May 06, 2019
By Sara Lankshear, RN, PhD , Jacqueline Limoges

Intra-professional collaboration: Timing is everything

In the history of nursing there are ongoing examples of how the profession has evolved to support positive patient outcomes and the modernization of the health system. In response to mounting evidence of the benefits of collaborative models of care, nurses from across Canada are committed to fostering intra-professional collaboration and are engaged in a professional practice strategy to support intra-professional collaboration.

To understand the magnitude of this effort, it is helpful to understand the complexity of nursing in Canada. Within the family of nursing there are four regulated designations: registered nurses, nurse practitioners, registered psychiatric nurses and licensed/registered practical nurses. Now consider the added level of complexity from 13 distinct jurisdictions, each with three to four designations (registered psychiatric nurses practise in Western provinces and Yukon only) and each with a variety of voices speaking about practice (e.g., regulatory bodies, professional associations, specialty practice groups, unions). Sometimes these entities speak with a unified voice about the various designations, sometimes less so. The result is confusion, not only within the profession but also among the public, employers and government.

To enhance the collective impact of nursing on patients and health-system outcomes, nurses must reconcile the confusion and develop the competencies required to fully engage in intra-professional collaboration.

As members of a knowledge based, self-regulated profession, nurses recognize the need for a cohesive approach to strengthen intra-professional collaboration.

Efforts to support intra-professional collaboration

Our scan of jurisdictional regulatory bodies and professional associations reveals the attempts to support intra-professional collaboration and to promote understanding of the unique contributions of each designation. For instance, numerous resources have been developed to address the distinct and overlapping nature of the roles and to promote role clarity and effective utilization of the RN and LPN/RPN roles (see Additional Resources at the bottom of the page for examples). While these resources are helpful, nurses are asking for additional resources that can be accessed by nurses across Canada. There is a growing recognition that we are stronger together that is creating a tipping point.

Within 2018 alone, historic developments signalled the increased awareness of the importance of intra-professional collaboration within the broader family of nursing.

  • June 2018: At CNA’s annual meeting of members, members voted in favour of expanding CNA’s membership to include licensed/registered practical nurses and registered psychiatric nurses.
  • September 2018: The College of Licensed Practical Nurses of British Columbia, the College of Registered Nurses of British Columbia and the College of Registered Psychiatric Nurses of British Columbia joined together to become the British Columbia College of Nursing Professionals.
  • November 2018: The board of the College of Licensed Practical Nurses of Nova Scotia and the council of the College of Registered Nurses of Nova Scotia approved a formal agreement to enable both colleges to move forward to create one nursing regulator that will regulate the practice of LPNs, RNs and NPs for the province of Nova Scotia.

These big, bold moves signal the readiness of nurses across the country to fully embrace a cohesive nursing profession. The benefits to the profession itself, the health of Canadians and the health system are motivating.

What the research is telling us

Researchers have explored intra-professional collaboration from various perspectives, including nursing education, point of care, leadership and policy. One of the strengths of this evidence is that most of it is “made in Canada” and addresses the unique Canadian context.

Students in both registered nurse and practical nurse programs recognize that role ambiguity, hierarchies and protection of professional boundaries hinder safe patient care and nursing practice, and that removing siloed education fosters intra-professional collaboration (Butcher, MacKinnon, Bruce, Gordon, & Koning, 2017; Limoges & Jagos, 2016). Faculty recognize that addressing hierarchies and educating students about the different nursing designations can support role clarity and promote effective intra-professional collaboration and communication (Limoges, Jagos, Lankshear, Madorin, & Witmer, 2018). Clearly, faculty and students are ready to embrace changes to ensure entry-to-practice education fully prepares graduates for practice.

Nurses working at point of care recognize that intra-professional collaboration and consultation will generate safer patient care (Ma, Park, & Shang, 2018). They also recognize that role clarity and working to full scope support intra-professional collaboration and high functioning teams (Baumann, Blythe, Norman, & Crea-Arsenio, 2014; Moore, Prentice, & Salfi, 2017). Collaboration and optimized scopes of practice are core features of the new delivery models aimed at supporting a person-focused health-care system and enhancing patient outcomes (Nelson et al., 2014).

It is recognized that leadership is required to establish expectations regarding collaboration (Lankshear, Rush, Weeres, & Martin, 2016; Moore et al., 2017) and to illuminate the complex social processes involved in collaboration, working to full scope and nurse-nurse interactions. Nurses have indicated that leadership is needed to ensure that work redesign supports professional, person-focused nursing care (MacKinnon, Butcher, & Bruce, 2018).

What nurses have told us

Over the past few years, we have been asked to facilitate discussions with CNA members and other nurses on behalf of CNA (Lankshear & Limoges, 2018). In 2018, we led a pan-Canadian Delphi study. We obtained input from more than 900 nurses, representing all designations, regarding the resources they feel would best support intra-professional collaboration. Six areas, deemed to be highly important, emerged:

  1. Develop resources to assist all nurses in understanding the unique contributions and value of their role.
  2. Ensure education strategies that support the development of intra-professional collaboration are embedded in the curricula of all NP, RN, Registered Psychiatric Nursing and practical nurse programs.
  3. Advocate for research to identify the enablers and outcomes of optimal intra-professional collaboration.
  4. Develop education for nurses on the scope of practice of each nursing designation, including distinct contributions and where there is overlap.
  5. Develop leadership strategies and competencies that support intra-professional collaboration.
  6. Develop a position statement on intra-professional practice.

At the end of 2018, we facilitated a think tank, in Toronto, Ontario which kicked off another national consultation strategy by CNA. This interactive event, involving nurses from all designations and domains of practice, enhanced clarity on what supports and resources are needed. Through dialogue, we realized that existing frameworks such as that provided by the Canadian Interprofessional Health Collaborative was not adequate to guide the unique nuances of intra-professional collaboration. This think tank generated the beginnings of a nursing-specific framework.

Each time we interact with nurses, we hear clear consensus that intra-professional collaboration is pivotal to patient care and healthy work environments. However, nurses and students require assistance to develop the capacities necessary for effective collaboration. The combination of research findings and stakeholder engagement is creating a powerful set of strategies that can be used to provide that assistance.

Implications for practice

One of these strategies is the list of reflective questions (see Table 1 [PDF, 22.1 KB] [PDF, 22.1 KB] for examples) which we developed through listening to nurses from various domains of practice and roles and by reviewing the existing research and our own findings.

Next steps

CNA is committed to providing support and developing resources to make intra-professional collaboration a reality. Over the coming months, the association will host three additional regional think tanks to build upon the draft nursing-specific intra-professional framework and to develop resources that reflect the nuances of the distinct jurisdictions. As well, CNA is spearheading the development of a position statement and providing additional opportunities for nurses in all designations across Canada to provide input into the position statement, framework and resources.

What we learned:

  • There is consensus among nurses that intra-professional collaboration is pivotal to high quality patient care and healthy work environments.
  • A nursing-specific framework and resources are being developed to support intra-professional collaboration.
  • Nurses across Canada will have opportunities to provide input into the development of resources to support intra-professional collaboration.

References

Baumann, A., Blythe, J., Norman, P., & Crea-Arsenio, M. (2014). High functioning nurse teams: Collaborative decisions for quality patient care. Nursing Health Services Research Unit, McMaster University.

Butcher, D. L., MacKinnon, K., Bruce, A., Gordon, C., & Koning, C. (2017). Experiences of pre-licensure or pre-registration health professional students and their educators in working with intra-professional teams: A qualitative systematic review. JBI Database of Systematic Reviews and Implementation Reports, 15(4), 1011-1056. doi:10.11124/JBISRIR-2016-003009

Canadian Interprofessional Health Collaborative (2010). A national interprofessional competency framework. Ottawa, ON: Author.  

Lankshear, S., & Limoges, J. (2018). Better together: A fresh look at collaboration within nursing. Canadian Nurse, 114(1), 18-20.

Lankshear, S., Rush, J., Weeres, A., & Martin, D. (2016). Enhancing role clarity for the practical nurse: A leadership imperative. Journal of Nursing Administration, 46(6), 300-307.

Limoges, J. M., & Jagos, K. (2016). Joint education fosters collaboration and role clarity between practical and degree nursing students. Journal of Nursing Education, 55(11), 623-630.

Limoges, J., Jagos, K., Lankshear, S., Madorin, S., & Witmer, D. (2018). Getting to the root of it: How do faculty address professional boundaries, role expansion, and intra-professional collaboration? Journal of Nursing Education and Practice, 8(9), doi: https://doi.org/10.5430/jnep.v8n9p113

Ma, C., Park, S. H., & Shang, J. (2018). Inter- and intra-disciplinary collaboration and patient safety outcomes in U.S. acute care hospital units: A cross-sectional study. International Journal of Nursing Studies, 85,1-6. https://doi.org/10.1016/j.ijnurstu.2018.05.001

MacKinnon, K., Butcher, D. L., & Bruce, A. (2018). Working to full scope: The reorganization of nursing work in two Canadian community hospitals. Global Qualitative Nursing Research, 5. doi:10.1177/2333393617753905.

Moore, J., Prentice, D., & Salfi, J. (2017). A mixed-methods pilot study of the factors that influence collaboration among registered nurses and registered practical nurses in acute care. Clinical Nursing Studies, 5(4). doi:10.5430/cns.v5n4p

Nelson, S., Turnbull, J., Bainbridge, L., Caulfield, T., Hudon, G., Kendel, D., … Sketris, I. (2014) Optimizing scopes of practice: New models for a new health care system. Canadian Academy of Health Sciences. Ottawa, Ontario.

Additional Resources
We retrieved these resources, which refer to collaborative practice, from the various nursing regulatory bodies and/or professional association websites. This is not intended to be an exhaustive list.

Alberta

College and Association of Registered Nurses of Alberta (2014)
Assignment of Client Care: Guidelines for Registered Nurses

College and Association of Registered Nurses of Alberta (2009)
Teamwork and Collaboration between Registered Nurses and Registered Midwives

Manitoba

College of Licensed Practical Nurses of Manitoba (2016)
Determining Appropriate LPN Practice: A Guide to Decision-Making

College of Registered Nurses of Manitoba, College of Licensed Practical Nurses of Manitoba,
College of Registered Psychiatric Nurses of Manitoba (2012)
Guiding Principles for Determining the Appropriate Nurse

College of Registered Nurses of Manitoba, College of Licensed Practical Nurses of Manitoba,
College of Registered Psychiatric Nurses of Manitoba (2010)
Understanding Scope of Practice for Licensed Practical Nurses, Registered Nurses and Registered Psychiatric Nurses in the Province of Manitoba

New Brunswick

Nurses Association of New Brunswick and Association of New Brunswick Licensed Practical Nurses (2015)
Guidelines for Intraprofessional Collaboration: Registered Nurses and Licensed Practical Nurses working together

Webcasts:

Collaboration: Shared Goals, Different Roles

RNs & LPNs Working Together: Bringing the Best of Both Professions to Patient Care

Newfoundland

Association of Registered Nurses of Newfoundland and Labrador (2013). Shared Competencies and Assignment of Care: Registered Nurses collaborating with Licensed Practical Nurses

Nova Scotia

College of Registered Nurses of Nova Scotia and College of Licensed Practice Nurses of Nova Scotia (2012)
Guidelines: Effective Utilization of RNs and LPNs in a Collaborative Practice Environment

College of Registered Nurses of Nova Scotia and College of Licensed Practice Nurses of Nova Scotia (2012)
Assignment and Delegation Guidelines for Registered Nurses and Licensed Practical Nurses

Ontario

College of Nurses of Ontario (2018)
RN and RPN Practice: The Client, the Nurse and the Environment

Registered Nurses’ Association of Ontario (2016)
Intra-professional Collaborative Practice Among Nurses, Second Edition

Registered Practical Nurses Association of Ontario (2014)
It’s All About Synergies: Understanding the Role of the Registered Practical Nurse in Ontario’s Health System.

Webcast:

College of Nurses of Ontario (2018)
RN and RPN Practice: The Client, the Nurse and the Environment

Prince Edward Island

Association of Registered Nurses of Prince Edward Island, Licensed Practical Nurses
Association of Prince Edward Island, Prince Edward Island Health Sector Council (n.d.)
Exemplary Care: Registered Nurses and Licensed Practical Nurses Working Together

Quebec

L’Ordre des infirmières et infirmiers du Québec, du Collège des médecins du Québec et de l’Ordre des pharmaciens du Québec (2015) Énoncé de position conjoint sur la collaboration interprofessionnelle : rehausser la qualité et la sécurité des soins

Saskatchewan

Registered Psychiatric Nurses Association of Saskatchewan, Saskatchewan Association of Licensed Practical Nurses, Saskatchewan Registered Nurses’ Association (2017)
Collaborative Decision-making Framework: Quality Nursing Practice

Sara Lankshear, RN, PhD, is a faculty member with the BScN Collaborative program at Georgian College in Barrie, ON. Her research interests include role clarity, intra and interprofessional collaboration and professional practice models.

Jacqueline Limoges, RN, PhD, is a BScN faculty member at Georgian College in Barrie, ON. Her research examines how nursing education influences nursing practice, knowledge production and social relations between nurses in the workplace.
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