Clinical decision making by registered nurses in residential aged care : a critical realist case study : a thesis presented in fulfilment of requirements for the degree of Doctor of Philosophy in Nursing at Massey University, Albany, New Zealand

Abstract

Increasing numbers of people are living longer and projections indicate that a greater number of frail elders will require support from the residential aged care sector. Registered nurses are the principal health care professional with sustained oversight of residents and make many of the clinical decisions that affect the health and outcomes of care of the residents. This thesis explains the clinical decisions that registered nurses make in the New Zealand residential aged care sector. The study was undertaken using a critical realist case study framework. This case study describes the clinical decisions the registered nurses make and explains the social structures through causative factors that intersect to cause, redirect, or block the clinical decisions. The data collection methods were participant observation, interview, and document analysis in three residential care facilities. Fourteen registered nurses participated in the study. Data analysis included reasoning processes whereby patterns from the data were reviewed within current knowledge, and explanations developed. The clinical decisions represent the comprehensive nature of nursing practice in this sector. Physical and mental health, and the management of behavioural issues in the context of gerontology are significant foci of nursing frail elders. Three causative factors inherent to the social structure of residential aged care were identified that generate, redirect, or block the clinical decisions. These causative factors are: the relationships the registered nurses develop with the resident, their family, and the general practitioner, which are embedded within the registered nurse role; the specific context of the residential aged care sector in which risk aversion, financial constraints, and limited support for the development of the registered nurses prevails; and the individuality of each registered nurse whose knowledge and agency affects their concern for, and management of, the residents. This thesis presents a comprehensive explanation of the complexity of the registered nurses’ clinical decisions. It identifies that some clinical decisions reside within a zone of certainty, as the registered nurse makes the decision to act or to not act. Other clinical decisions reside within the zone of uncertainty, as the registered nurse experiences indecision, and may ‘wait and watch’ or seek advice. Recommendations for practice focus on the clinical decisions within the zone of uncertainty, the subsequent ongoing professional development requirements, and the need for clinical support and clinical leadership.