What Does Make the RN Role Distinctive?

By: The Nurses Association of New Brunswick

Recently, in a bid for favour with LPN members, CUPE issued a statement to the media advising that LPNs could now do 90% of what RNs claimed as their scope of practice. That statement created a fervor of angst and anger among RNs in New Brunswick. NANB received several emails from RN members calling for retaliation, clarification, PR campaigns and a host of other activities.

in reflecting on this reaction, NANB considered the source of the 90% claim and the context in which it was delivered. It is well known that the New Brunswick LPN members have sought to leave CUPE for some years. CUPE’s statement was a strategic, well timed strategy to “win back” the favour of LPNs. Considering that other CUPE members have lobbied hard to leave their union, most recently the paramedic group, it is not surprising that when handed documents which outlined shared tasks of RNs and LPNs, CUPE used that information to advance their position.

The documents cited by CUPE included the LPN entry level competencies, published by the Canadian Council for Practical Nurse Regulators, and a New Brunswick nursing unit specific list of RN/LPN tasks used to assist in assigning care and collaboration for a specific patient population. In reviewing these documents, it was interesting to note the tasks that were solely RN specific, as those tasks (the unmentioned 10%) spoke much more succinctly to what CUPE chose not to mention. These tasks represented types of nursing care that require complex, critical thinking, constant assessment and evaluation and advanced knowledge of wound care, pharmacology, and pathophysiology. Upon further reflection, those items can still be categorized as tasks.

Tasks do not define nursing, although they are very much part of the work that registered nurses complete as part of their role. There is no defined constant whether it be cited as 90%, 20% or somewhere in between. It is the patient population and the context of care that defines what and how RNs and LPNs work together and may have overlapping scopes of practice. Even within a specific field of practice, the division of shared scope and responsibilities shifts frequently, often with each new patient or client case.

Unfortunately, tasks are what is considered visible work by the public, and RNs often struggle to describe a nursing process and way of managing care that experientially becomes as inherent as breathing. So, when an organization such as CUPE pronounces that RNs and LPNs work is 90% similar and RNs struggle to define and describe what makes their work unique, it creates a perfect storm.

So, what DOES make the RN role distinctive?

The foundation of registered nursing is assessment for the purpose of reducing risk or avoiding further risk. RN assessment is constant, expansive and represents a safety net for patients, and a support for other members of the health team. RN assessment and risk reduction is practiced with community clients and acute care patients. RN risk assessment can be about systemic patterns or focused details. Based on constant, ever-changing assessments RNs plan and revise plans of care, communicate with team members, act when necessary (tasks), and evaluate outcomes. The assessment, plan, evaluation, and adjust cycle is constant and continuous. RNs use this risk- reduction assessment cycle when educating communities, assigning patients to team members, providing 1:1 care in an ICU and when triaging multiple patients for urgent or emergency care.

It is this cycle that assures not only that the defined tasks are completed, but also encompasses a diverse and often extraordinary level of dynamic organization in order to assimilate all the necessary aspects of care required to ensure optimal health outcomes. Application of the risk-reduction cycle further assures that patients experience the least risk during their health care experience. The risk-reduction cycle is not a list of tasks, it far exceeds entry-level competencies, and it is mostly invisible.

Yes, that is correct…invisible. Similar to an iceberg, the primary and most critical part of an RN’s scope of practice is not easily seen. And yet, it can be described in a simple sentence. Nurses save lives.

Saving lives is a tremendous responsibility, and requires a combination of skills, competency, and continuous experiential learned knowledge for application. The risk reduction cycle cannot be measured by tasks, nor described in a percentage ratio such as stated by CUPE. Collaboration with other members of the health team is part of risk reduction, however tasks conducted, shared, or delegated to another member of the health team do not define the registered nursing scope of practice.

From every critical event it is important to consider lessons learned. The lesson intended in this opinion piece is that as nurses, no matter what role we enact daily, we must learn to describe what we do, what is the work of nursing. This is the only way to make our tremendous responsibility as registered nursing professionals visible to others, even to CUPE.