Healthcare assistant decision-making and information behaviour in long-term care settings : a thesis presented in partial fulfilment of the requirements for the degree of Doctor of Philosophy, Massey University, Palmerston North, New Zealand

Abstract

Healthcare assistants (HCAs) are an unregulated workforce who provide most of the care to those living in Aged Residential Care (ARC) in Aotearoa New Zealand. Despite being the essential workforce for the aged care sector, there is a paucity of literature regarding how healthcare assistants make decisions in their everyday work. Increased demand for aged care and health workforce shortages have led to HCAs often working under pressure and required to make decisions about all manner of care. This study explores the direct care decision-making of HCAs. Critical ethnography underpinned by Elfreda Chatman’s small world theory informed data collection. Direct observations and semi-structured interviews provided data on participant characteristics, decision types, the decision-making environment and information landscape. Experimental vignettes explored decision-making in uncertainty by progressively manipulating three dimensions of knowing: knowledge of the environment of care, knowledge of the resident (familiarity), and knowledge as (HCA) experience. Small world and decision-making theories framed data analysis. Decisions were conceptualised as decision schemas associated with specific care actions. Routine, easy and more difficult decisions were identified. Decisions were influenced by the institutional schedule, availability of resources, and the rules of work. Resident attributes, HCA traits, and task prioritisation influenced how decisions were actioned. Frequent informal handovers between HCAs supported situational awareness of resident and communal care demands. Vignette data provided two compelling findings: the more uncertainty, the higher the frequency of advice sought from an experienced HCA, and HCAs took an active role in assimilating new residents into institutional care routines. Models are offered conceptualising the interplay of tensions, certainty, uncertainty and risk with the constructs, attributes and traits used to frame decisions. Professional implications are related to the provision of safe care to residents and the support of HCAs. Study findings clarified opportunities for the co-creation of strategies to address concerns and better advocate for residents. Nurse educators/managers and registered nurses can support HCAs by sharing information considered to be of relevance to the work and decisions they make. Study findings further highlighted the influence of institutional routines and the value HCAs placed on information held by experienced HCAs.