Every academic leader in the health professions eventually learns to say the leaders in health education are expected to make decisions, often quickly, with incomplete information and real consequences to patients and students. Discussions of judgment under pressure tend to focus on the decision itself and the methodology behind the decision. This perspective argues that the more useful unit of analysis is the leader’s information environment – how well the leader keeps listening, how that environment was built before the crisis, how effectively the team functions with the leader, and how openly the reasoning behind a decision is shared afterward.

The earliest warning signs.

The first observable sign that a leader’s judgment is deteriorating is often behavioral rather than cognitive: the leader stops listening, stops asking questions, and begins to interpret what colleagues say to fit a conclusion already reached. A subtler form is performed listening, where attention is shown but input is quietly absorbed into an existing narrative.

This pattern is well documented. Confirmation bias, the tendency to seek and weigh evidence that supports prior beliefs, is among the most robust findings in cognitive psychology.¹ Heuristics are mental shortcuts but are not necessarily triggered by stress. However, under threat, individuals and organizations are known to experience a phenomenon known as threat-rigidity.² Threat-rigidity is characterized by restricted information processing and reverting to previously learned responses. Stress also produces premature closure, in which decision-makers stop scanning alternatives before all have been considered.³ Just as data can be made to support almost any conclusion, a stressed leader can make almost any conversation confirm what they already believe. For effective judgment under pressure, a great leader must be self-aware enough to understand these behaviors and stay present and poised.

Preparation precedes pressure.

Sleep deprivation, fatigue, and stress degrade performance^4,5 across safety-critical professions, from aviation to nursing and medicine. Interns working extended shifts of 24 hours or more made 36% more serious medical errors than those on reduced schedules.⁶ Yet attributing poor leadership decisions mainly to pressure risks missing a more modifiable cause. Leaders who have not built strong, trusted teams, have not made room to gather diverse input, or have inadequate self-care will enter high-stakes moments with less capacity to succeed. The decision then fails for reasons that could easily be corrected.

What this means is that judgment under pressure is best prepared long before the crisis. Leaders benefit from knowing the conditions under which their own performance declines, planning around those conditions, and investing in advance in the relationships that provide dissenting and complementary views.

Calibrating process to the time available.

A frequently overlooked first step in effective decision-making is assessing how urgent the decision really is. When a decision must be made rapidly, a complete picture may not be possible. When time allows, broad consultation is both feasible and warranted. Professional training tends to instill one default mode. Doctoral research rewards deep, extended deliberation; clinical training sometimes rewards speed and decisiveness in the clinic. Neither mode is universally correct. The error lies in applying one when the other would have been more appropriate.

Transparency under uncertainty.

When information is limited, trust is lost less through the decision than through opacity about the reasoning behind it. An effective approach is explicit: state what is known, what must be decided, why the decision is being made now, and a commitment to revisit it as evidence evolves. This mirrors the logic of hypothesis-driven science, in which provisional conclusions are routinely refined or overturned without implying bad faith.  Crisis-communication research shows that credibility depends on the openness with which leaders communicate about uncertainty rather than a projection of certainty.⁷ Leaders who openly acknowledge the limits of their knowledge also shape organizational culture. A study by Amy Edmondson showed that psychological safety within a team (1999) was associated with “learning behaviors”.⁸ For example, such teams were open to discussing errors and seeking feedback.

Conclusion.

Error-free judgment is an unrealistic standard. A more useful one is whether leaders reflect after poor decisions, avoid recreating the conditions that produced them, and keep listening as stakes rise. Judgment under pressure is less a trait displayed in the moment than a system built before the crisis.

References.

1. Nickerson RS. Confirmation bias: a ubiquitous phenomenon in many guises. Rev Gen Psychol. 1998;2(2):175-220. doi:10.1037/1089-2680.2.2.175.
2. Staw BM, Sandelands LE, Dutton JE. Threat rigidity effects in organizational behavior: a multilevel analysis. Adm Sci Q. 1981;26(4):501-524. doi:10.2307/2392337
3. Keinan, G. (1987). Decision making under stress: Scanning of alternatives under controllable and uncontrollable threats. Journal of Personality and Social Psychology, 52(3), 639–644. https://doi.org/10.1037/0022-3514.52.3.639
4. Starcke K, Brand M. Effects of stress on decisions under uncertainty: A meta-analysis. Psychol Bull. 2016 Sep;142(9):909-933. doi: 10.1037/bul0000060. Erratum in: Psychol Bull. 2016 Sep;142(9):933. doi: 10.1037/bul0000068. PMID: 27213236.
5. Lowe CJ, Safati A, Hall PA. The neurocognitive consequences of sleep restriction: A meta-analytic review. Neurosci Biobehav Rev. 2017 Sep;80:586-604. doi: 10.1016/j.neubiorev.2017.07.010. Epub 2017 Jul 28. PMID: 28757454.
6. Landrigan CP, Rothschild JM, Cronin JW, Kaushal R, Burdick E, Katz JT, Lilly CM, Stone PH, Lockley SW, Bates DW, Czeisler CA; New Collective Author. Effect of reducing interns’ work hours on serious medical errors in intensive care units. N Engl J Med. 2004 Oct 28;351(18):1838-48. doi: 10.1056/NEJMoa041406. PMID: 15509817.
7. MacKay M, Colangeli T, Thaivalappil A, Del Bianco A, McWhirter J, Papadopoulos A. A Review and Analysis of the Literature on Public Health Emergency Communication Practices. J Community Health. 2022 Feb;47(1):150-162. doi: 10.1007/s10900-021-01032-w. Epub 2021 Sep 13. PMID: 34515962; PMCID: PMC8436583.
8. Edmondson, A. (1999). Psychological Safety and Learning Behavior in Work Teams. Administrative Science Quarterly, 44(2), 350-383. https://doi.org/10.2307/2666999

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Author:

Schoen Kruse, PhD, MSHPEd

Dr. Kruse is the Senior Vice Provost for Academic Affairs and Integrated Learning at Texas Tech University Health Sciences Center. Dr. Kruse is a Senior Consultant for The Academy for Advancing Leadership.