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Publications & Resources > The Standard> March 2005

   Last modified: March 7, 2005

Collaboration on the Team

Clients benefit when RNs and RPNs work together

When Donna Spekavow graduated as an RN almost 30 years ago, the roles within the nursing profession were relatively straightforward.

“We used to look at things in terms of tasks,” says Spevakow, Chief of Nursing Practice at Hamilton Health Sciences. “The duties of the RN and the RPN were clearcut,” she says.

Today, the watchword in nursing is no longer “task.” Nursing is now a knowledge-based profession.

“Whether you’re an RN or RPN, before you do an assessment, you have to ask if you have the right knowledge, skill and judgment,” Spevakow says. “What is the predictability of the client? Can you manage the outcome? Who do you need to collaborate with? That’s a big shift from just thinking about skills and lists.”

Spevakow chaired a recent task force on the utilization of RNs and RPNs at the Hamilton Health Sciences Centre. The goal? To clarify practice expectations, understand the contributions of both categories of nurse, and improve collaboration, all with the aim of improving care processes and client outcomes.

As Spevakow notes, the health care environment is changing. Things are more hectic, facilities are moving toward clientcentred care models, roles are evolving, acuity is increasing and hospital stays are shortening. All of this means that nurses, more than ever, must use their critical-thinking skills — and share their thinking with each other and other team members.

Is that what’s actually happening in the workplace? If so, what supports it? If not, what are the obstacles? What differentiates RN and RPN roles? And what exactly does collaboration mean?

The College says that nursing is one profession with two categories of care providers — RNs and RPNs. As regulated health professionals, all RNs and RPNs are accountable for their knowledge, skill and judgment.

Nurses must also understand their roles before they can truly collaborate, says Sharon Avey-Morrison, RN, a Practice Consultant with the College of Nurses of Ontario.

She says that RNs and RPNs study from the same knowledge base and perform many of the same functions. However, RNs study longer and more in-depth. This results in a broader and deeper foundation of knowledge. As a result, the expectations for each category of nurse are different.

In general, RNs are prepared to care for more complex, unstable clients. RPNs are prepared to care for stable, less complex clients with more predictable outcomes. This isn’t a theoretical discussion, but a public safety and regulatory issue.

The College sets the standards for RNs and RPNs through publications like Utilization of RNs and RPNs and Entry-to-Practice Competencies.

Spevakow says the task force used the College documents as its guide and consulted with Avey-Morrison as a resource.

“The guidelines are there to help nurses make sound knowledge-based decisions,” says Avey-Morrison. “You have to think about your client’s overall care needs, the resources available in the environment and about the rationale for what you would or wouldn’t do.”

Does the care provided by RNs and RPNs overlap? All the time. For example, both can care for a client with a tracheotomy. But which type of nurse provides the care depends on the circumstances. Is it a new tracheotomy? How often has the client had trach care and suction in the past? Is the client’s health condition stable? What is the risk of the client experiencing negative outcomes in response to the tracheotomy care? All these variables come into play in guiding decisions about whether an RN of an RPN should provide care for such a client.

“Health professional roles have distinct areas of practice but in every profession there is some overlapping functions,” says Andrea Baumann, RN, Co-Director of the Nursing Health Services Research Unit at McMaster University.

The point is that all health professionals — nurses, doctors, physiotherapists, whoever — must collaborate for the system to work. “We have to factor in the depth and breadth of knowledge required to meet the client’s needs. When we understand and respect what each person brings to the table, we end up with more productive partnerships and consultations.”

In short, nurses and all professionals must practise within the scope of their experience and ability, and draw on each other’s strengths. “Instead of defining yourself purely by a list of tasks — what you do — think about what you know and can assess,” advises Avey-Morrison.

What does collaboration look like? It depends on the client and the setting.

“Due to the increasing complexity and scope of patient problems present in the health care environment, patient care now routinely combines the efforts of physicians of different disciplines, skilled nursing professionals and other health care professionals. Working together as a team, professionals must balance responsibilities, knowledge, and skills related to patient care against their roles as a team members in shared decision making,” says Monique Mohlmann, who’s in the Natal Intensive Care Unit (NICU) at Toronto’s Hospital for Sick Children. She has a unique perspective, because she was an RPN for 11 years before becoming an RN in 2003.

At the Hamilton Health Sciences Centre, one result of Spevakow’s task force is that units are making much more effective use of RPNs. For instance, on most units, RPNs now have client assignments of their own and administer medications, something that didn’t happen in the past.

“Before it was almost like RNs were telling RPNs what to do,” says Spevakow. Now, RNs and RPNs are each accountable for the care they provide. There’s also a real focus on collaboration. In fact, the assignment sheet on the pilot unit has a column that says ‘collaboration,’ letting the RPNs know who they can talk to about a client. What’s more important is just saying the word collaboration. Over time, that becomes part of the culture.”

That doesn’t mean constant, side-by-side interaction, but offering support as needed, says Sandra Hughes, RN, the charge nurse on high-risk obstetrics and gynecology at Hamilton Health Sciences.

For example, a client coming from the OR with normal vital signs may be assigned to an RPN. Suddenly, the client’s blood pressure drops and his/her pulse quickens. The RPN would consult with an RN about the change in vitals signs and collaborate on further assessments. This may include assigning the care to an RN if the client’s condition is becoming more complex or unstable.

“We have our assignments and do total primary care, but we know our limitations,” says Annette Nita, an RPN in post-partum and antenatals at Hamilton Health Sciences Centre. “If I have a post-partum mother whose vaginal blood loss is increasing, which if it continues could lead to a post-partum hemorrage, then I know I’m in a situation where I need to get help from an RN.”

Rita Sharratt, RN, a Clinical Manager at Hamilton Health Sciences, says the RNs had to be reassured that their expertise was needed even more in the new hospital environment.

“The RN is required to assess situations quickly and thoughtfully, and work with RPNs to determine how best to divide client care activities. To make decisions regarding client assignments, knowledge of both nursing roles is required,” says Sharratt.

Client assignments that fit with the knowledge, skills and abilities of RNs and RPNs promote quality time with clients.

“Collaboration is a two-way street,” says Nita. A veteran RPN (she started in 1964), she often has more knowledge and experience in certain areas and that she is able to share with novice RNs.

“A new RN on my floor may come to me with questions, because she might understand, say, the anatomy of the breast, but she has limited experience assisting a new mom with breast feeding,” says Nita. “You need education, but the actual hands-on experience is also part of what teaches you.”

Another institution that has explored RN and RPN collaboration is Toronto’s Baycrest Centre for Geriatric Care. Rachel Beaulieu, RN, a Nurse Manager in a unit for residents with cognitive change, has set up a unit council to eliminate role confusion and support working in partnership.

“It’s a decision-sharing group,” says Beaulieu. “If we have an issue regarding roles, such as who does a dressing, we’ll sit down and do an assessment together. We try to use everybody’s strengths. It’s not about titles — it’s about what we’re most competent to do. You have to evaluate the type of care that residents need, and create a milieu where RNs and RPNs can look at their competencies, ask for help and share their knowledge.”

That’s equally true in the community. Christine Giroux, a visiting RPN with Comcare Health Services in Kitchener, says that an RN usually does the initial assessment, then assigns the client to an RPN or RN, as indicated by the client’s needs.

“In the community, RPNs use their skills to the fullest,” says Giroux. “We’re independent and accountable for making our own decisions. The RNs I deal with are supervisors and case managers at a community care access centre. When there’s a need for further help, like getting a dietician or occupational therapist involved, I relay my input, and we discuss the best option. We all work as a team.”

What encourages collaboration? It starts with the employer, says Avey-Morrison. “You need to ensure an understanding of each other’s roles, good team dynamics, and open communication,” she says. “Employers have to focus on the knowledge, skills and experience that everyone brings — not just on tasks — and ensure that policies are consistent with the idea that both categories of nurses are autonomous professionals.”

The right staff mix is critical, Hughes says. If RPNs are carrying out their own assignments and administering meds, they need appropriate support. That can be tough if there’s a 50-50 split of RNs and RPNs on duty, and the RNs are already juggling a full plate of acute clients. “You need to have enough time for collaboration,” says Hughes.

Workplaces must encourage collaboration across the board, says Baumann. In some cases, a lack of collaboration between RNs and RPNs doesn’t reflect an inability to work together, but points to a problem with the workplace culture as a whole.

Another obstacle is that some nurses are stuck with rigid notions of what their colleagues are capable of. “Some oldschool RNs have difficulty understanding how far RPNs have come,” says Giroux. At the same time, some RNs may feel that their job is threatened by the enlarged RPN role, says Hughes. The fear that their role is being undermined can create some animosity, she suggests.

The reality is both roles are changing. Increases in education are preparing new and experienced RNs and RPNs to practise to their full abilities in today’s rapidly changing health care environment.

To Nita, RNs are dealing with even more acute clients, and complex procedures and technology. To Spevakow, they’re assuming more leadership on discharge planning. And to Hughes, they’re taking on more teaching and coaching roles, and being a “team leader” between disciplines.

While the capabilities of nurses have grown, so has their capacity to work together, Beaulieu says. “People are educated to work in collaboration, and to be more open to sharing,” she says.

When collaboration occurs, the results are meaningful for clients and nurses alike. Frustration decreases, mutual respect increases and client care improves. All roads lead to better client care.

“When we can trust and rely on each other, and work as professionals together, the work isn’t as hard,” says Beaulieu. “We end up with no duplication, enhanced team spirit and a better quality of life at work.”

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