The DECIDE Project - Nurses’ Scope of Practice in Home-Based Care, aka Role, Function, and Clinical Decision-Making, and its Contextual Modulators: A Sequential Mixed-Methods Design
Abstract
Background: While nurses’ understanding of their scope of practice is foundational to appropriate nursing care, limited empirical research has examined its enactment in home-based care or the influence of contextual modulators. Thus, the aim of DECIDE was to explore and describe nurses' scope of practice in home-based care, examine the possible shaping of contextual modulators on its enactment, and contribute to knowledge of the clinical reasoning underpinning registered nurses' clinical decision-making. Methods: A sequential mixed-methods design comprising four project strands was adopted: a scoping review (I), a multi-method (II), a qualitative descriptive (III), and a qualitative exploratory and descriptive design (IV). Data collection included literature searches, structured observations, focused interviews, and retrospective think-alouds; analysed using statistics, framework analysis, and modified clinical protocol analysis. Results: An uneven knowledge base concerning frailty and functional ability limitations, with registered nurses and home-based care less represented was identified (I). Observed activities mostly addressed physical and medical needs, while clinical decision-making mainly focused on assessment and least often evaluation (II). Nurses described broad-ranging, often overlapping activities, alongside differing clinical decision-making and responsibilities (III). Contextual modulators including stress, working conditions, and culture shaped enactment (II–III). Registered nurses’ clinical reasoning was structured, multi-layered, and contextually adaptive, with distinct reasoning structures across clinical domains (IV). Conclusion: Nurses’ scope of practice in home-based care can be understood as a context-sensitive, system-level phenomenon where role, function, and clinical decision-making are interconnected and shaped by contextual modulators. This understanding may inform research and support nurses’ practice, contributing to more appropriate care.