Decision-making for acutely ill nursing home residents: nurses in the middle

This paper is a report of a study to generate a model of nursing behaviours and social processes inherent in decision-making for acutely ill nursing home residents.

Most research concerning clinical decision-making in nursing homes focuses on the perspectives of doctors. Much less is known about the perspectives and actions of nurses with regard to decision-making, despite the centrality of their roles in nursing homes.

Grounded theory was used. Data were collected in 2004 in four nursing homes in the United States of America using in-depth, semi-structured interviews, 74 hours of non-participant observation and informal conversational interviews with key nursing staff involved in decision-making.

Nurses strive to create a plan of care acceptable to family members and doctors, consistent with wishes of residents and most comfortable for residents. A unifying theme of satisfying all sides emerged as representative of the negotiation strategies used by nurses to address these competing points of view. Four phases in this negotiation occurred: weighing the significance; notifying the family; feeling it out; and playing the middleman. The outcome was either a decision for life-prolongation or for palliative care.

Decisions for nursing home residents are complex and involve weighing and balancing the interests and preferences of many concerned participants, including residents, families and doctors. This process requires skill in clinical judgment, communication and collaboration.