creativity hat which helps you to find possible solutions and think through different routes to them. So, if your objective is to help overweight people, this might be achieved in a number of ways. Wearing this hat involves using creative techniques for finding solutions such as brainstorming, mind mapping and role playing. An important rule to remember when using a creative approach to decision making is to allow ideas to flow freely without interruption, leaving evaluation until the very end.

Finally, the blue hat is the directional hat that leaders use to direct thinking through using the other hats.

Grid analysis The tools covered so far can be used to help you to consider one option carefully. However, you often will have to compare several alternatives, each with its own factors to bear in mind. The grid analysis tool allows you to see things clearly. It works by producing two grids with the alternatives in rows and the relevant factors in columns.

For example, a pharmacist might want to prepare for the introduction of pharmacist prescribing, but having researched her options, finds she cannot decide what to do about it. Imagine she has to choose between completing four Centre for Pharmacy Postgraduate Education workshops scattered throughout the year, doing a distance learning pack or attending a week-long course in London. Factors that might be important to her could be cost, time required, the distance she would need to travel, the need to provide cover at her work and how much she will enjoy the course. First the pharmacist would draw up two grids as described above. In the first grid, for each alternative, she rates each factor (eg, 0=poor and 4=very good). For example, the CPPE workshops are free so it scores 4 compared with the weeklong course which costs £200 and scores 0. However, each factor will not be equally significant to her so, in the second grid, the pharmacist rates each factor in terms of importance (eg,1=least important and 5=most important) and then multiplies figures in the first grid using the importance rating for each factor. Figure 3 shows how the grid analysis might look. In the example, the CPPE workshop would be the best choice because it scores the most.

Figure 3: Example of using a grid analysis
How shall I learn about prescribing?     

Grid 1: unweighted assessment

factorsdistancetime neededcostlocum cover?fun 
CPPEworkshops213 
distance learning4 
week-long course11004 

Grid 2: weighted assessment

factorsdistancetime neededcostlocum cover?funtotal
importance?34215 
CPPEworkshops311538
distance learning12 436
week-long course124002027

Living with your decision

More often than not, a quick decision is needed and you will not have time to use the tools in this article. In such situations, you need to be able to answer three questions:

  • Are there any rules or guidelines that I must follow?
  • What are the likely consequences of my decision?
  • How will I justify my decision if asked to?

By default, making a decision implies rejection of at least one option. Rejection of an alternative is something that you as a decision maker have to come to terms with. Once you have made a decision in an appropriate way, stick with it. If necessary, reflect on the positive aspects of your decision and why these influenced your choice. Pharmacists are now working in an environment of accountability, so keep a record of how you came to your decision. In some cases, time may prove that you made the wrong decision. However, turn this into a positive by reflecting on the process you went through in making your decision and identify elements of the process that could have produced a better decision. A checklist for making decisions is suggested in Panel 1.

action : practice points

1. Visit www.mindtools.com/pages/main/newMN_TED.htm and look at other decision making tools such as:

  • Pareto analysis (a tool that helps you to select the most effective changes needed to solve a problem)
  • Decision tree analysis (a tool that takes into account likely outcomes of different options)
  • Paired comparison analysis (a tool that helps you to prioritise your actions)

2. Apply SWOT analyses to the options of continuing your practice just as it is and changing your practice.

3. When you are next faced with a complex decision to make, practise using the plus/minus/interesting analysis, then consider whether it has been useful. What would your decision have been otherwise?

evaluate

How could your learning have been more effective? What will you do now and how will this be achieved?

PANEL 1: DECISION MAKING CHECK LIST

  • l What are the key issues?
  • l How much time do you have; what deadlines do you need to set?
  • l Do you have all the facts/information you need?
  • l Who are the stakeholders, ie, who else will be affected by any decision you make?
  • l Who else do you need to consult?
  • l Are you committing yourself to a long-term decision or will a “stop-gap” solution suffice?
  • l What are the implications of your decision in terms of action?

(adapted from the Time Management Pocketbook)

FURTHER READING

  • Fleming I. Time management pocketbook 4th ed. Hampshire: Management Pocketbooks; 1997.
  • Langdon. K. Smart things to know about decision making. Oxford: Capstone Publishing; 2001.

Citation: The Pharmaceutical Journal URI: 10982031

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