February 2019

RPNs and RNs: How to determine who provides patient care

John is an RPN who has worked in a cardiac care unit for 10 years. His patient suddenly develops shortness of breath and low blood pressure. John’s colleague, Rebecca, an RN, offers to take over care of this patient. John feels that it is unnecessary to transfer care. He believes that he is the most appropriate care provider, because he is familiar with the patient’s condition and medical history, has worked with this patient population for many years, and has adequate resources available to provide safe care. He feels he has the knowledge, skill and judgment needed to provide safe care, and should proceed with caring for his patient.

Rebecca thinks that John should transfer care to her or another RN, because the patient’s condition has become more complex.

Who should provide care to the patient?

A nurse’s registration class does not determine who should provide care. The correct way to determine who should provide care is to use the three-factor framework. The three-factor framework is outlined in the RN and RPN Practice: The Client, the Nurse and the Environment practice guideline.


The patient
You must consider the complexity and predictability of the patient’s condition, as well as the potential for negative outcomes. For example, if you find your patient’s care needs suddenly become more complex, you will likely need to consult with your health care team. Collaboration is an essential part of nursing practice. The key is to work together with your team to best meet the patient’s needs.

The nurse
You must be aware of the limits of your individual competence and consult with other providers when required. Ensuring that you are competent in both the cognitive and technical aspects of a procedure prior to performing it is an accountability outlined in the Decisions About Procedures and Authority practice standard. Reflect on your practice and determine if you have the knowledge, skill and judgment to proceed. In some cases, you may determine that you have the knowledge, skill and judgment to provide care, but that consultation with the broader health care team is necessary to ensure that the patient receives safe care.

The environment
You must consider the stability and predictability of the practice environment and whether you have adequate supports and resources available. If you don’t have the support you need to provide safe care, consult with your team.  

How should John proceed?

John and Rebecca consult with their charge nurse. John then reflects on his own knowledge, skill and judgment, his familiarity with the patient’s condition and history, and the three-factor framework. He determines that he has the appropriate resources needed to manage the patient’s change in acuity. Through this process, John determines that he is an appropriate care provider and there is no need for a care transition.

John also recognizes that he must continue to assess his patient for changes in acuity, and continue to collaborate and communicate any changes in the patient’s condition to the health care team.

To learn more about the three-factor framework, read the RN and RPN Practice: The Client, the Nurse and the Environment practice guideline.

If you have questions about this or other parts of your nursing practice, contact CNO’s Practice Support staff. They can help you access the most relevant practice resources and suggest ways to support your decision-making.

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