RN/RPN Scope of Practice - Registered Practical … of RN & RPN Scope of Practice Nancy Pearce, ... Scholes & Vaughn, 2002; White et al., 2008). 2 2. ... A systematice approach to

Interprofessional Staffs’ Perception of RN & RPN Scope of PracticeNancy Pearce, RN, PhDClinical Nurse Specialist, Complex Continuing CareGrand River Hospital – Freeport Site

Karen Cziraki, RN, MSc, PhD StudentProfessional Practice SpecialistGrand River Hospital & Cambridge Memorial Hospital

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Background

• Scope of practice is defined as:• the roles, responsibilities, and activities health care

professionals are educated, competent, and legislated to perform (White et al., 2008).

• RN & RPN scope of practice evolving and expanding

• Role overlap, confusion, incomplete understanding of the scope of practice for RNs and RPNs (Besner et al., 2005; Scholes & Vaughn, 2002; White et al., 2008).

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Background

• Nursing Advisory Council (NAC) of Grand River Hospital (GRH) wanted a richer understanding of the issues

• Develop guiding principles for use within GRH to enhance interprofessional practice and optimize workforce utilization

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Objectives:

1. Determine nurses’ and other health care professionals’ perceptions of RN and RPN scope of practice;

2. Compare these findings to results of a provincial survey recently conducted by the RPNAO; and

3. Identify barriers and facilitators to maximizing nursing scope of practice within Grand River Hospital.

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Methods

• Two on-line surveys:

• 57-item survey targeted to nursing staff• Based on the Registered Practical Nurse Role Clarity Questionnaire©

(RPN-RCQ©)

• 23-item survey targeted to physician & allied staff• Select, modified questions from the RPN-RCQ© deemed salient to

physicians and allied health

• Included an open-ended question

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Methods

• Two on-line surveys:

• 57-item survey targeted to nursing staff• Based on the Registered Practical Nurse Role Clarity Questionnaire©

(RPN-RCQ©)

• 23-item survey targeted to physician & allied staff• Select, modified questions from the RPN-RCQ© deemed salient to

physicians and allied health

• Included an open-ended question

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Methods

• Survey was entered into SurveyMonkey®

• IP address feature disabled

• Links to the surveys sent to GRH staff through email

• Reminders sent 2 and 4 weeks later

• Chance to win one of two Tim’s or Subway $10.00 gift cards

• Promoted weekly in hospital newsletter7

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Results

• Response rate:• Nursing survey: 319 respondents (several incomplete surveys)

• (~ 30% response rate)

• Allied & Physician: 89 respondents (again, several incomplete surveys)

• (unknown response rate)

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Respondent DemographicsDemographic GRH % (n)

Professional DesignationTherapist (PT, OT, SPL, Rec, Resp)PhysicianOtherMissing

30.4 ( 27)33.7 ( 30)33.7 ( 30)

2.2 ( 2)

The area I work in hasRN & RPN staffRN staff onlyI don’t knowMissing

70.8 ( 63)11.2 ( 10)13.5 ( 12)

4.5 ( 4)

I have been working in healthcare for<1 to 5 years6 to 10 years11 to 20 yearsover 20 yearsMissing

24.7 ( 22)16.9 ( 15)24.7 ( 22)31.5 ( 28)

2.2 ( 2)

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KNOWLEDGE OF THE RPN ROLE & SCOPE OF PRACTICE

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Knowledge of the RPN Role & Scope of Practice

Item % (n)

The role of the RPN is clearStrongly disagree/disagreeDon’t know/not sureStrongly agree/agreeMissing (3)

38.4 (33)40.7 (35)10.9 (18)

RPNs must always work under the direct supervision of an RNStrongly disagree/disagreeDon’t know/not sureStrongly agree/agreeMissing (1)

42.0 (37)42.0 (37) 15.9 (14)

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Item % (n)

RPNs can perform the same controlled acts as the RNStrongly disagree/disagreeDon’t know/not sureStrongly agree/agreeMissing (0)

57.3 (51)31.5 (28)11.2 (10)

There is a large area of overlap in the roles that RNs & RPNs perform

Strongly disagree/disagreeDon’t know/not sureStrongly agree/agreeMissing (0)

1.1 ( 1)23.6 (21)75.3 (67)

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Item % (n)

The RPN role has evolved to include (roles) tasks that were previously exclusive to RNs only


0.0 ( 0)28.1 (25)70.8 (63)

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Qualitative Responses

• “I would benefit from more information to get clarity about scope of RPN role currently”

• “I am familiar with the scope of RPNs on my unit but not necessarily in other parts of the hospital”

• “We as physicians generally assume that RPNs are ‘supervised’ or mentored by RNs”

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Knowledge/Scope Key Findings:

• Generally aware that scope of practice has changed

• Generally unclear about the RPN scope of practice

• Misconceptions:• RPN must always work under the direct supervision of

an RN

• RPNs have different scope of practice with respect to ‘controlled acts’ 15

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ROLE CONFUSION & ROLE OPERATIONALIZATION*

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Note: Not an area reported by RPNAO

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Role Confusion & Operationalization

Item % (n)

Role Overlap creates confusionStrongly disagree/disagreeDon’t know/not sureStrongly agree/agreeMissing (2)

32.2 (28) 21.8 (19)46.0 (40)

Patient assignments for the RPN are based on the complexity of the patient(s)


16.9 (15)41.9 (36)40.7 (35)

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Role Confusion & Operationalization

Item % (n)

Patient assignments for the RPN are based on the degree of acuity or predictability of patient(s)


14.6 (13)44.9 (40)40.4 (36)

Patient assignments for the RN and RPN are based on the level of competency of the individual nurse


45.3 (39)36.0 (31)18.6 (16)

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• “I think there are some shared tasks that no one would be confused about such as basic patient care, medication provision. But I become confused about other tasks like verbal orders from physician, administration of high risk meds etc…”

• “The differences between the roles are confusing. I wish I knew more”

• “Neither are RPNs assigned more predictable less complex patients which would be safer…patients appear to be assigned according to their room number” 19

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Confusion & Operationalization: Key Findings

• Respondents report role overlap is creating confusion

• Some perceptions patients are not being assigned based on CNO Three Factor Framework

• Unclear whether this is perception or reality

• If reality, how wide & deep???

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TEAMWORK & RESPECT

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Teamwork & Respect

Item % (n)

The RPN is regarded as an equally contributing member of the healthcare team


3.4 ( 3)9.1 ( 8)

87.5 (77)

Generally there is harmony between the RNs & RPNsStrongly disagree/disagreeDon’t know/not sureStrongly agree/agreeMissing (1)

9.1 ( 8)38.6 (34)52.3 (46)

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Teamwork & Respect

Item % (n)

RNs & RPNs show consideration and respect for each otherStrongly disagree/disagreeDon’t know/not sureStrongly agree/agreeMissing (1)

5.7 ( 5)31.0 (27)63.2 (55)

RPNs are sought out by members of the healthcare team for help with problems


1.1 ( 1)27.6 (24)71.3 (62)

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• “Both RNs and RPNs play an extremely important role in the health care team, providing exceptional care to our patients.”

• “I do not think the title matters as much as the individual ability and drive and attention to detail for the individual nurse. I have worked with some spectacular RPNs who are miles ahead of a few RN’s…”

• “Both are excellent and needed and fantastic to work with”

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Respect and Teamwork: Key Findings

• RPN role is valued by allied/ physician staff

• RPNs are seen as an integral part of the team

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Next Steps

• Share results internally with key stakeholders

• Revisit the guiding principles

• Develop and implement an education plan• Patient assignments based on complexity,

predictability, competence of nurse (3-Factor Framework)

• RN and RPN scope of practice (trust, problem solving)

• Leadership education26

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Next Steps

• Review RN and RPN role descriptions

• Review and revise organizational policies to support and optimize RPN and RN scope of practice

• For RPNs:

• initiation of blood transfusions

• flushing of PICC lines

• insertion of NG Tubes

• expansion of IV Medications (above the drip chamber) 27

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Next Steps

• Review supporting structures and create a tool box

• Identify tools that:

• guide/support day to day decision making regarding patient assignments

• guide decision making concerning unit skill mix for planning purposes

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References

• Besner, J., Doran, D., McGillis, L., Giovannetti, P., Girard, F., Hill, W., et al. (2005). A systematice approach to maximizing nursing scope of practice. Ottawa, ON: Canadian Institute of Health Research.

• Registered Practical Nurses Association of Ontario (RPNAO) (2014). It’s All About Synergies: Understanding the Role of the Registered Practical Nurse in Ontario’s Health Care System. Mississauga, ON: RPNAO. Available: http://www.rpnao.org/sites/default/files/file/RPNAO_6006_RoleClarityBrochure_Final-online.pdf

• Scholes, J., & Vaughan, B. (2002). Cross-boundary working: Implications for the multiprofessional team. Journal of Clinical Nursing, 11(3), 399-408.

• White, D., Oelke, N. D., Besner, J., Doran, D., McGillis Hall, L., & Giovannetti, P. (2008). Nursing scope of practice: Descriptions and challenges. Nursing Leadership (Toronto, Ont.), 21(1), 44-57. 30

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http://www.rpnao.org/sites/default/files/file/RPNAO_6006_RoleClarityBrochure_Final-online.pdf

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Documents

RN/RPN Scope of Practice - Registered Practical … of RN & RPN Scope of Practice Nancy Pearce, ... Scholes & Vaughn, 2002; White et al., 2008). 2 2. ... A systematice approach to