The influence of the practice environment on sharing decision making between older persons and nurses in residential aged care: a qualitative person-centred study

Introduction: With an ageing population and global attention on how older people are cared for, there is a need to understand how older persons are enabled to participate in care decisions. Enabling and sharing decision making is promoted widely in healthcare, yet evidence demonstrates that shared decision making processes are not effectively translated into practice. The healthcare practice environment plays a key role in shaping how older people are included in their care. Further, residential aged care environments can be more complex, as paternalistic attitudes, rigidity and routine, resourcing, and workplace culture impact person-centred practice and sharing decision making processes. The aim of this research was to explore how the practice environment influences sharing decision making between older persons and nurses in residential aged care.Methodology and methods: Using person-centred methodology, older persons and nurses were recruited from an Australian residential aged care setting. Information was generated through emotional touchpoint interviews (n = 17; older persons n = 5; nurses n = 6), observations of practice (n = 8), and practice development methods. Creative hermeneutic analysis was used to iteratively interpret the information generated with participants to develop and refine themes, and reflexive journalling and participant dialogue supported analytic rigour.Findings: Seven components were found to influence the relational connectedness and sharing decision making between older persons and nurses: affirming personhood, reciprocal trustworthiness, time as presence, intentional way of being, negotiating relational boundaries, organisational values in action, and policies in practice. This research contributes a new perspective of sharing decision making as a relational process continuously influenced by the people, processes, and structures within the practice environment.Conclusions and implications: The practice environment was identified as key to how decision making occurs between older persons and nurses. To support sharing decision making, aged care organisations need flexible policies and workforce models that prioritise relationship building. Nurses should be supported to develop reflective and power sharing practices to enhance emotional intelligence, and have the time to connect meaningfully with older persons. Creating conditions where older people are respected, heard, and genuinely involved in care must be embedded within the elements of the practice environment of residential aged care.