Education Theory Made Practical: Naturalistic Decision Making

(From the E-i-C: Here are links to the introduction and previous chapter. We need your comments / peer review to make this primer on education theory better.  Please include them in the comments section at the end of each chapter. We will acknowledge your contribution in the forthcoming eBook.)

Naturalistic Decision Making

Authors: Clare Desmond, Josh Kornegay, Jillian Mongelluzzo

Editor: Michael Gottlieb

Naturalistic Decision Making
Main Authors or Originators:

Gary Klein and Judith Orasanu1–4

Other important authors:

Kenneth Hammond – Cognitive Continuum Theory5

Jens Rasmussen – Cognitive Control6

Part 1:  The Hook
Annie is a third-year Emergency Medicine resident on her trauma rotation. There was a gang-related shooting and three new traumas are about to arrive. While she has assisted with trauma procedures and practiced leading trauma resuscitations in the simulation lab, this is her first time leading a trauma resuscitation in real life. When the patients arrive, one has a gunshot wound to the chest, another has a gunshot wound to the abdomen, and a third has one to the leg. The patient with the wound to the chest is hypoxic and in respiratory distress. The abdominal wound is complaining of pain and his blood pressure is low. The leg wound is complaining of pain only.

Annie and her team must figure out how to best approach these patients.


Part 2:  The Core

Naturalistic decision making (NDM) was a theory developed by Gary Klein and Judith Orasanu that attempts to provide a framework for how people make decisions in the cognitively complex, real world environment.3 A central goal of NDM is to identify the cues that experts utilize for making complex decisions.7


Prior to the development of the NDM theory, most decision-making research was performed in a research lab setting. However, Klein and colleagues realized that the artificial setting of the lab may not accurately represent how people make decisions in their everyday lives.

In the research lab, people would typically look at all the options and give each of them equal weight. By observing experts in practice, however, Klein’s group discovered that people approached decisions differently and did not compare all options in an equal and systematic approach as had been seen in the research lab.2 Initial NDM researchers focused on field research of individuals who make decisions in high stakes settings. In 1989, the first NDM conference was held and the foundation of NDM was set.1 NDM researchers discovered that people frequently made decisions based on pattern recognition from previous experiences (i.e. tacit knowledge). Prior experiences help people categorize the current situation and choose a response based upon the category most consistent with the current situation. However, this may not necessarily be the best response when compared with a systematic review and analysis of all possible responses.2

One of the most popular models associated with NDM is the recognition-primed decision model. This model explains why people can make good decisions based on pattern recognition without comparing all the options. Initially, a person would pattern match a situation based on prior experiences. This is followed by a more analytical evaluation of the response, wherein the person mentally simulates the scenario and response. Based upon the simulation, the person will either adapt the response to the current situation or find a new response to fit the current situation.2

Modern takes or advances

Given the number of high stakes, high pressure decision making in medicine, NDM has been increasingly studied in this field.8,9 This theory is of particular importance for Emergency Medicine physicians who must frequently make quick and efficient decisions while simultaneously identifying the critical “no-miss” diagnoses (low frequency, high risk diagnoses). A recent qualitative study using head-mounted video gear by Emergency Physicians found that a physician’s differential diagnosis was primarily created before or within the first 5 minutes of an encounter with a patient, which is consistent with the naturalistic decision making theory.10

Macrocognition, the study of cognitive adaptations to complexity by the individual and the team, has also flourished from NDM.2,11 This theory suggests that experts will use multiple environmental and experiential cues to help identify the “big picture”.11 In the Emergency Department, this would be represented by the more senior Emergency Physician identifying and rapidly narrowing the differential diagnosis, while the more novice trainee might struggle with determining the diagnosis. In high volume or high acuity scenarios, previous mental rehearsal may be valuable for helping clinicians make sense of complex environments, as has been seen in previous studies of critical care medicine.12

Other examples of where this theory might apply in both the classroom & clinical setting

In fields combining high-stakes scenarios with short clinical decision making time, such as during a surgery or in the Emergency Department, NDM will be utilized to make rapid and timely decisions based upon prior knowledge. In the classroom, students may use NDM during various assessment modalities, including OSCEs (objective structured clinical examination) and MCQ (multiple choice question) exams. In understanding how students make decisions, educators can better target approaches to learning and assessments.

Annotated Bibliography of Key Papers

1. Klein G. Naturalistic Decision Making. Human Factors 2008;50(3):456-460.2

This article provides a history of the evolution of NDM. It describes the origin of NMD, growing out of observations that decision makers frequently relied upon prior experiences more than analytic systems when making complex decisions. The authors then discuss the concept of the Recognition-Primed Decision Model, to illustrate the tenets of NDM. The author also compares this with the System 1 and System 2 model of decision making. Finally, the author discusses applications of NDM in a variety of fields, including medicine and the military, while providing a nice flowsheet to simplify the model.

2. Lipshitz R, Klein G, Orasanu J, Salas E. Focus Article: Taking Stock of Naturalistic Decision Making. Journal of Behavioral Decision Making 2001;14:331-352.3

This article is an extensive overview article on the history of NDM, summarizing the research that has been performed since its emergence in the late 1980s. The authors describe how the theory has changed in definition over time and how the various models have contributed to the overall theory. In addition to the history behind the model, the article outlines the essential characteristics and contributions including; recognition-primed decisions, coping with uncertainty, team decision making, decision errors, and methodology. This article also does a good job at illustrating some of the limitations of this decision making theory along with a stepwise approach to overcoming some of these obstacles.

3. Falzer P. Cognitive Schema and Naturalistic Decision Making in Evidence-based Practices. Journal of Biomedical Informatics 2004;37:86-98.8

This paper places NDM firmly in the context of medical decision making. It compares NDM with Classical Decision Theory (CDT) arguing that NDM is better suited for decision-making in the medical arena. The authors highlight this utilizing a mathematical formula to explain the value in this area. Falzer then discusses image theory, providing further support of how NDM could be applied to medical decision making. Finally, the author translates the image theory approach into a four-step process to apply this to clinical decisions and evidence-based practice

4. Kahneman D, Klein G. Conditions for Intuitive Expertise: A Failure to Disagree. American Psychologist 2009;64(6):515-526.7

The article provides a summary of NDM in the context of the heuristics and bias theories. This article summarizes the similarities and differences between two of the major theories of expert decision making. Written by two of the leading authors in each field, this provides background on each of the theories and valuable insights into both theories and their relationship to each other..


Research on NDM is often criticized regarding its validity and methods. Bias is often introduced since the process of decision making is frequently studied using statements and reviewed thoughts from decision makers. Therefore, while there is extensive qualitative data, it is challenging to have quantitative data to support NDM. Additionally, this often contrasts the approach from Kahneman and colleagues, which theorizes that many decisions that involve intuition (i.e. fast thinking) are not as accurate as when analytical (i.e. slow thinking) is utilized.7

Part 3:  The Denouement
Annie uses her previous experience to quickly triage and categorize these patients. The numerous shifts where her attending had emphasized various triage skills with multiple scenarios had primed her to think through and react to this critical situation. She has the trauma team evaluate the abdominal pain to go to the operating room, while she and the emergency team evaluate the chest wound, which requires intubation and a tube thoracostomy. Since she knows that the leg wound is less serious, Annie can focus on the more critical patients to make timely decisions.

Annie reflects after this episode about the importance of experience, whether gained in a real-life or simulated environment. She is grateful for the high-volume exposure she experienced as a junior resident, but also now fully affirms the need to think through and mentally rehearse similar situations prior to an actual occurrence. She considers how she might utilize this experience to benefit others during her upcoming grand rounds lecture.



  1. Mann L. Decision making in action: Models and methods, Klein, G.A., Orasanu, J., Calderwood, R. and Zsambok, C.E. (eds). Norwood, NJ: Ablex, 1993, 480 pp. ISBN 0–89391–794–X (pb). J Behav Decis Mak. 1995;8(3):218-219. doi:10.1002/bdm.3960080307.
  2. Klein G, Associates K, Ara D. Libro Naturalistic Decision Making. Hum Factors. 2008;50(3):456-460. doi:10.1518/001872008X288385.
  3. Lipshitz R, Klein G, Orasanu J, Salas E. Taking stock of naturalistic decision making. J Behav Decis Mak. 2001;14(5):331-352. doi:10.1002/bdm.381.
  4. Patel VL, Kaufman DR, Arocha, JF. Emerging paradigms of cognition in medical decision-making. Journal of Biomedical Informatics. 2002; 35(1): 52-75. doi:10.1016/S1532-0464(02)00009-6.
  5. Hammond KR, Hamm RM, Grassia J, Pearson T. Direct comparison of the efficacy of intuitive and analytical cognition in expert judgment. IEEE Trans Syst Man Cybern. 1987;SMC-17(5):753-770. doi:10.1109/TSMC.1987.6499282.
  6. Rasmussen J. The role of hierarchical knowledge representation in decision making and system management. {IEEE} Trans Syst Man, Cybern. 1985;{SMC-15}(2):234-243.
  7. Kahneman D, Klein G. Conditions for intuitive expertise: a failure to disagree. Am Psychol. 2009;64(6):515-526. doi:10.1037/a0016755.
  8. Falzer PR. Cognitive schema and naturalistic decision making in evidence-based practices. J Biomed Inform. 2004;37(2):86-98. doi:10.1016/j.jbi.2004.02.002.
  9. Cristancho SM, Vanstone M, Lingard L, Lebel ME, Ott M. When surgeons face intraoperative challenges: A naturalistic model of surgical decision making. Am J Surg. 2013;205(2):156-162. doi:10.1016/j.amjsurg.2012.10.005.
  10. Pelaccia T, Tardif J, Triby E, et al. How and when do expert emergency physicians generate and evaluate diagnostic hypotheses? A qualitative study using head-mounted video cued-recall interviews. Ann Emerg Med. 2014;64(6):575-585. doi:10.1016/j.annemergmed.2014.05.003.
  11. Schubert CC, Denmark TK, Crandall B, Grome A, Pappas J. Characterizing novice-expert differences in macrocognition: An exploratory study of cognitive work in the emergency department. Ann Emerg Med. 2013;61(1):96-109. doi:10.1016/j.annemergmed.2012.08.034.
  12. Fackler JC, Watts C, Grome A, Miller T, Crandall B, Pronovost P. Critical care physician cognitive task analysis: an exploratory study. Crit Care. 2009;13(2):R33. doi:10.1186/cc7740.

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