University of Southern California Mrs. T.H. Chan Division of Occupational Science and Occupational Therapy
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Decision-Making

We make so many decisions every day, we probably don't even realize it when we do. "Should I wear something dressy, or are sweats okay?" "Do I want to eat now, or later?" "Is it better to buy the large size and store the extra, or just buy as much as I need?" Life moves forward because we are constantly making decisions and then acting on them. Sometimes we can't tell if a decision is good or bad until after it has already been made, and we can see the consequences, that is, what happens as a result of the decision. Anyone can make a decision that seems like a good one, and have it turn out differently than expected; although it is very frustrating, or even painful, when a decision comes out badly, it certainly doesn't mean a person is bad, or wrong, or not smart. The best anyone can do is develop their skills for moment-to-moment decision-making, treat important decisions seriously, and do their best to cope with the results in a positive way.

How do people learn to make the moment-to-moment decisions of everyday life? Many people started making decisions as children, guided by their parents in the form of safety rules - "Look both ways before crossing the street," "Don't talk to strangers," and so on - and rules about behaving - "Share your toys," "Use your indoor voice," and so on. Children hear these rules, and learn there are consequences for breaking rules, sometimes in the form of being scolded or having a punishment like a time-out, and sometimes in the form of an unpleasant result, like falling down or hurting themselves, or annoying playmates who then refuse to play with them anymore.

As we grow up and experience situations that our parents or teachers didn't prepare us for, we make decisions that seem good because they seem like they will help us earn money, or have fun, or achieve a goal. Sometimes the result is exactly what we hoped for, and sometimes it turns out wrong, like when someone goes out with friends to have fun and party and instead gets sick to their stomach, embarrassed that everybody saw them at their worst, and terribly hung over the next day. This learning by trying something and seeing the result is called trial-and-error, and it is how most adults make most decisions. The only trouble with trial-and-error is that sometimes the error can be a big one, and we're stuck with it. This can certainly be the case with pressure ulcers (which means the same thing as "pressure sores" or "bedsores"). For example, one of our study participants, Tom, decided he wanted to go back to a rehabilitation facility for assistance, and thought it would be all right to stop doing his pressure ulcer prevention practices. By time he was admitted to the facility, he had developed a pressure ulcer. Another example is Dave, who also participated in our study, wanted to make a quick return to his activities when he got a pressure ulcer, so, instead of taking time to rest in bed long enough for the pressure ulcers to have a chance to heal naturally, he decided to get muscle flap surgery each time. After a few surgeries, Dave has had so much muscle removed that he will probably not be able to have any more surgeries in the future.

There are better ways to guide decisions than simple trial-and-error. The name problem-solving skills refers to a group of methods that can be used to look at a situation and make a decision about it. Problem-solving skills include listing on a piece of paper (or computer screen) the possible good results (the pros) and the possible bad results (the cons) and comparing them to see which side of the paper looks more convincing; researching, or looking through books, magazines, newspapers and the Internet to find out more facts that might relate to the situation; identifying and writing down each step that would be needed to deal with the situation and making sure that each step is possible (and then using that list to "check off" each step that is completed); and looking for experts or other people whose opinion you respect to find out what their advice is. To learn problem-solving skills, ask your doctor for a referral, or prescription for specialized health care, for occupational therapy. Occupational therapists are experts at teaching people problem-solving skills that relate to their lives; if you like to use the Internet, you can learn more about occupational therapy from the website of the American Occupational Therapy Association.

Another rule for good decision-making is, not to make a decision when it's not needed. A simpler way to put this is that old saying, "If it ain't broke, don't fix it." Often, we think that we have to change things that really are working just fine, and that decision to change turns a situation that was calm into a big mess. An example of this was experienced by Charlie, who took part in our study. He was living in a nursing home when a couple he barely knew offered to let him live with them. Charlie decided to leave the home and move in with the family. He didn't call them first to confirm that he was coming. When Charlie arrived at their home, he found out that the husband had passed away, and the wife now didn't want Charlie to stay with her. As a result, he wound up homeless for a few weeks, during which time he was attacked, robbed and developed pressure ulcers. This was a case where Charlie really didn't need to make a decision in the first place; he could have stayed at the nursing home, where he was getting good care, even if he wasn't entirely satisfied living there.

A very common case in which people make bad decisions is when they decide to do something risky. People, especially young people, take risks because it can be exciting to take chances, like competing in extreme sports. Sometimes people take risks or make bad decisions about their health as a form of denial (that is, acting like nothing is wrong when it would be upsetting to admit there's a problem) about their spinal cord injury 1 2, like our study participant Rachel, who refused to learn how to feed herself or have her truck adapted so she could drive it herself because, as she put it, "I don't have transverse myelitis [the illness that paralyzed her]. I don't claim it. just do not. I don't claim it. I feel in my heart that I am going to get up, so I don't claim it." They might even take risks because they feel "there's nothing left to lose," 2 like Steve, a study participant who returned to dealing drugs and challenged rivals to kill him after he broke up with his wife. Some risky activities can literally put your life on the line, such as joining a gang or dealing or using drugs. Six participants in our study, or 30% of the total number who took part, were involved with gangs, and five of them received their spinal cord injuries in shootings that were gang-related. (The sixth gang member was injured in a high-speed car chase, trying to escape the police after he got drunk and stole a car.) And Steve was later killed in street violence related to drug-dealing. Obviously, getting involved in dangerous activities, or taking unnecessary risks, can be a very bad decision indeed.

It is also important to see if there are ways of doing an activity that would make it less risky; this is sometimes called "harm reduction," and research shows that it can help keep people from getting hurt, or even improve their health 3. For example, when a driver uses a seat belt, there's less risk that the driver would be injured in an accident. When a person with a spinal cord injury spends hours up in their wheelchair, there will be less risk of getting a pressure ulcer if the person remembers to do pressure reliefs and makes an extra careful skin check before going to bed that night. The advantage of harm reduction is that you can still do the activity that you were interested in, but with a much better chance of staying healthy.

Once a person has made a decision, good or bad, the next important step is to accept the results and move on. Sooner or later, everyone makes a bad decision - it's only human! - so the trick is to deal with it. Even if you realize that things aren't turning out the way you intended, you can't go back and change the past. Replaying the situation in your mind, or feeling regret about the way things have turned out, is playing "The Blame Game," which wastes time. If you take it too far, it might even lead to depression. Instead of feeling bad about a decision, it's much more important to identify what you don't like about the results, and start making new decisions that could get you back on the right track. You could call this way of handling a problem making a "Plan B," or an alternate way to do things when something unexpected happens.

In our study, moment-to-moment decision-making in everyday life about seemingly ordinary or minor matters played a huge role in the development of pressure ulcers for many of the participants. Recognizing when a decision is needed and when things are just fine the way the are, using problem-solving skills when it is time to make a decision, avoiding taking unnecessary risks and accepting the results of a decision and dealing with it are all ways that you can help yourself to make better decisions, and to improve the results you get. Even when you may not have a lot of options to choose from, you still have control over which choice you make; take the time and effort to make your decision well!

To learn more tips about making good decisions, there are a few websites to check out on the Internet, but keep in mind that when you type in "decision making" or "problem solving" on most browsers, a lot of the links that are offered have to do with making decisions in business, or teaching others (especially teenagers) how to make decisions. The Ottawa Personal Decision Guide, on the website of the Ottawa Health Research Institute in Canada, is designed to help people assess their decision making needs, plan the next steps, and track their progress in decision making, and can be used for any health-related and/or social decision. (Note: the OHRI website gives you an option of registering or not; if you do choose to register on this website, it is free, and they don't request any personal information.) How to Develop Your Decision-Making Skills, on a health website sponsored by the U.S. Army Office of the Surgeon General, the U.S. Army Center for Health Promotion and Preventive Medicine, the Army National Guard, and the Office of the Chief, Army Reserve, does not mention the Army; written by a faculty advisor at Mahalingam College of Engineering and Technology (in India), it is for anyone who is interested in making better decisions, whether in a group situation or by themselves. On the skills4study website, from the book publisher Palgrave Macmillan, there is a great list of steps for problem solving that can be used equally well for students who are planning how to study for a class or for anyone who is planning how to deal with a new or difficult task. There is also a very interesting article, You Are How You Feel on the website of Craig Hospital in Denver, Colorado, which starts off by talking about how much your attitude about your health can influence how you feel, but then takes it one step further by giving suggestions about how a good attitude can help you make good choices.

1 Wichowski, H. C., & Kubsch, S. M. (1997). The relationship of self-perception of illness and compliance with health care regimens. Journal of Advanced Nursing, 25, 548-553.

2 Witkowski, J. A., & Parish, L. C. (2000). The decubitus ulcer: Skin failure and destructive behavior. International Journal of Dermatology, 39, (12), 894-896.

3 Schmidt, J., & Williams, E. (1999). When all else fails, try Harm Reduction. American Journal of Nursing, 99, (10), 67-70.