Interprofessional Staffs Perception of RN & RPN Scope of Practice Nancy Pearce, RN, PhD Clinical Nurse Specialist, Complex Continuing Care Grand River Hospital Freeport Site Karen Cziraki, RN, MSc, PhD Student Professional Practice Specialist Grand River Hospital & Cambridge Memorial Hospital 1
Background 2 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). 2
Background 3 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 3
Objectives: 4 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. 4
Methods 5 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 5
Methods 6 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 6
Methods 7 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 newsletter 7
Results 8 Response rate: Nursing survey: 319 respondents (several incomplete surveys) (~ 30% response rate) Allied & Physician: 89 respondents (again, several incomplete surveys) (unknown response rate) 8
Respondent Demographics Demographic Professional Designation Therapist (PT, OT, SPL, Rec, Resp) Physician Other Missing The area I work in has RN & RPN staff RN staff only I don t know Missing I have been working in healthcare for <1 to 5 years 6 to 10 years 11 to 20 years over 20 years Missing GRH % (n) 30.4 ( 27) 33.7 ( 30) 33.7 ( 30) 2.2 ( 2) 70.8 ( 63) 11.2 ( 10) 13.5 ( 12) 4.5 ( 4) 24.7 ( 22) 16.9 ( 15) 24.7 ( 22) 31.5 ( 28) 2.2 ( 2) 9
10 KNOWLEDGE OF THE RPN ROLE & SCOPE OF PRACTICE 10
Knowledge of the RPN Role & Scope of Practice Item The role of the RPN is clear Strongly disagree/disagree Don t know/not sure Strongly agree/agree Missing (3) RPNs must always work under the direct supervision of an RN Strongly disagree/disagree Don t know/not sure Strongly agree/agree Missing (1) % (n) 38.4 (33) 40.7 (35) 10.9 (18) 42.0 (37) 42.0 (37) 15.9 (14) 11
Knowledge of the RPN Role & Scope of Practice Item RPNs can perform the same controlled acts as the RN Strongly disagree/disagree Don t know/not sure Strongly agree/agree Missing (0) There is a large area of overlap in the roles that RNs & RPNs perform Strongly disagree/disagree Don t know/not sure Strongly agree/agree Missing (0) % (n) 57.3 (51) 31.5 (28) 11.2 (10) 1.1 ( 1) 23.6 (21) 75.3 (67) 12
Knowledge of the RPN Role & Scope of Practice Item The RPN role has evolved to include (roles) tasks that were previously exclusive to RNs only Strongly disagree/disagree Don t know/not sure Strongly agree/agree Missing (1) % (n) 0.0 ( 0) 28.1 (25) 70.8 (63) 13
Qualitative Responses 14 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 14
Knowledge/Scope Key Findings: 15 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
16 ROLE CONFUSION & ROLE OPERATIONALIZATION* 16 Note: Not an area reported by RPNAO
Role Confusion & Operationalization Item Role Overlap creates confusion Strongly disagree/disagree Don t know/not sure Strongly agree/agree Missing (2) Patient assignments for the RPN are based on the complexity of the patient(s) Strongly disagree/disagree Don t know/not sure Strongly agree/agree Missing (3) % (n) 32.2 (28) 21.8 (19) 46.0 (40) 16.9 (15) 41.9 (36) 40.7 (35) 17
Role Confusion & Operationalization Item Patient assignments for the RPN are based on the degree of acuity or predictability of patient(s) Strongly disagree/disagree Don t know/not sure Strongly agree/agree Missing (0) Patient assignments for the RN and RPN are based on the level of competency of the individual nurse Strongly disagree/disagree Don t know/not sure Strongly agree/agree Missing (3) % (n) 14.6 (13) 44.9 (40) 40.4 (36) 45.3 (39) 36.0 (31) 18.6 (16) 18
Qualitative Responses 19 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
Confusion & Operationalization: Key Findings 20 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??? 20
21 TEAMWORK & RESPECT 21
Teamwork & Respect Item The RPN is regarded as an equally contributing member of the healthcare team Strongly disagree/disagree Don t know/not sure Strongly agree/agree Missing (1) Generally there is harmony between the RNs & RPNs Strongly disagree/disagree Don t know/not sure Strongly agree/agree Missing (1) % (n) 3.4 ( 3) 9.1 ( 8) 87.5 (77) 9.1 ( 8) 38.6 (34) 52.3 (46) 22
Teamwork & Respect Item RNs & RPNs show consideration and respect for each other Strongly disagree/disagree Don t know/not sure Strongly agree/agree Missing (1) RPNs are sought out by members of the healthcare team for help with problems Strongly disagree/disagree Don t know/not sure Strongly agree/agree Missing (2) % (n) 5.7 ( 5) 31.0 (27) 63.2 (55) 1.1 ( 1) 27.6 (24) 71.3 (62) 23
Qualitative Responses 24 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 24
Respect and Teamwork: Key Findings 25 RPN role is valued by allied/ physician staff RPNs are seen as an integral part of the team 25
Next Steps 26 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 education 26
Next Steps 27 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
Next Steps 28 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 28
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References 30 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_rolecla ritybrochure_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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