Analysis of key decision-making incidents in the life of a nursing home resident.

PURPOSE: This study examined change in the decision-making autonomy of a single nursing facility resident. DESIGN AND METHODS: This case analysis was part of a larger 3-year ethnographic investigation of decision-making events in four nursing facilities. In this case analysis, the resident, her daughter, and three staff members closely associated with the resident's care were each interviewed five times over a 15-month period. RESULTS: Analysis of interview transcripts revealed four themes in decision making. Temporal change was evident in a complex scenario regarding room changes. Spatial context reflected the need for predictability and adaptability in decisions using space. Interdependence of decisions and decision makers was most evident with medical treatment and health care decisions. Awareness, being informed, and knowing what was going on was the final theme. IMPLICATIONS: Despite having the best interests of the resident in mind, the process of decision making in nursing facilities may contribute to a pattern of gradual withdrawal of decisional autonomy from residents regardless of their ability to make decisions.

Clinical considerations. Surrogate decision making for hospitalized elders.

Nurses are increasingly caring for older persons who have become decisionally incapacitated due to acute or chronic illnesses. A nurse may be called on to share in the decision-making process for the elderly patient or to assist in bringing about a surrogate decision involving the patient's relatives and the medical team.

Model for integration of CNS with nursing management and staff development.

The contemporary health care environment is changing rapidly in response to complex economic factors and changes in patterns of care. Coupled with limited nursing resources, these changes challenge the nursing profession to critically evaluate the effectiveness and quality of care delivery, particularly that of advanced practitioners. This paper presents a model for the integration of Clinical Nurse Specialist (CNS) practice with that of the Clinical Nurse Manager (CNM) and Staff Development Instructor (SDI). The model demonstrates that, although the CNS, CNM, and SDI share the same role dimensions, the central focus of each role determines and differentiates its unique practice arena. The interelationship of dimensions within roles and the complementarity between roles result in significant, nonduplicative contributions to high-quality, cost-effective care by the CNS, as well as the CNM and SDI.