Background: Nurses’, both registered and non-registered, understanding of their scope of practice is foundational to ensure tailored and appropriate nursing care. While scope of practice has been described conceptually and theoretically, there has been limited empirical research exploring how it is enacted in home-based care. Furthermore, the possible shaping of contextual modulators on nurses' scope of practice has received limited empirical attention. Previous research suggests that uncertainty remains among nurses regarding their scope of practice, understood here as role, function, and clinical decision-making, as well as the clinical reasoning structures underpinning this decision-making.
Aim: 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: This thesis aligns with the British medical research council's methodological framework and adopts a sequential mixed methods design. It comprises four project strands, each employing a distinct yet complementary design. The strands included a scoping review (Paper I), a multi-method design (Paper II), a qualitative descriptive design (Paper III), and a qualitative exploratory and descriptive design (Paper IV). Data were collected and analysed through systematic literature searches and descriptive categorisation (Paper I); direct structured observations with field notes, descriptive and comparative statistics, and thematic sorting of textual data (Paper II); individual focused interviews and dyadic framework analysis (Paper III); and retrospective think-aloud technique analysed by an artificial intelligence assisted modified clinical protocol analysis (Paper IV).
Results: Across the project strands, the combined findings progressively advanced the understanding of nurses’ scope of practice in home-based care. Previous research suggested an uneven knowledge base concerning frailty and functional ability limitations, with registered nurses and home-based care less represented than non-registered nurses and facility-based care (Paper I). These findings informed the subsequent strands by highlighting the need to investigate nurses’ scope of practice in home-based care. While most care activities observed among nurses focused on older people's physical and medical needs, observational cues related to their clinical decision-making focused mostly on assessment and least often on evaluation (Paper II). Expanding on these observations, nurses’ descriptions characterised their scope of practice as a broad range of activities and responsibilities, alongside decision-making. While both registered and non-registered nurses described ongoing observations and assessment, their analytical depth and rationale differed but their descriptions mirrored shared conceptual understandings. Although their activity repertoires overlapped, their responsibilities diverged, including clinical leadership and organisational responsibilities (Paper III). Across the strands, both numerical and textual findings showed that contextual modulators, such as stress, interruptions, suboptimal working conditions, and culture, shaped (modulated) nurses’ practice (Papers II–III). In strand IV registered nurses’ clinical reasoning underpinning their clinical decision-making was identified as structured, multi-layered, and contextually adaptive, with different clinical domains associated with distinct reasoning structures (Paper IV).
Conclusion: Nurses' scope of practice in home-based care should be conceptualised as a context-sensitive, system-level phenomenon in which distinct but interconnected dimensions are shaped (modulated) by the contextual features of their enactment, rather than as a collection of isolated activities or formal responsibilities. Future research should investigate scope of practice as an interconnected nursing phenomenon, accounting for the contextual modulators that can shape – modulate - its enactment. Initiatives aiming to strengthen clinical leadership, decision-making autonomy, and organisational prerequisites may support nurses, and particularly registered nurses, in enacting their scope of practice, and thereby contribute to safer and more optimal care.