Nursing scope of practice: descriptions and challenges

The nursing workforce is faced with shortages of near crisis proportions, yet little is understood about the optimal utilization of various categories of nurses - Licensed Practical Nurses (LPNs), Registered Nurses (RNs) and Registered Psychiatric Nurses (RPNs). The primary purpose in this study was to elicit the perceptions of nurses (RNs, LPNs, and RPNs) of what "working to full scope of practice" meant to them. Participants included acute care nurses in three health regions in western Canada. A key finding from the study was the fact that nurses most often discussed scope of practice by reference to the tasks they perform, rather than the roles they play in healthcare delivery. Assessment and coordination of care were two components of nursing work that most differentiated the three nursing roles. Nonetheless, insufficient role differentiation among nurses and between nurses and other healthcare professionals leaves some nurses feeling devalued and not respected for their contribution to healthcare delivery.     

Impact of health reform on registered psychiatric nursing practice

This paper addresses the impact of health reform on registered psychiatric nursing practice. Over a nine-month period, seven focus groups were conducted with registered psychiatric nurses (RPNs; n = 33) from a variety of practice settings in south central regions of the province of Manitoba located in western Canada. Analysis of data collected from the focus groups are summarized according to the four probing questions utilized in this study, and are discussed in relation to: past registered psychiatric nursing, influential factors, future for registered psychiatric nursing, and proactive strategies. It is acknowledged that while reform has created an increase in the degree and level of independence for RPNs, findings suggest that some RPNs are concerned about insufficient preparation for these new and expanded roles, and all study participants are concerned about the current and future shortage of RPNs. Recommendations include commitment of sufficient funding and employer support for advanced education of RPNs as well as provision of additional funding for increases in the number of available seats for psychiatric nursing education, additional RPN faculty resources and a graduate education programme specifically designed for RPNs.     

Conceptualizing structural violence in the context of mental health nursing

This article explores how the intersections of gendered, racialized and neoliberal dynamics reproduce social inequality and shape the violence that nurses face. Grounded in the interviews and focus groups conducted with a purposeful sample of 17 registered nurses (RNs) and registered practical nurses (RPNs) currently working in Ontario's mental health sector, our analysis underscores the need to move beyond reductionist notions of violence as simply individual physical or psychological events. While acknowledging that violence is a very real and disturbing experience for individual nurses, our article casts light on the importance of a broader, power structure analysis of violence experienced by nurses in this sector, arguing that effective redress lies beyond blame shifting between clients/patients and nurses. Our analysis illustrates how assumptions about gender, race and care operate in the context of global, neoliberal forces to reinforce, intensify and create, as well as obscure, structural violence through mechanisms of individualization and normalization.     

Online communities of practice to support collaborative mental health practice in rural areas

The provision of quality mental health services in rural areas continues to be an ongoing challenge for nurses and the patients they serve. The use of computer mediated communication to construct collaborative learning environments similar to those suggested in Wenger's community of practice framework has the potential to mitigate a number of the difficulties faced by rural health care providers. The author presents a brief discussion of social learning theories, the communities of practice framework, and related concepts. Examples of current online communities of practice used as a means for knowledge construction in various professional disciplines are presented in building the case for the fit between online communities of practice and the needs of nurses in rural mental health. Nurses providing mental health care in rural areas have documented needs for interdisciplinary teamwork, access to a collaborative learning environment, and ongoing contact with expert resources. The construction of online communities of practice could potentially address a multitude of concerns identified by nurses practicing mental health care in rural areas.     

Work Setting, Community Attachment, and Satisfaction Among Rural and Remote Nurses

ABSTRACT Objectives: To describe community satisfaction and attachment among rural and remote registered nurses (RNs) in Canada.
Design and Sample: Cross-sectional survey of rural and remote RNs in Canada as part of a multimethod study.The sample consisted of a stratified random sample of RNs living in rural areas of the western country and the total population of RNs who worked in three northern regional areas and those in outpost settings. A subset of 3,331 rural and remote RNs who mainly worked in acute care, long-term care, community health, home care, and primary care comprised the sample.
Measures: The home community satisfaction scale measured community satisfaction, whereas single-item questions measured work community satisfaction and overall job satisfaction. Community variables were compared across practice areas using analysis of variance, whereas a thematic analysis was conducted of the open-ended questions.
Results: Home care and community health RNs were significantly more satisfied with their work community than RNs from other practice areas. RNs who grew up in rural communities were more satisfied with their current home community. Four themes emerged from the open-ended responses that describe community satisfaction and community attachment.
Conclusions: Recruitment and retention strategies need to include mechanisms that focus on community satisfaction, which will enhance job satisfaction.     

"I'm a different kind of nurse": advice from nurses in rural and remote Canada

The sustainability of the rural and remote nursing workforce in Canada is increasingly at issue as the country becomes more urbanized and the nursing workforce ages. In order to support the retention of nurses in rural and remote communities and the recruitment of nurses to these communities, we require a better understanding of what is important to rural and remote nurses themselves. As part of the in-depth interviews conducted within The Nature of Nursing Practice in Rural and Remote Canada, a national research project, registered nurses (RNs) were asked what advice they would have for new nurses, educators, administrators and policy makers. This is the first of two papers describing that advice. It focuses on RNs in acute care, long-term care, home care, community health/public health and primary care roles in rural and remote communities across the country. The RNs were generous with their advice and gave many rich examples. While they were enthusiastic about their nursing practice and encouraging of other nurses to work in rural settings, they were intent that improvements be made in several key areas: education available to new practitioners and themselves, working conditions for rural and remote nurses, leadership, organizational supports and policies that better support rural and remote practice and communities.     

A profile of registered nurses in rural and remote Canada.

Research on nursing practice issues in rural and remote areas of Canada is very limited. This report describes the method and initial results of a comprehensive survey of registered nurses (RNs) practising outside the commuting zones of large urban centres, designed to determine: who practises nursing in rural and remote Canada; the nature and scope of their nursing practice; and their satisfaction with their work, community, and practice supports. Using a mailed questionnaire with persistent follow-up, the data-collection frame included a stratified random sample of rural RNs and the full population of RNs who worked in the northern territories and outpost ("remote") settings. The analyses focus on regional comparisons of demographics and primary work settings and on provincial comparisons of satisfaction levels related to work and community. The survey is part of a larger multi-method project intended to inform policy on rural nursing practice in Canada.     

The experience of gatekeeping: a psychiatric nurse in an emergency department

Emergency departments are increasingly identified as the entry point to mental health services. In the hope of facilitating the flow of psychiatric patients through a general hospital's emergency department, experienced psychiatric nurses were asked to participate in a pilot project in a general hospital in Canada. This paper is a reflection of one emergency psychiatric nurse's (EPN) experience of her role being transformed into that of a gatekeeper. The notion of "gatekeeper" as a metaphor highlights "keeping psychiatric patients out" of an already strained emergency system. As a means to balance fiscal demands with patient care, the EPN inadvertently served to obscure entry for patients with mental illness who were seeking emergency services.     

Difference in work-related violence by nurse license type.

Nurses are at considerable risk for work-related violence. This study compared the experiences of work-related violence among registered nurses (RNs) and licensed practical nurses (LPNs) to quantify differences in risks and exposures and to gain insight into possible interventions. A random sample (n = 6,300) of licensed Minnesota nurses was surveyed regarding the previous 12-month period. Nurses self-reported violent events and demographic information. After adjustment for potential confounders and nonresponse, LPNs had an increased risk for both physical assault (odds ratio = 1.4; 95% confidence interval = 1.1-1.9) and nonphysical violence (odds ratio = 1.2; 95% confidence interval = 1.0-1.5) compared to RNs. Some exposures resulted in increased risks for both types of violence for RNs and LPNs: working primarily in psychiatric departments and long-term care facilities. In contrast, working in clinics resulted in decreased risks for both license types. Some risks varied by license type. Risk of physical assault was increased for LPNs working with neonatal/pediatric patients, whereas RNs' risk was decreased. RNs' risk of physical violence increased while providing care, whereas LPNs' risk increased while supervising care. A better understanding of how this problem varies by license type and work setting will assist in designing efficacious interventions.     

The Experience of Gatekeeping: A Psychiatric Nurse in an Emergency Department

Emergency departments are increasingly identified as the entry point to mental health services. In the hope of facilitating the flow of psychiatric patients through a general hospital's emergency department, experienced psychiatric nurses were asked to participate in a pilot project in a general hospital in Canada. This paper is a reflection of one emergency psychiatric nurse's (EPN) experience of her role being transformed into that of a gatekeeper. The notion of “gatekeeper” as a metaphor highlights “keeping psychiatric patients out” of an already strained emergency system. As a means to balance fiscal demands with patient care, the EPN inadvertently served to obscure entry for patients with mental illness who were seeking emergency services.     

‘Violence is Not Part of Our Job’: A Thematic Analysis of Psychiatric Mental Health Nurses’ Experiences of Patient Assaults from a New Zealand Perspective

This paper describes psychiatric mental health nurses’ (PMHN) experiences of patient assaults within mental healthcare settings using a thematic analytical approach. The aim of the study was to explore and describe psychiatric mental health nurses’ experiences of patient assaults. The major findings of the study related to the nature and impact of assaults and supportive strategies associated with violence perpetrated by patients against psychiatric mental health nurses. Perpetrator risk factors for patients include mental health disorders, alcohol and drug use and the inability to deal with situational crises. The injuries sustained by nurses in the context of the study include lacerations, head injuries, dislocations and bruises. Psychological harm has also occurred, including quite severe mental health problems, such as post-traumatic stress disorder. Protective strategies for combating negative consequences of workplace violence include practice of self-defence, social support and a supportive and consultative workplace culture with access to counselling services and assistance in all aspects, including finances. The paper concludes that while healthcare employers need to provide better support services to the healthcare professionals who are assaulted, the legal system also needs to acknowledge that assaults against nurses are a violation of human rights and violence should not to be tolerated as part of working in mental healthcare settings.     

Remote nursing certified practice: viewing nursing and nurse practitioner practice through a social justice lens

Remote Nursing Certified Practice (RNCP) was introduced in 2010 to regulate nursing practice in remote, largely First Nations communities in British Columbia, Canada. These are communities that often experience profound health and health-care inequities. Typically nurses are the main health-care providers. Using a critical social justice lens, the authors explore the clinical and ethical implications of RNCP in terms of access to equitable, high-quality primary health care.They examine the fit between the level and scope of health services provided by registered nurses working under RNCP and the health needs of remote First Nations communities. In doing so, they draw comparisons between nurse practitioners (NPs) and outpost nurses working in NP roles who historically were employed to provide health care in these communities.The authors conclude by calling for nursing regulations that support equitable, high-quality primary care for all British Columbians.     

Role transition in rural and remote primary health care nursing: a scoping literature review

In order to align health services with population health needs, health authorities in sparsely populated rural and northern Canada are exploring how to better organize and deliver primary health care (PHC) services. A significant component of PHC innovation involves changes to the roles, work settings, and practice modes of registered nurses.While many studies have identified the need to revise nursing roles, few have examined the transition itself. The authors present the findings of a scoping literature review examining the transition of nursing roles in PHC, with a focus on rural and remote settings. Their review of 69 articles provides clear examples of the process of role transition and key professional and organizational issues, while also identifying the supports needed to change and sustain nurses' roles and responsibilities in PHC.     

Nursing workforce utilization: an examination of facilitators and barriers on scope of practice

Several reports have highlighted the need to address underutilization of health human resources, but barriers to and facilitators of role optimization for nurses are poorly understood. The purpose in this study was to understand the perceptions of nurses - Licensed Practical Nurses (LPNs), Registered Nurses (RNs) and Registered Psychiatric Nurses (RPNs) - of the extent to which they can work to full scope of practice and identify barriers and facilitators in optimizing their roles. As part of a mixed-methods study, semi-structured interviews were conducted with 167 acute care nurses (RNs, LPNs, RPNs and nurse managers) in three western Canadian health regions. Approximately 48% of all nurses interviewed felt they were working to full scope, at least some of the time. Barriers to working to full scope included heavy workload, high patient acuity, lack of time, poor communication and ineffective teamwork. Identified facilitators were working as a team, management and leadership support and support for continuing education. Barriers need to be addressed in light of nursing shortages, as these are closely related to job satisfaction and directly affect the retention and recruitment of all groups of nurses. Policies and strategies based on these findings must be developed to ensure that nurses can work to their full scope of practice.     

Towards a model for understanding the development of post‐traumatic stress and general distress in mental health nurses

In their daily work, mental health nurses (MHN) are often exposed to stressful events, including patient‐perpetrated aggression and violence. Personal safety and health concerns, as well as concern for the physical and psychological well‐being of patients, dominate; these concerns have a profound impact on nurses. This cross‐sectional study explored and compared the psychological well‐being of 196 hospital‐based MHN (97 forensic and 99 mainstream registered psychiatric nurses or psychiatric state enrolled nurses). The aim was to examine exposure to inpatient aggression and work stress, and identify factors contributing to the development of post‐traumatic stress reactions and general distress. Multiple regression analyses indicated that working in a mainstream setting is associated with increased work stress; however, mainstream and forensic nurses experienced similar psychological well‐being. As a group, 14–17% of mainstream and forensic nurses met the diagnostic criteria for post‐traumatic stress disorder, and 36% scored above the threshold for psychiatric caseness. A tentative model of post‐traumatic stress and general distress in nurses was developed, illustrating the impact of aggression and stress on well‐being. The present study affirms that mental health nursing is a challenging and stressful occupation. Implications for organizations, managers, and individual nurses are discussed.     

Learning needs of nurses working in Canada's First Nations communities and hospitals

BACKGROUND: What are the learning needs of nurses providing services to Canada's First Nations Communities and Hospitals? First Nations (or Indian Band) are similar to communities except some comprise more than one geographic Native community. Aboriginal (or Native) individuals are members of the North American Indian, Inuit, or Métis peoples of Canada; those who reported being a Treaty or Registered Indian (with the Federal Government); or those who are members of an Indian Band/First Nation. METHOD: A Canada-wide survey was completed to determine the learning needs of nurses working with Canada's Aboriginal persons. RESULTS: Nurses indicated both broad and specific aspects of their clinical practice, which were important to their continuing education (CE) needs. Broad thematic areas for continuing education included the following: emergency/acute care and obstetrics/gynecology clinical skills, health and physical assessment, mental health, and prenatal and postnatal care. Specific areas nurses cited for CE included issues related to: victims of violence; non-compliant clients; substance abuse; and fetal alcohol syndrome. CONCLUSION: This study examined the learning needs of nurses working with Canada's Native people and provided a basis for comparing and contrasting CE issues of these nurses to other nurses working in remote locations around the world.     

Nursing considerations for dual diagnosis in mental health

It is the intention of this literature review to present suggestions for nursing practice with reference to the care of the dually diagnosed. Nursing care of the dually diagnosed client is complex. Clinicians from both drug and alcohol services and mental health services have long recognized that neither service area provides adequate clinical care to those clients who have a dual diagnosis of substance abuse and mental illness. It is now > 10 years since a ground-breaking Australian study recognized this. To ascertain whether there has been improvement in the service management of clients who have a dual diagnosis, and to determine the best practice interventions in the area of mental health nursing, we undertook a review of the literature. The databases CINAHL, MEDLINE, PsycARTICLES and PsychINFO were searched and 185 articles met the inclusion criteria. From this review, it seems that gaps still remain in the provision of services and that mental health nurses might be best placed to provide integrated care to those clients who have a dual diagnosis and present to mental health services. This requires mental health nurses to have skills in substance use detection and knowledge of potential care implications for the client in the context of their substance use.     

Educational needs of psychiatric nurses for continuing competency

BACKGROUND: Practice setting diversification has created an increased need for psychiatric nurses to assume more independent roles, while at the same time being able to demonstrate the corresponding degree of competency to practice. Psychiatric nurses were invited to share their perceptions concerning changes occurring in mental health care, proactive strategies for participating in these changes, and educational opportunities to ensure continuing competency to practice. METHOD: Focus groups were conducted with psychiatric nurses located in various Regional Health Authorities in southern and central regions of Manitoba, Canada. RESULTS: Research findings suggest that psychiatric nurses are primarily concerned with balancing the requirement to demonstrate continuing competence to practice with the challenges associated with the evolving mental healthcare system. CONCLUSION: If the requirement for continuing competence is to be reasonable and achievable, it will be essential that the program generate insight into the necessity for such a program to be implemented and acquire support among the registered psychiatric nurse membership.