Ethics & Decision Making

Paper 11: Assessment and decision making processes community nurses use to care for clients living in domestic squalor

Dr Debbie Kralik, General Manager, Strategy and Research, Royal District Nursing Service of South Australia

This presentation will report the findings of a study that aimed to understand the assessment and decision making processes that district nurses' use to provide effective care to people who live in severe domestic squalor.

District nurses care for people in their home environment; hence they see many different people living in diverse contexts. Each day they make assessments of their clients' homes, considering the client's and their own safety. They do this to promote an optimal context for healing and wellbeing. Some homes that nurses enter raise concern because of the squalid conditions in which the client lives. The nursing literature offers little about the ways community nurses care for this challenging client group. Therefore it is useful to understand the assessment and ethical clinical decision making processes nurses use to plan care in such challenging environments.

A qualitative biographical study design was employed which included literature and semi-structured interviews with 20 district nurses who had cared for people living in severe domestic squalor.

District nurses clearly work carefully, sensitively and thoughtfully in their approach to this client group. The nurses assesses clients living in squalor by; building a composite picture over time, using observation and multi-sensory information gathering skills, and using careful and focused questioning once rapport has been established. Their clinical decisions are person-centred. The nurses say lack of communication and insufficient sharing of important assessment data between health services may be a by-product of privacy legislation which they believe has led to an increase in protective behaviours by organisations keen to prevent litigation. Obtaining this information from clients living in squalor is often time consuming because trust must be established before truthful and appropriate assessment can occur.

The issue of assessing cognitive capacity for a population that is notoriously uncooperative is itself challenging. The nurses endorse the clients' right to live as they choose and they distinguish situations of self-neglect and hoarding by the level of hygiene of the environment.