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  Nursing Standards  

   Last modified Mar. 15, 2005

RNs and RPNs – Working Together

Introduction

In Ontario, nursing is one profession with two categories, Registered Nurse (RN) and Registered Practical Nurse (RPN). Although there are areas of overlap between the two categories in the performance of certain client care tasks, critical practice differences exist. These differences are based on entry and ongoing nursing knowledge, and competencies. While it is important to be able to articulate these differences to ensure that the most appropriate care providers are matched with the appropriate client populations, it is also important that RNs and RPNs work together to collaborate to meet client care goals. Research results are now providing evidence of the impact of collaborative nursing (RN and RPN) practice on the delivery of safe and effective client care1. Research, however, has not determined the precise mix of registered staff that leads to the most effective and efficient client care.

As the regulatory body for both categories of nurses, it is the responsibility of the College of Nurses of Ontario (CNO) to clearly describe the scope of practice for nurses (RNs and RPNs). Since both categories share a legislated scope of practice, there is often confusion on the part of nurses, employers, the public, and even other nursing organizations, as to which category of nurse is prepared to meet the varying needs of clients. CNO has interpreted the level of autonomy and consultation required for each category of nurse, through documents such as the Utilization of RNs and RPNs practice guideline. This document guides the determination of appropriate nursing staff mix based on characteristics of the client population, the environment and the nurse.

Educational Differences

The basis of differentiation in RN and RPN practice begins with the foundational program of nursing education. Although there have been changes to both the registered nursing and practical nursing programs, effective January 1, 2005, the inherent educational differences and consequent practice differences remain. RNs now graduate with a baccalaureate degree in nursing. RPNs graduate with a two-year practical nursing diploma. Educational programs are becoming available for RPNs who wish to obtain the additional theory and clinical application required to become an RN. These programs (approximately three years in length) provide an opportunity for RPNs to obtain a baccalaureate degree in nursing.

Practice Differences

Although both categories of nurse take academic courses in their foundational programs that have similar titles, there is a difference in both the depth and breadth of knowledge that is covered, in the competencies that are developed, and in the expectations for clinical performance. For example, differences exist in the creation and implementation of care plans. An RPN, after carrying out a client assessment, is required to determine if she/he is able to meet the client care needs or if consultation with an RN is required. The consultation may result in a sharing of ideas and approaches or, in fact, may involve transferring the care to an RN, depending on the complexity and acuity of the client and the environmental factors. (See attached table.) An RN, drawing on a more in-depth theoretical and clinical knowledge base, has a greater range of care delivery options from which to select when adopting a plan of care.

For example, an RN can carry out a broader, more in-depth assessment, and is expected to be able to analyze and synthesize client data to a much greater extent than an RPN. An RN is prepared to address complex, unpredictable client care needs.

While both categories may be capable of performing a patient care intervention, the technical performance alone is not sufficient. The technical performance must be accompanied by a specific level of cognitive ability (i.e., critical thinking, decision-making, professional judgment). The presence of these cognitive competencies in the care provider, in combination with client and environmental characteristics, are critical to decisions around staff mix and assignments of care providers to clients. Collaboration among RNs and RPNs is an essential determinant in supporting ongoing decision-making about matching care providers competencies and skills with client care needs.

How does this translate into practice? An RPN independently cares for an elderly client in the community who has controlled diabetes and an infected foot ulcer that is responding well to treatment. In the same practice setting, an RN cares for a client with diabetes who has an infected foot ulcer that is not healing well, and whose blood sugars are fluctuating. Again, the emphasis is not just on the skill of providing the wound care but rather on the complexity and/or acuity of the client, the predictability of the client’s needs, the nurse’s knowledge, skill and judgment to assess and manage the outcomes, and the environmental supports. Each nurse, whether RN or RPN, must continually assess these factors. Understanding these concepts emphasizes the importance of professional judgment rather than sole reliance on technical skills.

Decision-Making Factors and Questions to Consider

As a result of the differences in education, RNs and RPNs have different levels of autonomy in practice. The level of RN and RPN autonomy and the degree of required consultation are directly influenced by the client’s condition and the environment in which care is provided between the categories of nurses. (See table.)

When determining staff mix, decision-makers are encouraged to consider the following questions:

  • What competencies are essential in providing client care that will lead to a positive client outcome?
  • Does the unit workload allow adequate time for consultation and collaboration amongst nursing staff?
  • Is there a methodology available within the organization to evaluate the impact of staff mix, or changes in staff mix on client outcome?

Changes that occur in staff mix in the absence of evaluation and evidence-based decision making will lead to further confusion on the part of governments who fund nursing services, employers who determine staff mix, and RNs and RPNs who are responsible (within the range of the competencies of their category) for delivering safe, effective and ethical care.

The following table outlines the client factors and environmental circumstances that influence the level of RN and RPN autonomy and consultation.2

RPNs and RNs can independently care for clients defined as low risk with little or no consultation.

RPNs and RN collaborate at varying degrees in the care of clients in the medium-risk category.

RNs care independently and RPNs may be involved in limited aspects of care provided to clients in the high-risk category.

Client

Predictable

  • Outcomes and changes

 

 

 

 

Moderately predictable

  • Health conditions may not be controlled or managed
  • A number of identifiable changes could occur
  • Timing may not be predictable

Unpredictable

  • Outcomes and changes

Less complex

  • Care needs well defined
  • Coping mechanisms and support systems in place
  • Health condition well controlled
  • Little fluctuation over time
  • Individual, family or group

Moderately complex

  • Readily identifiable or established care needs which may/may not be related
  • Full range of coping mechanisms may/ may not be in place

More Complex

  • Care needs not well defined/established or changing
  • Coping mechanisms and supports unknown, not functioning or not in place
  • Health condition not well controlled or managed
  • Requires close, frequent monitoring and reassessment
  • Fluctuating condition
  • Communities and populations

Low risk of negative outcome in response to care

  • Localized and manageable responses
  • Obvious signs and symptoms

Moderate risk of negative outcomes

  • A number of identifiable negative outcomes are possible
  • Outcomes have a systemic effect creating an urgent or emergent situation

High risk of negative outcome in response to care

  • Unpredictable, systemic or wide- ranging responses
  • Signs and symptoms subtle and difficult to detect
  • Effect may be immediate, systemic and/or create an urgent or emergent situation

Environment

Many practice supports

  • Clear and identified supports (e.g., policies, plans of care assessment tools)
  • High proportion of expert nurses
  • High proportion of nurses familiar with environment

Some practice supports

  • Have policies, parameters, plans of care that may be individualized to meet client care needs
  • Some independent decision making required

Few practice supports

  • Unclear or no policies, plans of care, or assessment tools
  • Low proportion of expert nurses or high proportion of novices
  • Low proportion of nurses familiar with the environment

Many consultative resources

Stable and predictable environment

  • Low rate of client turnover
  • Few unpredictable events

Some consultative resources

Moderately stable and predictable environment

  • Turnover of clients
  • Considerable variation of overall client care needs

Few consultative resources

Unstable and unpredictable environment

  • The number and types of clients requiring urgent care are not consistently predictable
  • It is difficult to identify an overall consistent level of client care requirements
  • Wide variety of care needs within a group
  • High rate of client turnover
  • Many unpredictable events

 

For more information, please contact a Practice Consultant at ppd@cnomail.org.

 

 

Endnotes

  1. L. McGillis Hall; D. Irvine Doran, "A Study of the Impact of Nursing Staff Mix Models and Organizational Change Strategies on Patient, System and Nurse Outcomes" (2001), Faculty of Nursing, University of Toronto
  2. College of Nurses of Ontario : Utilization of RNs and RPNs practice guideline (2004) and Alberta Association of Registered Nurses Guidelines for Assignment of Patient/Client Care and Staffing Decisions (2003).

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