NURSING STAFF PARTICIPATION IN END OF LIFE NUTRITION AND HYDRATION DECISION MAKING PROCESSES IN A RURAL NURSING HOME

Abstract

Decreased or absent oral intake, common among nursing home residents nearing the end of life, often triggers decision making regarding the course of care. Residents, family members, and medical providers hold final responsibility for decisions in these situations, yet the consistent presence of nursing staff places them in a unique position to influence and support decision making processes. Despite this potential, the participation of nursing staff in these decisions is minimally described in current literature. The purpose of this focused ethnographic study was to better understand the participation of nursing staff members, inclusive of Registered Nurses, Licensed Practical Nurses, and Nursing Assistants, in end of life nutrition and hydration decision making processes in a rural nursing home. Semi-structured interviews with 19 nursing staff members, field observations during interviews, and review of relevant documents were used to collect data from a single nursing home in a rural region of North Carolina. An adaptation of Bryon, Gastmans, and de Casterlé's striving for 'good care' framework served as the conceptual framework informing this study. The inductive approaches described by Mason, and by Roper and Shapira, were used to guide data analysis. Nursing staff participation in end of life nutrition and hydration decision making processes in this rural nursing home was closely aligned with type of decision and participant role, of Nursing Assistant, Licensed Practical Nurse, or Registered Nurse, and influenced by a variety of other factors at both individual and group levels. Three primary themes were identified: Formal Decision Making (with subthemes of communicating resident issues, initiating and coordinating decision processes, assuring regulatory compliance, and influencing); Informal Decision Making, (with subthemes of knowing residents and families, instituting feeding interventions not requiring formal medical orders, respecting and honoring, and guiding the resident and family) and Influential Factors (with subthemes of personal experiences/beliefs, unpredictable trajectory, relationship with resident/family, and organizational culture). Findings suggest nursing staff in this facility participate in nutrition and hydration decision making processes to a greater extent than even they realize, especially informal decision making, in their efforts to comfort and provide good care to residents nearing end of life. Factors identified as hindering their efforts include limited awareness of current evidence and best practices, delays in formal decision making, and lack of professional role clarity, especially among LPNs. Comfort with coworkers and supervisors, positive past experiences, and established relationships with residents and family members were identified as supporting participation. This study contributes to the understanding of nursing staff participation in nutrition and hydration decision making processes for residents nearing end of life in rural nursing homes. Further research in other facilities, integration of findings into interventions to support evidence based best practices, and critical evaluation of the relationship between formal decision making and policy implementation are suggested.