Introduction
There is a Registered Nurse (RN) shortage in our Ontario hospitals today. However, this is not the crisis the media may portray it as. There are many Registered Practical Nurses (RPN) working and available to work in Ontario. The crisis is that too often RPNs are not being allowed to work in the entire hospital or to work within their full scope of practice. The crisis is that RPNs have been pushed out of some Ontario hospital units (for example, mother-baby units). The crisis in Ontario hospitals is this waste of RPN nursing resources. RPNs are skilled nurses and their training and nursing resources are being wasted.
This study surveyed more than 2000 RPNs and other hospital workers in order to determine:
1) what skills RPNs were using and where,
2) how many RPNs were working and where.
By using telephone interviews and focus group sessions, we discovered:
1) RPNs were not using all of the skills that they were trained to do,
2) RPNs were not in every unit in every hospital and that RPNs had been pushed out of units they had previously worked in which resulted in a very inefficient nursing team.
RPNs are Professional and Competent Nurses
The following statement from the College of Nurses of Ontario shows the competency of RPNs:
“RPNs can provide care in complex clinical situations in a variety of practical areas.” (College of Nurses of Ontario: Entry to Practice Competencies for Ontario Registered Practical Nurses, September 1999).
The Registered Practical Nurses Association of Ontario (RPNAO) also describes the professionalism of RPNs:
“Registered Practical Nurses are NURSES and are accountable to the CNO. They are Educated and Regulated for Quality Care. Registered Practical Nurses are valuable and cost-effective partners of a health team, especially when used to the maximum of their scope of practice.” RPNAO Utilization Survey, 1998
Instead of wasting valuable health care dollars, Ontario hospital administrators should be using an appropriate number of RPNs to their full capacity. Appropriate ratios of RN:RPNs allow all nurses to work to their full scope of practice. In order to improve patient care and working conditions in Ontario hospitals, there is room for both RPNs and RNs. An integrated health care team includes all types of nurses.
Methodology
Section I
A telephone survey was conducted with 31 CUPE/OCHU hospital locals, which is approximately 1550 health care workers, from across Ontario. Research participants were asked the following questions:Section II
RPNs from seven Ontario hospitals representing approximately 400 health care workers from across the province were interviewed in focus group sessions. The following questions were discussed:
The hospitals varied in size. RPNs worked at the following area hospitals:
Hospital Area No. of Beds (Range)
1) Western: 125-150 beds
2) Hamilton-Niagara: 200-300 beds
3) Greater Toronto Area: 300-400 beds
4) Central: 130-160 beds
5) Eastern: 150-200 beds
6) Northeastern: 200-300 beds
7) Northwestern: 50-70 beds
The calculations use a full day, rather than strictly a paid day, for simplification purposes. For instance, when calculating a 7.5 hour paid day, an 8 hour day was used instead. This was consistent for both RN and RPN calculations.
The number and type of units studied varied for each hospital in order to clearly understand all hospital situations. The exact name of each hospital unit was changed to a more generic term in order to protect the identity of the hospital.
Employee benefit costs are not included. Only full-time maximum wages are used.
From the staffing information gathered, a present and proposed RN:RPN ratio was calculated. A ratio was calculated using percentages. Absolute staffing numbers were not used in order to protect the identity of the hospital.
Section I – RPN Skill Utilization
Our research regarding RPN skill utilization uncovered startling results. RPNs are being pushed out of hospital units they have traditionally worked in, have never worked in some hospital units where they are badly needed, and are often not allowed to perform some of the skills they have been trained to do.
RPNs are being pushed out of some hospital units. Mother-baby units, Intensive care, Emergency and Pediatrics, are all examples of such units. RPNs have had a tradition of exemplary service in these units.
RPNs are trained to work in every hospital unit. RPNs can work in surgery and other acute care units just as they work, for example, in chronic care. At some hospital sites, an OCHU/CUPE RPN Committee member reports, “RPNs are on all the Medical, Surgical and Obstetric floors (while at another site of the same hospital) RNs are only on these units – go figure and then they tell me we are 20 million over budget…I wonder why?” RPNs should be active in every unit and their training allows for this.
RPNs are trained to do a wide spectrum of skills which should be fully utilized. We found that in some hospital units, RPNs were trained by the hospital or through a college course to do the following skills, but are not being allowed to use them:
- Medication (and Narcotics), Intramuscular Injections, Packing, Irrigation, Recording, Tube feeds, SQ meds, Trach. care, Dr.’s orders, Insulin, Sublingual, Transcribing of Meds, Catheterization (Intermittent and Indwelling), Wound irrigation, Pack-Wound Management, Suctioning, IVs, Sutures, Clips and Drains.
Too often RPNs are not allowed to utilize the above skills in acute care hospital units. Sometimes, this occurs, in the very same hospitals where RPNs are allowed to utilize these skills in chronic care or long term care units. However, RPNs in some acute care hospital units are utilizing most of their skills. Sometimes skill utilization can even vary from floor to floor within one unit. For instance, within one unit in one hospital, RPNs can catheterize whereas on another floor within this same unit, RPNs cannot catheterize. A standardization of full skill utilization should occur across all hospital units and throughout all hospitals in Ontario.
RPNs can perform many of the advance nursing skills within their scope of practice, especially if working with another registered health care professional (ie. doctor, RN). This means, that RPNs can be in every hospital unit using all of their training - no matter the predictability of the patient’s outcome.
Full RPN utilization frees up an RN to use all of their advanced skills. As Michael Hurley, Ontario Council of Hospital Unions (OCHU) President indicates; “The hospital should use every member of the health care team responsibly”. This means allowing both RNs and RPNs to use all of the skills that they have been trained to do.
RPNs should be using their full scope of practice. However, full RPN skill utilization could lead to excessive workload with the present number of RPNs. A staffing change may be important to ensure patient and nurse safety. Therefore, in many cases, more RPNs may be required. With more nursing staff, utilizing all of their skills, hospital patient care will improve drastically. Hospitals will be able to afford such a change, if RN:RPN staffing ratios are altered. As it becomes increasingly difficult to replace RNs, full RPN utilization becomes essential and is both a cost effective and healthy direction.
Section II – RPN/RN Complement (Staffing)
RN Heavy Staffing Complements
When RPNs are not allowed to use their full scope of practice, in some cases, RN hours have been increased. Consequently, many Ontario hospital staffing complements comprise of too many RN hours which is not cost-effective health care. Presently, there is “duplication of nursing work”, says one of the OCHU/CUPE RPN Committee representatives, “there is such a difference in education levels (four years of university for RNs compared to 2 years of college for RPNs), would you want duplication between an RN and an RPN? Each should be doing the job that she or he was trained to do.”
Increasing the Number of full time RPNs
Full RPN utilization will mean increased workloads. An increased number of RPNs will be needed in order to prevent overwork and excessive RPN workloads. The new staffing complements mean improved patient care and safe working conditions for all nurses since the savings which result can be used to hire more full-time nurses.
The following are the results of our RPN focus group sessions. The RPNs were asked about their present hospital staffing complement and how they would like to see this change if RPNs were fully utilized. Significant hospital cost savings were discovered.
There are many hospital units without RPNs. We have included some of the units where RPNs work.
Hospital A
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| Present Complement Ratio | RN | RPN |
| Mental Health Unit | 67% | 33% |
| Medical/Palliative | 63% | 37% |
| Rehab./Chronic Unit | 48% | 52% |
| Surgical | 71% | 29% |
| Present Complement Cost | $11,662.20 |
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| Proposed New Complement Ratio | RN | RPN |
| Mental Health Unit | 36% | 64% |
| Medical/Palliative | 37% | 63% |
| Rehab./Chronic Unit | 21% | 79% |
| Surgical | 40% | 60% |
| Proposed New Complement Cost | $10,045.32 |
Complement Cost Difference for a 24 hour period $1,616.88 x 365 days
= $590,161.20 year
= for instance, 1.5 additional RPNs and 1 additional RN for a 24 hour period
Hospital B<>
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| Present Complement Ratio | RN | RPN |
| Medical Unit | 86% | 14% |
| O.R. | 85% | 15% |
| Medical Unit B | 57% | 43% |
| Surgery | 83% | 17% |
| Present Complement Cost | $21,902.72 |
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| Proposed New Complement Ratio | RN | RPN |
| Medical Unit | 71% | 29% |
| O.R. | 72% | 28% |
| Medical Unit B | 43% | 57% |
| Surgery | 74% | 26% |
| Proposed New Complement Cost | $20,622.96 |
Complement Cost Difference for a 24 hour period $1,279.76 x 365 days
= $467,112.40 year
= for instance, 1.3 additional RPNs and 0.9 additional RN for a 24 hour period
Hospital C
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| Present Complement Ratio | RN | RPN |
| Surgery/Pediatrics | 60% | 40% |
| Medical | 56% | 44% |
| Chronic Care Unit | 70% | 30% |
| Emergency | 100% | 0% |
| Present Complement Cost | $45,657.60 |
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| Proposed New Complement Ratio | RN | RPN |
| Surgery/Pediatrics | 40% | 60% |
| Medical | 44% | 56% |
| Chronic Care Unit | 26% | 74% |
| Emergency | 87% | 13% |
| Proposed New Complement Cost | $42,985.68 |
Complement Cost Difference for a 24 hour period $2,671.92 x 365 days
= $975,250.80 year
= for instance, 3.1 additional RPNs and 1.8 additional RNs for a 24 hour period
Hospital D
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| Present Complement Ratio | RN | RPN |
| Medicine | 50% | 50% |
| Ortho Surgery | 60% | 40% |
| Medicine-Cardiac | 100% | 0% |
| Present Complement Cost | $45,198.72 |
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| Proposed New Complement Ratio | RN | RPN |
| Medicine | 42% | 58% |
| Ortho Surgery | 43% | 57% |
| Medicine-Cardiac | 64% | 36% |
| Proposed New Complement Cost | $38,656.64 |
Complement Cost Difference for a 24 hour period $6,542.08 x 365 days
= $2,387,859.20 year
= for instance, 6.6 additional RPNs and 4.5 additional RNs for a 24 hour period
Hospital E
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| Present Complement Ratio | RN | RPN |
| Surgery | 82% | 18% |
| Medicine | 69% | 31% |
| Mother Baby Unit | 67% | 33% |
| Geriatric Assessment Unit | 27% | 73% |
| Present Complement Cost | $42,548.40 |
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| Proposed New Complement Ratio | RN | RPN |
| Surgery | 55% | 45% |
| Medicine | 37% | 63% |
| Mother Baby Unit | 50% | 50% |
| Geriatric Assessment Unit | 27% | 73% |
| Proposed New Complement Cost | $38,849.04 |
Complement Cost Difference for a 24 hour period $3,699.36 x 365 days
= $1,350,266.40 year
= for instance, 4 additional RPNs and 2.5 additional RNs for a 24 hour period
Hospital F
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| Present Complement Ratio | RN | RPN |
| Medical Unit A | 57% | 43% |
| Complex Continuing Care | 45% | 55% |
| Rehabilitation | 64% | 36% |
| Medical Unit B | 86% | 14% |
| Present Complement Cost | $37,047.58 |
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| Proposed New Complement Ratio | RN | RPN |
| Medical Unit A | 43% | 57% |
| Complex Continuing Care | 38% | 62% |
| Rehabilitation | 50% | 50% |
| Medical Unit B | 55% | 45% |
| Proposed New Complement Cost | $35,398.80 |
Complement Cost Difference for a 24 hour period $1,648.78 x 365 days
= $601,804.70 year
= for instance, 1.7 additional RPNs and 1.1 additional RNs for a 24 hour period
Hospital G
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| Present Complement Ratio | RN | RPN |
| Chronic Care Unit | 45% | 55% |
| Medical/Surgical | 62% | 38% |
| O.R. | 60% | 40% |
| Present Complement Cost | $15,018.64 |
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| Proposed New Complement Ratio | RN | RPN |
| Chronic Care Unit | 36% | 64% |
| Medical/Surgical | 55% | 45% |
| O.R. | 60% | 40% |
| Proposed New Complement Cost | $14,399.92 |
Complement Cost Difference for a 24 hour period $618.72 x 365 days
= $225,832.80/year
= for instance, 0.7 additional RPNs and 0.4 additional RNs for a 24 hour period
Conclusion
Patient care in Ontario hospitals is diminishing. Better patient care means increased hospital staffing. RPNs, who are trained professional nurses, are not being fully utilized, which is wasting valuable resources. The RN shortage provides Ontario hospitals with the opportunity to implement an appropriate RN:RPN ratio, where RPNs are using all of their skills and training.
RPNs are trained in a wide variety of skills. RPNs should have the opportunity to work to their full scope of practice. Hospitals need RPNs to work in all hospital units: acute or `active’ units, as well as chronic care – consistently throughout Ontario.
Past hospital accreditation reviews have suggested such changes. Many Ontario hospitals, however, have not implemented them. The nursing crisis in Ontario hospitals today is not necessarily the shortage of RNs. The real crisis is the ineffective use and lack of RPNs. RPNs are key to finding a sustainable solution to the crisis in our Ontario hospitals.
APPENDIX 2
The following provides is a “skill list” for Registered Practical Nurses (RPNs). A skill list is only one part of the RPN competencies and scope of practice. Registered Practical Nurses are nurses. They have the educational background that provides quality care in diverse settings.
AIRWAY MANAGEMENT
-Deep breathing and coughing
-Positioning
-Percussing
-Vibrating chest
-Providing postural drainage
-Collection of sputum specimens
-Oxygen administration
-Nasal cannula
-Face mask
-Venturi mask
-Rebreathing mask
-Oxygen tent
-Lung and thoracic assessment
-Suctioning:
-Oropharyngeal
-Nasopharyngeal
-Pulse oximetry
-Pulse Doppler
-Care of chest tubes
-Care of chest drainage system
-Provide client teaching
ELIMINATION MANAGEMENT
-Urinary catheterization
-Intermittent catheterization
-Care of indwelling catheter
-Removal of indwelling catheter
-Application of condom catheter
-Urinary catheter irrigation
-Continuous bladder irrigation management
-Care of ileal conduit
-Bladder training
-Assessment of urinary retention
-Collection of urinary specimens
-Provide appropriate client teaching
-Laxatives
-Suppositories
-Enemas
-Fecal impaction removal
-Insertion of rectal tube
-Fecal/stool collection
-Ostomy care/stoma management
-Stomal irrigation
ENTERAL FEEDING
-Management of a kangaroo pump
-Calculate flow rate
-Management and maintenance of J – tubes and G – tubes
-Provide client teaching
MEDICATION MANAGEMENT
-Oral medications
-Eye medications
-Ear medications
-Topical medication
-Inhalation therapy
-Medications via G – tube
-Subcutaneous injections
-Intramuscular injections
-Oral narcotics
-Narcotic count
-Provide client teaching
WOUND MANAGEMENT
-Provide medical/surgical asepsis wound care
-Care of drains
-Removal of sutures/clips/drains
-Simple/complex wound care
-Irrigation of wounds
-Packing of complex/simple wounds
-Provide client teaching
INFUSION MANAGEMENT
-Assess client with IV therapy
-Maintain peripheral venous lines
-Calculate flow rate
-Set-up of IV lines
-Hang non-medicated solutions/infusions
-Discontinue an IV
-Document rate/solution of an IV
-Monitor blood transfusion therapy
-Monitor rate of blood transfusion
-Co-sign blood transfusion administration
-Provide client teaching
ASSESSMENT SKILLS
-Abdomen
-Cardiovascular system
-Head, eyes, ear, nose, throat
-Integumentary system
-Musculoskeletal system
-Neck, lymph nodes, breast
-Neurologic system
-Peripheral vascular system
-Respiratory system
-Elder assessment
-Obsterical
-Mental health
-Pediatric assessment
-Pain assessment
-Documentation and client teaching
ADDITIONAL COMPETENCIES
-Blood glucose monitoring
-Renal dialysis
-Operating room
-Scrub nurse
-Circulating nurse
RESPONSIBILITES
-Taking physician orders over the phone
-Transcribe physician orders
-Transcribe medication orders
Registered Practical Nurses are Educated and Regulated for Quality Care.
(Adapted from the RPNAO).
main Researcher - Heather Farrow