Objectives: To determine the best available evidence on residential aged care facility staff experiences of decision-making at the time of a resident deterioration, and to explore the factors that influence decisions to transfer to the emergency department.
Inclusion criteria: Types of participants
All levels of residential aged care facility nursing and care staff were included, namely, registered nurses, enrolled nurses and personal care attendants.
Phenomena of interest
This meta-synthesis explores the experiences of residential aged care facility staff in decision-making when a resident's health deteriorates, including factors that impact on staff decisions to transfer residents to the emergency department.
Types of studies
Primarily qualitative studies were included in the review. Studies incorporating surveys were also included if they reported in sufficient detail the analysis of qualitative data gathered through open-ended questions.
Search strategy: Key databases including CINAHL, Medline and Embase were searched. Studies were limited to English language papers published between the years 1989, when a foundational study into RACF staff decision-making was undertaken and 2011.when the database search was undertaken.
Methodological quality: Seventeen studies were considered to be of sufficiently sound methodological quality after being critiqued using the critical appraisal criteria in the Joanna Briggs Institute - Qualitative Assessment and Review Instrument (JBI-QARI). There was considerable variation in the quality of the studies; excellent quality (n=8); very good quality (n=2); good quality (n=6); and reasonable quality (n=1).
Data collection: Data were extracted using the standardized data extraction tool from JBI-QARI for interpretive and critical research.
Data synthesis: The data were synthesized using the Joanna Briggs Institute approach of meta-synthesis by meta-aggregation using JBI-QARI.
Results: Seventeen studies were included in the review. Findings were aggregated into five synthesized findings. The syntheses indicate that several factors influence decisions to transfer, including: limited staffing capacity to assess and manage residents on-site, fear related to working outside one's capacity, isolation from multidisciplinary support and healthcare resources, communication challenges between key decision makers, limited ability to rely on early planning documents and variable perceptions regarding the complexity of care that can be provided in the residential aged care setting.
Conclusions: Residential aged care facility staff play a key role in decision-making at the time of a resident's deterioration. Multiple factors influence decisions to transfer to the emergency department rather than to continue care on site, including limited flexibility in staffing capacity, poor access to multidisciplinary support, difficulties in discussing a resident's deterioration with other decision makers and fear of working outside of their scope of practice.
Implications for practice: The review findings identified the need for flexible staffing models and improved access to health care personnel and resources in a timely manner to enable the provision of additional care to residents whose health has deteriorated. Additionally, education needs to integrate sufficient focus on developing residential aged care facility staff assessment and clinical communication skills to enable them to recognize and effectively report signs of resident deterioration.
Implications for research: Further research is needed to examine how greater access to multidisciplinary input and health care resources impact on transfer decisions. The role of personal care assistants has been poorly reported to date; therefore further understanding of the impact of skill mix and nursing workload on decisions to transfer is warranted. Additionally, schemes that aim to increase residential aged care facility staff confidence and skills in managing residents when they deteriorate need to be explored.