This comprehensive introduction highlights the key aspects of the journal pre-proof titled “The Human Brain in Decision-Making Processes in Hospital Administrative and Financial Units: Neural Mechanisms, Theta Activity, and Awareness” by Zeynep Merve Dinler and Mahmut Akbolat. Published in Behavioural Brain Research in 2025, the article is available via DOI: https://doi.org/10.1016/j.bbr.2025.115737. It is important to note that this is a pre-proof version, which has undergone enhancements after acceptance but is not yet the definitive version of record and may undergo further copyediting, typesetting, and review.
The study addresses a critical gap in understanding the neural mechanisms underlying decision-making in high-stakes professional environments, specifically within hospital administrative and financial units. Daily decisions made by personnel in these units significantly impact hospital financial outcomes, resource allocation, and patient care, yet the specific neural processes for intuitive versus rational judgments remain largely unexplored. The research integrates cognitive neuroscience, decision-making theories, and healthcare management to investigate how the human brain functions during these processes.
The primary aims of the study were threefold:
- To examine theta activity (4–7 Hz) in the frontal region during rational decision-making. The frontal region, particularly the prefrontal cortex (PFC), is known for its role in executive control, working memory, and logical reasoning, making it central to rational processing.
- To examine theta activity in the temporal region during intuitive decision-making. Temporal and limbic regions are implicated in intuitive processes due to their involvement in affective and memory-related processing, as well as language processing and semantic memory.
- To evaluate awareness levels using a decision-making scale administered to personnel in hospital administrative and financial units.
Methodology: The study included 56 participants (32 women, 24 men) from hospital administrative and financial units in Turkey. Participants were right-handed, employed in the target units, had no neurological or psychiatric diagnoses, were not on medication, and scored 21 or higher on the Montreal Cognitive Assessment (MoCA) test, confirming adequate cognitive function.
The experimental design involved Electroencephalogram (EEG) recordings during three phases:
- Spontaneous EEG Recording: Baseline brain activity was recorded during resting states with eyes open and closed.
- Lexical Decision Task for Intuitive Decision-Making: Participants responded to visually presented words, categorized as meaningful, meaningless, or misspelled meaningful words. Meaningless words were used to assess intuitive decision-making, while misspelled meaningful words were used for rational decision-making. The task measured response times, with fast responses indicative of intuitive (System 1) and deliberate responses reflecting rational (System 2) decision-making, aligning with Kahneman’s dual-process theory. Stimuli included ecologically relevant terms identified through qualitative interviews with hospital staff, such as “HIC” (Health Implementation Communiqué) and “invoice”.
- Decision-Making Paradigm for Rational Decision Implementation: Participants evaluated highlighted sections of 20 critical hospital administrative and financial documents to determine if they could be detrimental to the hospital. This phase, requiring careful reflection, aligned with “slow thinking” and rational decision-making during implementation.
EEG data were analyzed using Brain Vision Analyzer software, focusing on theta (4–7 Hz) responses. Analyses were performed for spectral power changes within specific time windows (0–100 ms, 200–400 ms, and 300–500 ms) and across various brain regions.
Key Findings:
- Intuitive Decision-Making: A significant increase in theta activity was observed in the temporal regions (e.g., T7 and CP5) during intuitive decision-making under verbal stimulus conditions, particularly in the 0–100 ms time window. This early activation is associated with language processing, semantic memory, and sensory/spatial information processing, supporting the role of fast, automatic System 1 processes. This finding supported Hypothesis H1.
- Rational Decision-Making: A significant increase in theta activity was found in the frontal region (F7 and F8) during rational decision-making, especially in the 200–400 ms time window. This reflects enhanced cognitive engagement, executive control, and deliberative thinking, consistent with System 2 activation and cognitive control theories. This finding supported Hypothesis H2.
- Response Times: Response times were shortest for intuitive decision-making, followed by rational decision-making under lexicality, and longest for rational decision-making during implementation. This aligns with Kahneman’s “slow thinking” concept for rational decisions.
- Awareness and Self-Report Scales: Weak negative correlations were found between rational decision-making scale scores and theta activity in the T7 region (r = –.129), and between intuitive decision-making scale scores and theta activity in the T8 region (r = –.180). Overall, no significant correlations were found between self-reported intuitive or rational decision-making scores and the corresponding EEG results, particularly for F7 and F8 regions in rational decision-making. However, a significant negative correlation (r = –.537, p < .001) was found between rational decision-making scale scores and F7 activity during the rational implementation condition, suggesting that higher self-reported rationality may sometimes be associated with lower frontal theta engagement in applied contexts. This discrepancy indicates that self-report scales may only partially capture underlying neurophysiological mechanisms and that individuals may lack full awareness of their real-time cognitive responses. This partial support led to the acceptance of Hypothesis H3.
- Cognitive Capacity (MoCA Scores): MoCA scores were negatively correlated with frontal theta activity, suggesting that individuals with lower cognitive scores exhibited higher frontal theta power, possibly indicating increased cognitive effort. Higher MoCA scores were positively correlated with longer response times in the rational decision-making condition, implying that individuals with higher cognitive capacity may take more time for deliberate analysis.
- Sex Differences: While females exhibited stronger theta responses in some frontal and parietal regions, these differences did not consistently reach statistical significance across all comparisons, though effect size analyses showed small to moderate effects.
Significance and Implications: This study is novel as it is the first to apply this neuroscientific approach within healthcare management, addressing a significant gap in understanding decision-making in high-stakes professional settings. The findings underscore the crucial role of regional brain oscillations in differentiating between rational and intuitive decision-making, providing valuable insights into their neural basis. The research extends dual-process theories by offering empirical neurophysiological support for the distinction between intuitive and rational processing in real-world professional contexts.
Practically, the study has important implications for enhancing cognitive assessment tools and improving outcomes in critical professional roles within healthcare administration. The results suggest that EEG-based decision-making models could improve personnel selection and training programs, potentially leading to more effective decisions and optimized operational workflows through interventions like neurofeedback training that target frontal theta activity.
Limitations: The study’s scope has limitations, including a sample limited to personnel from hospital administrative and financial departments and decision-making tasks based solely on visual stimuli with a fixed number of items. The reliance on self-report scales for awareness assessment may not fully capture real-time cognitive processes, a common challenge in such research. Although the sample size (56 participants) met the power analysis requirements, its relatively small and non-random nature may limit the broader generalizability of behavioral findings, while acknowledging that electrophysiological responses are often consistent across populations.
Future Research Recommendations: The authors recommend future research to:
- Integrate complementary methods like think-aloud protocols, post-decision justification, or eye-tracking to gain deeper insights into participants’ awareness and processing strategies.
- Employ more comprehensive and varied scales, along with ecologically valid task designs and diverse samples.
- Design new experiments using brain modulation techniques in interdisciplinary teams (neurologists, psychologists, healthcare managers) to enhance decision-making effectiveness.
- Expand studies to different functional units within hospitals based on the context and nature of decisions.
- Incorporate perspectives from healthcare managers and policymakers in future EEG studies to minimize error rates.
- Explore less familiar, ambiguous, or contextually nuanced lexical stimuli to investigate whether such variations elicit more pronounced theta responses in later time windows, while maintaining the intuitive nature of decision-making.
- Replicate the EEG paradigm across different healthcare systems and cultural contexts, incorporating culturally adapted cognitive assessments to enhance generalizability.
- Utilize multimodal neuroimaging (e.g., fMRI combined with EEG) for a more comprehensive understanding of neural dynamics.
This study represents a significant step in understanding the neural underpinnings of complex decision-making in vital professional settings, paving the way for targeted interventions and improved cognitive assessment tools in healthcare.
Reference: Dinler, Z. M., & Akbolat, M. (2025). The Human Brain in Decision-Making Processes in Hospital Administrative and Financial Units: Neural Mechanisms, Theta Activity, and Awareness. Behavioural Brain Research. https://doi.org/10.1016/j.bbr.2025.115737