Understanding aged care emergency department presentations: The voices of nurses from residential aged care facilities.

Understanding aged care emergency department presentations: The voices of nurses from residential aged care facilities.

Abstract
Objective: To explore the perceptions of registered nurses and personal care workers in residential aged care facilities (RACFs) regarding factors contributing to early clinical deterioration and potentially unnecessary hospital presentations.

Background: Persistent workforce shortages, inadequate staffing levels, inconsistent care standards, and suboptimal communication in RACFs contribute to increased hospital transfers. However, many hospital presentations from RACFS are unwarranted and avoidable, and many residents could be better treated by alternative means in place.

Study design and methods: This study used a qualitative methodology in which semi-structured focus groups with registered nurses and personal care workers from two private RACFs in Queensland were used to gather in-depth accounts of experience and perceptions. Data was analysed using Braun and Clarke's reflexive thematic analysis approach.

Results: Four major themes emerged: 1) Clinical decision-making and confidence under pressure, with RNs reporting low confidence and anxiety regarding whether or not to transfer; 2) Organisational and interprofessional dynamics, with staff describing tensions with emergency and ambulance services; 3) Clinical reasoning and support structures, where staff described the value of Nurse Practitioners and clinical guidelines in decision making; 4) PCW role clarity and communication, where uncertainty about scope of practice and fragmented handover procedures were described.

Conclusion: Hospital transfer decisions in aged care are complex and heavily influenced by the experience and confidence of Registered Nurses (RNs). Less experienced RNs tend to make more cautious decisions, sometimes leading to avoidable transfers. Nurse Practitioners (NPs) help support better decisions, but organisational pressures and unclear roles, especially for Personal Care Workers (PCWs), create challenges. These factors collectively promoted risk-averse decision-making and increased reliance on hospital transfers. Improving training, clarifying roles, and fostering teamwork can reduce unnecessary transfers and improve care quality.

Implications for research, policy, and practice: There is a need to further investigate the impact of RN experience levels on hospital transfer rates. More attention needs to be given to developing effective models for integrating NPs into aged care teams. Further study the role and training needs of PCWs in early detection and decision-making.