ORIGINAL RESEARCH

The emergent relevance of care staff decision-making and situation awareness to mobility care in nursing homes: an ethnographic study Janice Taylor, Jane Sims & Terry P. Haines Accepted for publication 15 March 2014

Correspondence to J. Taylor: e-mail: [email protected] Janice Taylor BAppSc MGeron CertIVTAA HDR Candidate Faculty of Medicine, Nursing and Health Sciences, Monash University, Notting Hill, Victoria, Australia Jane Sims MSc PhD Senior Research Fellow Faculty of Medicine, Nursing and Health Sciences, Monash University, Notting Hill, Victoria, Australia Terry P. Haines BPhysiotherapy PhD GCert Health Economics Director of Research Allied Health Research Unit, Kingston Centre, Southern Health, Cheltenham, Victoria, Australia and Southern Physiotherapy Clinical School, Monash University, Melbourne, Victoria, Australia

T A Y L O R J . , S I M S J . & H A I N E S T . P . ( 2 0 1 4 ) The emergent relevance of care staff decision-making and situation awareness to mobility care in nursing homes: an ethnographic study. Journal of Advanced Nursing 70(12), 2767–2778. doi: 10.1111/jan.12425

Abstract Aim. To explore mobility care as provided by care staff in nursing homes. Background. Care staff regularly assist residents with their mobility. Nurses are increasingly reliant on such staff to provide safe and quality mobility care. However, the nature of care staff decision-making when providing assistance has not been fully addressed in the literature. Design. A focused ethnography. Method. The study was conducted in four nursing homes in Melbourne, Australia. Non-participant observations of residents and staff in 2011. Focus groups with 18 nurses, care and lifestyle staff were conducted at three facilities in 2012. Thematic analysis was employed for focus groups and content analysis for observation data. Cognitive Continuum Theory and the notion of ‘situation awareness’ assisted data interpretation. Findings. Decision-making during mobility care emerged as a major theme. Using Cognitive Continuum Theory as a guide, nursing home staff’s decision-making was described as ranging from system-aided, through resident- and peer-aided, to reflective and intuitive. Staff seemed aware of the need for resident-aided decision-making consistent with person-centred care. Habitual mobility care based on shared mental models occurred. It was noted that levels of situation awareness may vary among staff. Conclusion. Care staff may benefit from support via collaborative and reflective practice to develop decision-making skills, situation awareness and person-centred mobility care. Further research is required to explore the connection between staff’s skills in mobility care and their decision-making competence as well as how these factors link to quality mobility care. Keywords: cognitive continuum theory, decision-making, ethnography, focus groups, mental models, mobility care, nursing homes, observation, quality of care, situation awareness

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Why is this research needed? ● The decision-making competence of care staff during mobility care is important as nurses are increasingly reliant on care staff to make decisions, such as when to report

2012, 2013b). This article contributes to the body of knowledge regarding mobility care by describing care staff decision-making practices and suggesting how to improve care staff’s decision-making competences and mobility care.

resident status changes. ● As the safety and quality of mobility care are dependent on decisions care staff make on the spur of the moment, the nature of care staff decision-making needs to be understood. ● The nature of care staff decision-making when providing mobility assistance has not been well addressed: a deeper understanding may guide practice improvement.

What are the key findings? ● Cognitive modes of care staff decision-making can be described using the Cognitive Continuum Theory and vary from system-aided through resident/peer-aided to reflective and intuitive modes of practice. ● Mobility care based on shared mental models or norms of behaviour may be provided in a habitual manner that is task- rather than person-centred. ● Levels of situation awareness may vary amongst care staff with higher levels improving the safety and quality of mobility care.

How should the findings be used to influence policy/ practice? ● The findings suggest that care staff need to develop cognitive modes of decision-making practice and situation awareness to improve both the safety and quality of mobility care. ● Collaborative support for care staff may improve peeraided judgements, reflective and intuitive practice and situation awareness during mobility care.

Introduction Care staff, also referred to as personal carers, nurse assistants or certified assistants in nursing, provide most of the direct care, including mobility care, in nursing homes. To optimize residents’ mobility and quality of life, staff require competencies in manual handling and mobility promotion (Brown Wilson 2000, Taylor et al. 2011) and should provide opportunities for resident choice and autonomy (Clarke et al. 2009, Taylor et al. 2013a). Staff motivation and organizational factors, such as care protocols, time and equipment availability, contribute towards safe and effective mobility care (Koppelaar et al. 2009, 2011). Importantly, individualized and person-centred approaches to mobility care, in a risk management context, are required (Brooker 2004, W
angblad et al. 2009, Clarke et al. 2011, Taylor et al. 2768

Background Mobility care aims for optimal resident outcomes plus staff and resident safety (Brown Wilson 2000). Functional training provided by carers can improve residents’ mobility (Schnelle et al. 2002, Ouslander et al. 2005, Forster et al. 2009), which in turn contributes to residents’ quality of life and independence (Bourret et al. 2002, Edwards et al. 2003). Multifaceted approaches to safe manual handling reduce staff injuries and improve their safety (Nelson et al. 2006). Safe manual handling interventions have also improved resident self-performance during transfers and reduced resident falls (Nelson et al. 2008). Care staff have been referred to as gatekeepers of residents’ mobility (Bourret et al. 2002). As gatekeepers, staff need to be well trained in the use of the mobility-enhancing strategies and the application of person-centred approaches to optimize residents’ mobility, autonomy and control (Taylor et al. 2013b). The staff’s gatekeeper role during mobility care is even more salient when we consider the reliance of nurses on care staff to register and report changes in residents’ health and behaviour (Jones et al. 2002). However, the training and support that care staff need to adequately fulfil their role are lacking (Anderson et al. 2005, Andersen 2008, Siegel & Young 2010), including mobility care (W
angblad et al. 2009). During mobility care, care staff may need competences in decision-making as well as in safe manual handling, mobility optimization and person-centred care. Decision-making during care (direct decision-making) and in teams (participatory or collaborative decision-making) is a poorly understood aspect of care staff’s role (Yeatts et al. 2010, Willemse et al. 2012). Decision-making is dependent on observations where phenomena are noticed or perceived and judgements, which determine subsequent actions (Lauri & Salantera 1998). Decision-making has been explored in terms of care staff empowerment, decisional authority and supervisor support (Willemse et al. 2012, Chaudhuri et al. 2013). However, literature on this topic remains limited. The current study, based on findings from observations and focus groups, was part of a larger focused ethnography that explored the nature of the resident–staff assistive relationship during mobility care in nursing homes (Taylor et al. 2012, 2013a). The aim of the research was to © 2014 John Wiley & Sons Ltd

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Care staff decision-making and situation awareness during mobility care

explore mobility care provided in nursing homes. Care staff decision-making emerged as a key theme and the purpose of this article is to describe this finding and explore the implications for practice. Interpretation of findings was guided by application of a theory of decision-making, namely Cognitive Continuum Theory (CCT) (Standing 2008). General theories of decision-making have focused on models of analysis and intuition counterpoised against the nature of the task and context (Lauri & Salantera 1998). In CCT, decision-making ranges from intuitive to analytical and is set against tasks or judgement situations (Cader et al. 2005, Standing 2008); analytical and intuitive thinking are at the opposite ends of a continuum. Task characteristics determine which type of thinking dominates or is required (Harbison 2001). Intuitive judgements are more likely when tasks are unexpected, unfamiliar or low in organizational characteristics or structure (Standing 2008). Standing’s model presents nine cognitive modes of nurses’ decisionmaking ranging from intuitive judgement to experimental research (Figure 1). CCT has practical features, good explanatory power (Harbison 2001, Cader et al. 2005), has been adapted to nursing practice (Standing 2008) and judged relevant to care staff decision-making.

Design This focused ethnography paid attention to culture and practice related to mobility care rather than nursing home culture in its entirety as would occur in ethnography. Focused or applied ethnography is described as ideal for healthcare research on quality and safety (Dixon-Woods 2003, Savage 2006). It has the advantage over ethnography of requiring less time in the field (Willis & Anderson 2010).

Participants Access was gained to four nursing homes in Melbourne, Australia, through collegial networks and the public domain. Site managers were interviewed to ascertain their facilities’ characteristics (Table 1). Convenience sampling was used to recruit participants for focus groups at three sites. Inclusion criteria were that care staff were primarily involved with resident care. Lifestyle staff were also invited as they routinely assist in resident mobilization. Invitations to participate were issued via manager announcements at staff meetings and notices on staff noticeboards. Characteristics of the eighteen staff who participated in focus groups are presented in Table 2.

The study Data collection Aim The study aimed to explore mobility care provided by care staff in nursing homes.

High

Nurses ‘live’ accountability for their decisions

‘Faceless’ decisions e.g. developing policy, clinical guidelines; management; interpreting test results

Observations The first author (JT) conducted non-participant observations of residents and staff at four facilities during 6 months Collective prior approval by a formal ethical committee Experimental research

Interpret & apply ethical & professional codes of conduct

Correspondence

Survey research

Competence

(Practical relevance, empirical accuracy, Evidence-based, effective outcome)

Qualitative research Active research and clinical audit

Possibility of manipulating variables;

Critical review of experimental and research evidence

TASK STRUCTURE ‘Face-to-face’ decisions e.g. plan, deliver & review care with patients; communicate & empathise with patients

Visibility of process;

System aided judgement Patient & Peer aided judgement Reflective judgement

High

Time required Coherence

Competence

(Sound rationale, retraceable, defensible non-contradictory, logical process)

Intuitive judgement Low Intuition [Tacit]

COGNITIVE MODE (Source of knowledge)

Analysis [Explicit]

Low

Figure 1 Standing’s revised cognitive continuum theory of decision-making. Reproduced from Standing, M. 2008. Clinical judgement and decision-making in nursing – nine modes of practice in a revised cognitive continuum. Journal of Advanced Nursing, 62(1), 124–134, with permission. © 2014 John Wiley & Sons Ltd

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Table 1 Characteristics of participating facilities. Facility

A

B

C

D

No. nursing home beds No. staff Facility type Morning shift staff to resident Ratios Hours of physiotherapy per week Physiotherapy per resident per week (minutes) Manual handling policy MH trainers

90 130 Not-for-profit 1:7

30 50 Community-governed 1:5

88 90 Community-governed 1:5

45 65 Private 1:7

26

8

16

4

17

16

11

5

Risk identification

No Lift

No Lift

Minimal Lift

& management External consultant, train-the-trainer and peer leaders

Physiotherapist (extra hours)

External consultant, train-the-trainer and peer leaders

Internal nursing staff with training certification

Table 2 Focus group staff characteristics. No. years’ experience

Facility

ID

Gender

Designation

Qualification

A (n = 7)

1 2 3 4 5 6 7 1 2 3 4 1

F F M M M F F F F F F F

Personal care assistant Personal care assistant Registered Nurse Division 1 Registered Nurse Division 2 Registered Nurse Division 2 Personal care assistant Personal care assistant Registered Nurse Division 2 Personal care assistant Personal care assistant Lifestyle assistant Lifestyle & leisure assistant

2 3 4 5 6

F F F F F

Lifestyle & leisure assistant Registered Nurse Division 2 Personal care assistant Personal care assistant Lifestyle & leisure team leader

7

F

Lifestyle & leisure assistant

Certificate 3 (personal care) Certificate 3 (personal care) Degree in nursing Certificate 4 in nursing Certificate 4 in nursing Certificate 3 (personal care) Certificate 3 (personal care) Certificate 4 in nursing Certificate 3 (personal care) Certificate 3 (personal care) Not specified Certificate 4 (Leisure & health) Certificate 3 (personal care) Certificate 4 (Leisure & lifestyle) Certificate 4 in nursing Certificate 3 (personal care) Certificate 3 (personal care) Diploma in welfare Certificate 4 (Leisure & lifestyle) Certificate 3 (personal care) Certificate 4 (Leisure & lifestyle)

B (n = 4)

C (n = 7)

from September 2011. Observations occurred at times of peak activity, from early morning until after the midday meal in public areas as limited by the ethics approval. The aim was for observations to be unobtrusive to minimize interference with staff’s busy daily schedules and to minimize the Hawthorne effect or behaviour modification due to the presence of an observer (Pope & Mays 2006). Observed mobility events included resident transfers in and 2770

2–5 years 2–5 years 2–5 years 1–2 years 5–10 years >10 years 2–5 years 5–10 years >10 years 5–10 years 5–10 years 0–1 years 2–5 years >10 years >10 years 5–10 years 5–10 years 5–10 years

out of chairs and wheelchairs and walking in the facility. Multiple events were observed, limited only by the researcher’s ability to focus on the details of one event at a time. Observations were recorded immediately after an event using a tool designed for the purpose (Data S1). The first author (JT) adapted the tool from previous work by Johnsson et al. (2004), then trialled and refined it to include further cues to facilitate recording of event details. © 2014 John Wiley & Sons Ltd

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Field notes were made during and after observation sessions. Focus groups The first author (JT) conducted focus groups at three facilities during a 5 weeks from early September 2012. Each session lasted 60 minutes. Focus group guides, including a question schedule (Data S2), were prepared in advance. Questions were derived from the first author (xx)’s practical experience as a physiotherapist working in nursing homes for over 20 years, her theoretical orientation to the research question and similar previous studies. Questions aimed to elicit staff’s experiences regarding mobility care and related teamwork. Findings from the broader study, such as those arising from resident interviews (Taylor et al. 2013a), were presented to expand discussion and build on previous findings. Focus groups were audiotaped and field notes made after the session.

Ethical considerations Formal ethics approval was obtained from the Monash University Human Research Ethics Committee, which conforms to the provisions of the Declaration of Helsinki (version 2000). The four facilities at which observations were conducted provided consent for access to public areas of the facilities. Focus group participants provided written consent. Consent for unobtrusive observations of residents and staff in public areas of facilities was not sought as such activity is consistent with usual continuous improvement activities and posed no risk to those observed. All collected data were de-identified.

Data analysis Focus group discussions were transcribed verbatim, read as a whole and then phrases coded. N Vivo 9 software (QSR International 2010) was used to manage the data during coding. The process of determining and refining content categories was iterative, with emerging findings, patterns and themes being identified. To identify themes meaningful to participants, inductive analysis occurred. Qualitative thematic analysis (Pope et al. 2006, Liamputtong & Serry 2010) was employed for focus group data and supplemented by qualitative content analysis of observational data (Pope et al. 2006). Data analysis and interpretation of findings were guided by the decision-making theory, CCT (Standing 2008). Cognitive modes of decisionmaking range from intuitive judgement to experimental research. © 2014 John Wiley & Sons Ltd

Care staff decision-making and situation awareness during mobility care

Rigour Focus group transcripts, observation records and field notes were preserved for study verification. Co-authors (JS, TH) checked the credibility of the first author (JT)’s coding and categories and verified emergent themes. Data collection continued until data saturation was achieved with the third focus group where no significant new themes were identified. Verbatim quotations from focus groups appear below. The study method was appraised using the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist (Tong et al. 2007), which validated the study design and research procedures and supported triangulation of focus group and observational data.

Findings Overall, 53 mobility events were observed (19
5 hours), of which 41 involved resident–staff interactions. Thirty-one (75%) of resident–staff interactions were dyadic in nature (staff + resident = 2). Other interactions involved two or more staff. Focus group findings were assigned to categories, including resident factors, staff factors, equipment, training, teamwork and decision-making. Emerging themes were the resident–staff relationship, prioritization/coping, teamwork and decision-making. Themes of relationships (Brown Wilson & Davies 2009, Heliker & Hoang Thanh 2010), coping (Boeije et al. 1997, Freshwater & Cahill 2010) and teamwork (Scott-Cawiezell et al. 2004, Siegel & Young 2010) have been well addressed in the literature with less attention paid to care staff decision-making. We focus on the decision-making theme as it provides an interesting lens to explore the findings. Emerging sub-themes corresponded closely to categories in CCT. The sub-themes ‘system-aided judgements’ and ‘peer/resident-aided judgements’ arose primarily from the focus group data. The sub-themes ‘reflective and intuitive practice vs. habitual behaviour’ and ‘situation awareness’ were identified primarily from observation data. Situation awareness is defined as the process of perception, followed by understanding and the forming of judgements (Endsley 1995) (Figure 2). It is therefore closely related to decisionmaking. These sub-themes are discussed below.

System-aided judgement System aides such as handovers, assessment by physiotherapists and care plans directed how mobility care was provided in each participating facility. However, judgements regarding residents’ mobility could not always wait for physiotherapy assessment: 2771

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• • • • •

System capability Interface design Stress & workload Complexity Automation

Feedback

SITUATION AWARENESS

State of the environment

Perception of elements in current situation LEVEL 1

Comprehension of current situation

LEVEL 2

Decision

Projection of future status

Performance of action

LEVEL 3

Information Processing Mechanisms

• Goals & objectives • Preconceptions (Expectations)

Long Term Memory Stores

Automaticity

• Abilities • Experience • Thinking

Figure 2 A model of situation awareness in dynamic decision-making. Reproduced from Endsley, M. R. 1995. Toward a theory of situational awareness in dynamic systems. Human Factors, 37(1), 32–64, with permission.

B-S2:

‘Sometimes we might get them (residents) in on a Friday afternoon and physio’s not in till Monday so we’ve got the weekend. So we’ve got to try and figure. . .read back and see what notes he’s come in with. And that’s where the RN (Registered Nurse) should be involved as well because she’s got all the paperwork.’

After assessment, mobility care plans were devised to instruct and guide staff – a system designed to aid staff judgements in mobility care provision. Routines were another system aide that simplified staff’s work. Routines were designed to avoid ‘double-handling’, (where tasks were performed twice), so that staff could be more time-efficient: A-S6:

‘You get it all done on the chair and it’s all done. It’s. . .The only things you really need to do are the changing of the pad; you can do all that on the bed, you know without, you know. . . . Then it becomes double-handling. So trying to make those things effective.’

Resident mobility reviews could be prompted by care staff who felt that care plans no longer corresponded to a resident’s current needs: 2772

A-S2:

‘Like, the resident used to be walking; now they’re becoming resistive or cannot stand up for a long time. Then we can notify the RN (registered nurse) to notify the physio to assess.’

It was not clear on what basis care staff made their judgements and decisions to report mobility changes or recommend changes to care plans. Some care staff were confident in knowing when changes in residents’ mobility status had occurred and this confidence extended to them making judgements regarding possible care plan changes: A-S6:

‘He’s getting harder and harder to manage now, so um, interventions for that – maybe putting him on a full lifting machine rather than a standing machine.’

While systems were in place to aid mobility care, they did not assist with every scenario that confronted care staff. Also, on being asked whether certain practices described by staff were in the resident care plans, one answered, ‘Some of it.’ (B-S3). There was little evidence

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of explicit systems to assist care staff make judgements about changes in mobility. Some participants indicated existence of an informal rule regarding reporting of major vs. minor changes, where major changes might include falls: A-S4:

‘If it’s nothing major, like something that’s acute, usually the staff can just make that decision as we go. But if it’s something major, let’s say maybe it’s post fall, that’s when we have to call in the physio and then review and we can pick up from there.’

In situations where systems were not used by staff, they used intuitive, reflective and resident/peer-aided judgements, as discussed below.

Peer/resident-aided judgement Participants created a picture of a team approach to mobility care. However, care staff’s knowledge, confidence and experience affected their ability to make decisions and seek advice: A-S1:

A-S6:

‘Oh yes, seeing difficult situations (would be a challenge); cause they (new staff)’ve had no experience in that area. It would be very difficult to, yeah, to know what to do.’ ‘You don’t want to make a mistake and some people don’t have that verbal ability to go ‘Well can you help me?’ or ‘I’m not sure of this’.’

Care staff decision-making and situation awareness during mobility care

B-S1:

One relatively new staff member suggested that the onus was on newer staff to communicate with more experienced staff: C-S1:

‘Or some say if he’s been put in a wheelchair he’s gonna be safer. Like I come along and I say, ‘No, no, he’s safer in his chair, not in the wheelchair. . . We’ve, we’ve got nothing (in the care plan) to say he’s allowed to be in that wheelchair. . .’

Despite evidence of disagreements, other care staff, plus team leaders, nurses and physiotherapists, were identified as advisors who could provide support. It was highlighted that care staff with less experience benefited from following those with greater experience: A-S7:

‘Yeah, they have to be followers because we are more experienced. We know the routine and the policy.’

© 2014 John Wiley & Sons Ltd

‘Like if I haven’t had much experience with one resident I might say to my buddy ‘How, you know, what, you know, how do you approach her?’ or ‘How do you do this?’ and they’ll give me tips, you know, how to deal with that resident.’

Whilst care staff depended on their team for advice, there was no guarantee that those on whom they depended had the knowledge to provide the best advice: B-S2:

‘But she (an inexperienced carer) didn’t know that (siting a resident in a wheelchair was not safe) and someone else has come along and told them to put him in a wheelchair.’

Care staff were aware of the need for resident-aided judgements: A-S1:

‘I, yeah, assist them (residents) if they want assistance. . . always ask them if they want assistance to stand up or if they’re still mobile.’

Taking heed of residents needs could involve altering the equipment used during care: A-S4:

Staff could have differing views that created dissension or confusion at times. In the following situation, one staff member used system-aided judgement to strengthen her argument regarding how to care for a resident: B-S2:

‘We can see straightaway whether the er, residents, are in pain, whether this is the, er, um, right machine that we use for them. . .’

‘So sometimes in the morning you might use a standing machine, but depends on how they’re feeling that day, you might switch to a lifting machine, you know, depending on how they’re feeling.’

Reflective and intuitive practice vs. habitual behaviour It was difficult to determine when care staff acted habitually vs. using intuitive and reflective modes of decision-making. One focus group participant alluded to the need to use reflection: C-S3:

‘You have to adapt yourself and prioritize the safety and all these things, you know?’ From the observational data and findings, some staff appeared to use intuitive or reflective modes of decisionmaking. For example, the attention of one staff member, Sally (pseudonym), was captured when she became aware of a resident’s call for help. The resident, Betty (pseudonym), was walking along a corridor using a wheeled 2773

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walking frame. Sally acted swiftly to be beside Betty who then arrived at a chair and safely sat down. Sally had made a judgement and acted on it even though Betty’s need had not been clear. (Once Betty was seated, it became apparent she wanted reassurance regarding an appointment and this was attended to by the facility receptionist). In this scenario, Sally responded to an unexpected and seemingly urgent need for physical assistance. She operated intuitively or reflectively, accounting for possible risk inherent in Betty’s urgent call for assistance. Other staff appeared to use intuitive or reflective decision-making in a scenario where many residents requiring assistance were anxious to leave an exercise room. There were not enough staff to immediately assist all the residents. Staff managed the situation, each reassuring residents who had to wait and prioritizing their input to those who most needed attention. This dynamic situation again demonstrated staff using intuitive or reflective judgements appropriately. By contrast, habitual staff behaviour was also observed. For example, during one observation, two staff followed a shared mental model that appeared to require little cognitive processing; they worked in well-rehearsed unison, without speaking to each other or the resident they were assisting. Everyone knew ‘the script’ as staff transferred the passive resident from her chair using a standing machine, the resident generally responding just enough for the transfer to be performed safely. At one point, however, the resident had not put her hands on the machine to hold on and the staff took her hands, in an automatic way, like she always needed prompting to do this, to place her hands on the machine.

Situation awareness The first two scenarios above, included as examples of intuitive or reflective practice in action, highlighted staff’s dynamic and appropriate responses to situations. Staff responses in these scenarios suggested situation awareness. The carer, Sally, focused on what she determined to be the task in the moment to assist the resident, Betty. Similarly, staff managed the situation well after the exercise session, maintaining awareness of residents’ needs and their capacity to assist, given the circumstance. In both scenarios, situation awareness may have assisted staff to effectively manage situations with low levels of task structure and high degrees of uncertainty. In the last scenario, two staff transferred a resident with a standing machine safely. However, on returning the resident from her room to the lounge on the standing machine after toileting, they were challenged by another staff mem2774

ber who indicated that moving the resident over a large distance using the standing machine was unsafe. Whilst the two staff had had a shared mental model, it was not shared by the third staff member who considered their decisionmaking and possibly situation awareness, to be faulty.

Discussion The increasing reliance of nurses on care staff in nursing homes and the complexity of care emphasize the timeliness of a focus on care staff decision-making (Jones et al. 2002, W
angblad et al. 2009). The findings from this study highlight that care staff make decisions in different ways: they may be aided by systems such as care plans; they may be guided by residents or peers; or they may make decisions more intuitively. Some authors suggest that systems are required for quality care and safety (Hignett & Richardson 1995, Harbison 2001). However, fallibility can occur during any of the decision-making practice modes (Standing 2008). Furthermore, care staff may not always follow systems such as care plans. Similarly, Rycroft-Malone et al. (2009) found that nurses may not use protocols, another form of system aide, preferring to source advice from colleagues or follow instincts based on experience. Although approaches to care that are not system-aided may be a concern, they may be more flexible and allow staff to better manage contingencies such as resident status changes (W
angblad et al. 2009). Quality and safe mobility care may therefore depend on staff having the ability to make decisions in a variety of ways rather than relying solely on system aides. Care staff in this study described new and inexperienced staff as needing support from more experienced staff during mobility care. The noted value of support provided by physiotherapists and nurses has been reported elsewhere (W
angblad et al. 2009, Siegel & Young 2010). Care staff may also act as peer leaders. Study participants felt they had the knowledge of residents, routines, equipment and policies and the decision-making skills that enabled them to lead others. However, it emerged that, regardless of the support available, new staff may not know how to ask for or seek out help. Furthermore, it has been suggested that care staff may not feel confident to approach busy nurses with resident concerns (Crogan & Shultz 2000). Collaborative approaches to mobility care that develop care staff’s confidence as well as decision-making and communication skills may be required. Collaboration regarding manual handling has been recommended between nurses and physiotherapists in the United Kingdom (Fletcher 1997) and the USA (Nelson et al. 2005) © 2014 John Wiley & Sons Ltd

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and the global importance of interprofessional collaboration at all levels is recognized by the World Health Organization (2010). However, this study and other research indicate that barriers to care staff involvement in collaborative teamwork exist in nursing homes (Scott-Cawiezell et al. 2004, Anderson et al. 2005, Andersen 2008). Such barriers need to be addressed through opportunities such as coaching and formal and informal meetings (Anderson et al. 2005). The use of peer leaders and practice reviews should be considered: these contribute towards improved manual handling practice that reduces staff injuries and improves resident mobility outcomes (Nelson et al. 2006, 2008). Care staff inclusion in collaborative inter-professional approaches to care may provide an opportunity for team discussion regarding different mental models of care provision. Atwal et al. (2006) highlight a similar call for assistant staff in rehabilitation settings to be included in collaborative care. Exposure to shared decision-making may enhance care staff’s confidence in making their own decisions (Chaudhuri et al. 2013). Evidence that nurses in acute settings prefer peer-aided decision-making over reliance on systems (Rycroft-Malone et al. 2009) further reinforces the potential value of collaborative support for care staff in nursing homes. However, peer advisors and leaders should have the appropriate mental models, knowledge and skills. Mechanisms in the nursing home should also support this kind of knowledge transfer. There is an increasing interest in person-centred care in nursing homes (Dow et al. 2006). Standing’s model of CCT includes resident-aided judgement, which is consistent with calls for person-centred consideration of resident autonomy and shared decision-making (Whitler 1996, Davies et al. 1997, McCormack 2001, McCormack & McCance 2010). Intuitive decision-making may also be salient to person-centred approaches to mobility care. Staff who are person-centred during mobility care are more likely to respond to residents’ needs intuitively in the moment and may make more appropriate responses to situations with low task structure such as when rapid responses are required. In contrast, staff who are task-oriented are more likely to provide care in a habitual manner and to be less engaged with the resident. With habitual behaviour, staff tend to follow ingrained patterns of behaviour, particularly in situations of perceived certainty and high task structure (Ajzen 2005). An analogy with driving a car demonstrates the distinction; someone can drive a car automatically (habitually) until an unexpected situation arises requiring an intuitive response to avoid an adverse outcome such as a collision. To improve person-centred care, an understanding of the distinction between intuitive and habitual practice is advis© 2014 John Wiley & Sons Ltd

Care staff decision-making and situation awareness during mobility care

able, even though both forms of practice may be based on understandings that are tacit and difficult to communicate (Dampney et al. 2002). Situation awareness (SA) may enable staff to be more engaged and responsive during mobility care thus limiting task-oriented, habitual care. Situation awareness is linked to the onset of the decision-making process (Mosier & Fischer 2010) and considers the influence of factors such as distractions, the need for multitasking, tiredness and time pressures (Stubbings et al. 2012). High levels of SA may help staff know when to use system aides, when to seek advice or alternatively when to act on their intuitive judgement. Ways of improving SA include helping staff to understand the decision-making process, training staff in decision-making competence and use of interdisciplinary learning (Stubbings et al. 2012). There may also be useful correlations between situation awareness, mindfulness and person-centred care. Being aware or mindful in the moment may not only allow staff to intuitively respond to residents’ needs in the moment, thus allaying residents’ agitation, but may also help staff feel less burdened (Lantz et al. 1997, McBee 2003). While there is currently no agreement regarding the level of SA that will best support decision-making (Mosier & Fischer 2010), this study highlights the need to explore SA along with other aspects of decision-making in relation to person-centred mobility care. With the ageing of the global population and consequent pressures on the aged care workforce, moves towards more supportive and participatory models of care that aim to empower care staff are being explored (Nolan et al. 2008, Willemse et al. 2012). Organizational cultures that promote respect and support by nurse leaders for care staff may result in frontline staff feeling safer, less marginalized and stressed and thus more able to provide better care (Cherry et al. 2007, Andersen 2008, Siegel & Young 2010). Supervisor support and shared governance are associated with better decision-making (Chaudhuri et al. 2013). Logically, this should result in better care. While development of SA and intuitive judgements may improve direct decision-making, peer-aided and reflective judgements facilitated by welltrained peer leaders may improve staff’s participatory decision-making.

Limitations The intended study participants were direct care workers as it was thought that they would feel freer to speak in the focus groups if more qualified supervisors were absent. As invitations were issued by facility managers, the process was outside the researcher’s direct control and staff with a range 2775

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of qualifications, including supervisors, chose to participate in the groups. The presence of supervisors did not seem to prevent other staff from freely expressing their opinions; there were good levels of participation by all. The study design included non-participant and unobtrusive observations to minimize disturbance to daily care and maintain a naturalistic research setting. A participant observer may have gained a deeper understanding of care staff’s cognitive processing during mobility events by interacting with study participants and exploring the influence of mental models, norms of behaviour and situation awareness. The focus of this study was mobility care during morning shifts, a time of peak activity and, due to the limits of the ethics approval, observations in public areas. Future research could explore mobility care across 24 hours, in bedrooms and bathrooms as well as in public areas. Whilst study findings cannot be generalized to other populations, we believe this is the first research to explore care staff decision-making during mobility events in nursing homes. The study has provided insights and directions for future research.

Conclusion Care staff make decisions regarding appropriate mobility care on a daily basis with some decisions resulting in actions that are safer and more effective than others. As the goal is for care staff to provide consistently high-quality and safe mobility care that supports residents’ quality of life, training needs to focus on staff’s decision-making competence as well as their knowledge and skills in mobility care. Insights gained from this study employing Standing’s model of Cognitive Continuum Theory include the role of cognitive decision-making during mobility care. A combined focus on systems, peer leadership, person-centred and reflective practice is supported by the study findings. The possible role of situation awareness in improving mobility care practice was highlighted. There is a need for further research to explore care staff decisionmaking, care staff’s need for support and how these factors link to quality mobility care, safety and residents’ quality of life.

Acknowledgements Janice Taylor is currently supported by an Australian Postgraduate Award and previously by a Primary Health Care Research Evaluation & Development Fellowship 2009. Assoc Prof Haines is supported by a National Health & Medical Research Council Career Development Award.

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Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Conflict of interest No conflict of interest has been declared by the authors.

Author contributions All authors have agreed on the final version and meet at least one of the following criteria [recommended by the ICMJE (http://www.icmje.org/ethical_1author.html)]:

• •

substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data; drafting the article or revising it critically for important intellectual content.

Supporting Information Online Additional Supporting Information may be found in the online version of this article: Data S1. Observation instrument. Data S2. Focus group questions schedule.

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