Jun 01, 2013
Collaborative Nursing Practice: RNs and LPNs Working Together
A high level of employee engagement transforms a traditional hierarchical nursing structure into an environment where RNs and LPNs collaboratively care for sets of patients and make team-based decisions
Providence Health Care (PHC) is one of Canada’s largest faith-based health-care organizations. It operates 16 health-care facilities in Greater Vancouver, with more than 1,300 total beds, and employs approximately 2,000 registered nurses and 300 licensed practical nurses. PHC focuses its services on six “populations of emphasis”: cardio-pulmonary risks and illnesses, HIV/AIDS, mental health, renal risks and illness, specialized needs in aging and urban health.
In 2007, administrators in PHC’s facilities, like many others in B.C., were worried about a looming shortage of RNs and were already experiencing rising overtime and sick time costs. At that time, two nursing care models were in use at PHC: in one, RNs were given patient assignments in a specific section of the unit and were identified as the nurse in charge of patients in that section. LPNs “floated” in the unit, helping with tasks such as taking vital signs and answering call bells. In the other model, RNs and LPNs were given shared assignments, again in a section of the unit, with clearly defined tasks for each type of nurse. Under these models, neither RNs nor LPNs were working to the fullest extent of their respective scopes of practice.
Collaborative nursing practice (CNP) was launched in 2007 to better use the skills of all nurses to help PHC survive the predicted shortages and to improve teamwork and job satisfaction. Schober and MacKay’s (2004) definition of collaborative nursing practice as a “cooperative venture” was adopted: all regulated nurses contribute to patient-centred care goals, drawing upon effective communication skills and shared decision-making.
CNP incorporates features of a primary nursing care model, wherein a single nurse is assigned as the MRN (most responsible nurse) for a set of patients for the duration of his/her shift. MRNs provide basic care, conduct assessments, perform and evaluate interventions, and consult with other members of the health-care team as required. Patients are assigned a number from 1 to 3, according to the predictability, complexity and acuity of their condition. This number is used to determine the appropriate nurse assignment. Because some aspects of care could be beyond the MRN’s scope of practice if that individual is an LPN, an RN buddy system was put in place to support the LPN, foster teamwork and ensure safe patient care.
Since the implementation, LPNs have provided more comprehensive patient care, whereas RNs have maximized multi-faceted competencies through assignments to patients with complex needs and through opportunities to apply advanced skills and orchestrate challenging discharge planning requirements. Nurses learned to carefully consider how to align their colleagues’ knowledge and skills with patient status. LPNs and RNs were able to recognize the value of each nursing role, share the workload equitably and work together to optimize patient care.
Keys to successful implementation
By the end of 2011, 20 units across PHC had fully implemented CNP. A survey of nurses conducted pre- and post-implementation showed an improvement in how well the LPN role is understood and better use of skill sets.
Employee engagement was at the core of the implementation and was, in our opinion, the main reason for success in changing the nursing culture. Among the other contributing factors were adjustments made to the implementation schedule to address challenges as they emerged, sustainability strategies that were built in from the start, and visible, supportive leadership at all levels.
Invest in leadership. The project team consisted of a nurse educator and a change specialist (PHC’s change department supports staff through significant transitions and provides project management expertise). A practice consultant guided the project, and the director of nursing acted as the project champion, ensuring dedicated resources were allocated. Each unit recruited a unit advisory group (UAG) comprising LPNs, RNs and unit leaders, e.g., nurse manager, nurse clinical leader, nurse educator. Under the guidance of the project team, these groups planned all aspects of the implementation for their units, determined what tools were needed to help LPNs and RNs work together and communicated with and got feedback from their peers. Unit managers assumed responsibility for maintaining high turnouts at UAG meetings and other sessions. Post-implementation, these group members continued as unofficial champions to support staff through the transition.
Enhance nurses’ knowledge and skills to help them succeed.In preparation for working to an expanded scope, LPNs attended workshops we had developed that focused on physical assessments and laboratory values, consultation with physicians, pharmacology, medication administration and PHC’s medication system. To bridge the theory-to-practice gap, LPNs also did preceptor shifts with RNs, with the LPNs gradually beginning to take over a full assignment of patients that was appropriate to their competency level. LPNs used a standardized checklist during these shifts as a tool to help ensure they consolidated their new skills. The length of each preceptorship was determined by the LPN’s level of comfort in performing the new skills, as assessed by the LPN and RN.
Initially, our planning and education focused on the LPN group, because we assumed that the RNs would rise to the challenge of taking on more complex assignments. However, we learned that switching to CNP meant that RNs required specific support and education as well, so we designed workshops for them on the role of charge nurse and on how to coach staff during the go-live period. Practical scenarios and approaches for dealing with typical work management issues were presented.
All workshop participants gained an understanding of how the RN and LPN roles differed. Under the new model of care, assigning nurses to the right patients required a good understanding of the skill set and competency level of each type of nurse.
Changing nursing roles and function highlighted the need to provide additional support. In Year 4 of this project, PHC’s professional practice office created nurse mentor positions designed for RNs with training in critical care. In this role, they identify and work through practice concerns with both LPNs and RNs. They respond to requests for assistance in managing complex cases, help review skills and advise on when to get help from other members of the health-care team.
Allocate sufficient time to do it right. We actively encouraged nurses to attend the meetings and workshops and participate in preceptorships and coaching opportunities. We communicated frequently with them, via e-mail, a CNP website and face-to-face meetings. We gave updates at nurses’ report and created resource binders to house CNP documents and minutes from meetings and a question-and-answer binder to keep up an ongoing dialogue with nurses.
The two-way communication helped us identify barriers to implementing CNP on the units and provided an outlet for concerns to be expressed. For some nurses, CNP struck at the very core of their identity and their sense of importance to the organization. Some LPNs feared they might fail in their expanded role and have their employment terminated; some RNs worried they would be replaced by LPNs.
The project team recognized the need to address these fears. Multiple pre-implementation communication sessions were held in each unit to explain what CNP was, how it would be implemented and what impact it would have. We repeated the sessions to ensure that as many nurses as possible had an opportunity to contribute to discussions about the need for CNP.
Implementation time — from the date of the first communication sessions to the point when staff were working fully in the new model — ranged from one to six months, depending on the unit’s size, the amount of clinical education nurses required and the challenges of scheduling staff to attend workshops and preceptorship shifts. To minimize “change fatigue,” rollouts of CNP were sometimes rescheduled so as not to interfere with other organizational changes, resulting in the occasional delay in going live.
Facilitate, model and sustain collaboration.We found thatCNP shines a light on the performance strengths and deficiencies of individuals and teams. Some nurses experienced the shift in practice very personally while they were on the learning curve, feeling at times confident about their skills and then less certain about them. Ironically, collaboration actually suffered during the early stages while everyone concentrated on honing clinical skills and learning new roles. We introduced regular huddles and more structured shift handovers as ways to bring people together more often.
At around the six-week mark post-implementation, nurses began to experience the inevitable frictions and uncertainties of being in the “storming” stage of team development (Tuckman, 1965). As they tried out new ways of working together, the heightened stress sometimes resulted in irritation and uncomfortable exchanges between co-workers. We introduced team sustainment sessions with the purpose of having everyone on the team articulate a shared vision, achieve a better understanding of the challenges others were experiencing, devise solutions for specific problems and agree on how they would work together.
Understanding why staff members might be reluctant to ask questions and change traditional practices helped the project team approach the various units and their cultures with greater sensitivity. We introduced a silent brainstorming technique to balance out power dynamics in larger gatherings of staff and to acquire a broader range of ideas. In response to indications that staff were drifting back into obsolete practices, we instituted regular check-ins to identify issues and actions for improvement.
Our final task was to create a document outlining nursing roles and responsibilities, which promoted consistent nursing practices and standards for all CNP units.
We administered a short questionnaire at the initial communication sessions and again six months post-implementation. Nurses were asked to respond to seven statements; these addressed their perceptions of the manageability of their workload, job satisfaction, the extent to which their skill set was being used, working as a team, the LPN role, quality of care delivery and their units as good places to work. From a total sample size of 700 LPNs and RNs from the 20 participating units, 288 nurses completed the survey initially and 240 completed it after implementation.
The results confirmed that there had been a significant positive impact on perceptions of how well skill sets were used, as there was an increase in mean scores (with a moderate effect size of d = +.45). Respondents reported that CNP had made workloads somewhat more manageable, with a small but significant increase in scores (d = +.27). Finally, there was a substantial improvement (d = +.67) in the level of understanding of the LPN role.The survey results tell only part of the story. There was a marked reduction in calls for extra staffing to respond to patient care needs. Units that were not initially part of the project plan asked for CNP to be implemented. CNP is viewed as a positive initiative and is now solidly established across PHC.
Bringing clarity to the LPN role: Alberta’s experience
Helping employers and managers determine who should be providing care is one of Teresa Bateman’s jobs as director of professional practice for the College of Licensed Practical Nurses of Alberta. An LPN herself, she regularly responds to queries from nurse managers who are making decisions about staffing models and need clarity about the LPN role. Because that role has changed so significantly over the years, not everyone is clear about what LPNs can and can’t do. The province’s 2003 Health Professions Act granted LPNs the authority to practise more independently within their scope of practice. Additional competencies were added to their scope, including administeringintravenous and intramuscular medications and immunizations (with appropriate training). Such changes have meant that LPNs are now able to work in more sectors and take on expanded roles that include full patient care. “There are opportunities today for LPNs in every area of care,” Bateman says. “It really just depends upon what the assignment looks like and how LPNs are prepared to assume that role.”
In some workplaces, teams prepared for changes in LPN scope of practice with education, planning and discussions about the effects on both groups of nurses. Other teams didn’t do such preparation; they just advanced the LPNs and didn’t address the RN role. “It caused a lot of issues,” Bateman says, referring to units in chaos during those times.
“You know if we did this better, using LPNs on a team to the fullest of their ability should allow RNs to practise to the maximum of their ability,” she says, “and that would be a win-win for everyone.”
– From an interview with Sue Cavanaugh
Expanding education opportunities is key
LPN Maria Langille is a staff nurse in the restorative care unit at Sutherland Harris Memorial Hospital in Pictou, N.S. She is also a vice-president, representing LPNs, on the Nova Scotia Nurses’ Union board of directors. She has seen her share of tensions between LPNs and RNs over the years. “I’ve had RNs say to me, ‘Oh, the LPNs think they’re RNs now.’ Well, no, we don’t.”
Langille believes that education is what’s needed to help RNs and LPNs understand what LPNs can and can’t do. Five years ago, she and a physician at her hospital began organizing monthly in-service sessions; they bring in experts to discuss whatever topics are appropriate for the patient population. The events are open to all who are interested, rather than just a specific profession or specialized group; one of the goals is to ensure that RNs and LPNs attend the sessions together. “The best thing about the sessions is that they help us become aware of what everyone else can do,” Langille explains. “For example, we brought in someone to go over central lines. LPNs can’t access them, but they can do the dressings. Some of the RNs didn’t know that.” It’s a progressive way of teaching that has really caught on. “Management didn’t support the sessions very much at first because they didn’t understand the need for them,” she says. “But since they’ve seen how this approach creates a stronger knowledge base for both the RNs and the LPNs, they’ve come around.”
“It’s a lot of work to put the sessions together, but it pays off in creating a better work environment,” Langille says.
Schober, M., & MacKay, N. (2004). Collaborative practice in the 21st century . Geneva: International Council of Nurses.
Tuckman, B. (1965). Developmental sequence in small groups . Psychological Bulletin, 63(6), 384-399.