Decision-making during high-risk events: a systematic literature review
Open accessAbstract
Effective decision-making in crisis events is challenging due to time pressure, uncertainty, and dynamic decisional environments. We conducted a systematic literature review in PubMed and PsycINFO, identifying 32 empiric research papers that examine how trained professionals make naturalistic decisions under pressure. We used structured qualitative analysis methods to extract key themes. The studies explored different aspects of decision-making across multiple domains. The majority (19) focused on healthcare; military, fire and rescue, oil installation, and aviation domains were also represented. We found appreciable variability in research focus, methodology, and decision-making descriptions. We identified five main themes: (1) decision-making strategy, (2) time pressure, (3) stress, (4) uncertainty, and (5) errors. Recognition-primed decision-making (RPD) strategies were reported in all studies that analyzed this aspect. Analytical strategies were also prominent, appearing more frequently in contexts with less time pressure and explicit training to generate multiple explanations. Practitioner experience, time pressure, stress, and uncertainty were major influencing factors. Professionals must adapt to the time available, types of uncertainty, and individual skills when making decisions in high-risk situations. Improved understanding of these decisional factors can inform evidence-based enhancements to training, technology, and process design.
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Literature shows that stress, affect, and uncertainty systematically shape judgment quality, risk processing, and reliance on heuristics in high-stakes environments.
“Literature shows that stress, affect, and uncertainty systematically shape judgment quality, risk processing, and reliance on heuristics in high-stakes environments (Lerner et al., 2015; Reale et al., 2023).”
From Enhancement of modern defense capabilities by convergence of cognitive neuroscience and artificial intelligence (2026) · cites this paper as Reale et al., 2023
The Results sections on stress and uncertainty report effects on decision-making in high-risk situations, and the Discussion links nonproductive emotional responses to decision-making difficulties. But the paper does not establish that stress, affect, and uncertainty systematically shape risk processing or reliance on heuristics; its Performance section says none of the reviewed studies measured uncertainty’s effect on decision-making performance. Page numbers are unavailable in our copy. (LLM, conf=0.86)
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Flagged first, then by citations
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Cited by
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“Literature shows that stress, affect, and uncertainty systematically shape judgment quality, risk processing, and reliance on heuristics in high-stakes environments (Lerner et al., 2015; Reale et al., 2023).”
- Authors
- Reale, C., Salwei, M. E., Militello, L. G., Weinger, M. B., Burden, A., Sushereba, C., Torsher, L. C., Andreae, M. H., Gaba, D. M., McIvor, W. R., Banerjee, A., Slagle, J., & Anders, S.
- Affiliations
- Vanderbilt University Medical Center (US)
- Applied Decision Science (United States) (US)
- Cooper Medical School of Rowan University (US)
- Mayo Clinic (US)
- University of Utah (US)
- VA Palo Alto Health Care System (US)
- University of Pittsburgh (US)
- Corresponding author
- Reale, Carrie
- ORCID
- Venue
- Journal of Cognitive Engineering and Decision Making
- Publisher
- SAGE Publications
- Published
- 2023-01-17
- Volume
- 17
- Issue
- 2
- Pages
- 188-212
- ISSN
- 1555-3434 (ISSN-L)
- PMC
- PMC10564111
- OpenAlex
- W4319834122
- Cited by
- 78
- References
- 62
- Citations by year
- 2026: 39 · 2025: 27 · 2024: 9 · 2023: 3
- FWCI
- 3.62
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Locations
- Journal of Cognitive Engineering and Decision Making (publishedVersion)
- PubMed (publishedVersion)
- PubMed Central (acceptedVersion)
- Funders
- National Library of Medicine Institutional Training Program in Biomedical Informatics and Data Science (T15LM007450-19)
- Agency for Healthcare Research and Quality (R18HS26158 / K12HS026395 / 1K01HS029042)
- Topics
- Health Sciences › Medicine › Family Practice › Clinical Reasoning and Diagnostic Skills
- Social Sciences › Decision Sciences › Management Science and Operations Research › Leadership, Behavior, and Decision-Making Studies
- Social Sciences › Decision Sciences › General Decision Sciences › Decision-Making and Behavioral Economics
- Keywords
- decision-making under pressure, high-risk decision-making, naturalistic decision making, recognition-primed decision, time pressure, stress, uncertainty, decision errors, practitioner experiences, crisis management, healthcare decision-making, military decision-making, aviation decision making, fire and rescue services
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