Recognition and assessment of resident’ deterioration in the nursing home setting: A critical ethnography.

Here is the structured PICO analysis for the fiftieth article you uploaded:

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Full Title (verbatim and exact):

“Recognition and assessment of resident’ deterioration in the nursing home setting: A critical ethnography”

Laging B, Kenny A, Bauer M, Nay R

Journal of Clinical Nursing (2018); 27:1452–1463

DOI: https://doi.org/10.1111/jocn.14292

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Type of Article:

Critical ethnography (qualitative observational study with semi-structured interviews)

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PICO Analysis:

Population:

Nursing home residents, nurses, personal care assistants (PCAs), general practitioners (GPs), and family members in two Australian nursing homes
66 participants: 3 GPs, 10 registered nurses (RNs), 10 enrolled nurses (ENs), 8 PCAs, 20 residents, and 15 family members
Included residents with cognitive or physical impairment and high care needs in long-term care settings

Intervention (Exposure/Phenomenon of Interest):

Recognition and assessment of clinical deterioration in residents
Focus on how deterioration was identified, who noticed it (nurse, PCA, family), and how decisions were made to escalate care (including hospital transfers)
Explores the sociocultural and organisational influences on assessment practices and care decision-making

Comparator:

Not applicable (qualitative ethnographic study)
Comparisons were made across staff roles (RNs vs PCAs), between different facilities, and by familiarity with residents

Outcome:

1. Person-centred outcomes (observational and interpretive):

Variable recognition of deterioration due to inconsistent staffing and role confusion
Residents and families reported:
- Preference for care continuity and staff familiarity
- Delays in symptom recognition
- Missed opportunities to respond to early signs of decline
Examples included ignored pain, worsening oedema, and delayed referrals resulting in distress or potentially preventable hospitalisations

2. Process outcomes:

Identified four themes:
1. Delegation and inconsistency of care – RNs relied heavily on PCAs who lacked training but had close proximity to residents
2. Mass care with a task focus – Task-driven routines and time pressures compromised individualised care
3. Undervaluing nursing assessment – Nursing judgement often sidelined in favour of protocols; RNs felt unsupported in acting autonomously
4. Philosophy of care influenced practice – Some staff downplayed signs of deterioration to avoid unnecessary interventions; others advocated strongly for or against transfer

3. Health system outcomes:

Avoidable hospital transfers often resulted from:
- Poor recognition and documentation
- Lack of timely, skilled assessment
- Inflexible policies or fear of litigation
Underutilisation of nurses’ clinical judgement led to increased reliance on hospital-based decisions and external diagnostics (e.g., “they want the hospital to confirm what we already know”)

Summary Conclusion:

This ethnographic study highlights the critical role of staff consistency, skill mix, and autonomy in recognising and responding to deterioration in nursing home residents. While PCAs often notice early changes due to frequent resident contact, they are not adequately supported or trained to act on these signs. Registered nurses, meanwhile, face role confusion and limited authority in decision-making, exacerbated by task-focused routines and rigid protocols. The findings suggest that improving clinical autonomy, interdisciplinary collaboration, and workforce continuity could lead to better, more person-centred care and reduce unnecessary hospital transfers.

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