The social organization of registered nurses and licensed practical nurses working together: an instituional ethnography

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University of New Brunswick


Across Canada, registered nurses (RNs) and licensed practical nurses (LPNs) work closely together to provide care to patients in many different healthcare settings. How they work together in some settings recently changed with a nursing care delivery reform initiative throughout one provincial health authority. In 2015, a new nursing care model, Organizing Nursing Team Resources for Accountability Collaboration and Communication (ONTRACC), was piloted on some hospital units. Through the ONTRACC model, RNs and LPNs worked more autonomously and to their full scopes of practice, with independent patient assignments. This study, guided by institutional ethnography (IE), explicates how RNs and LPNs worked together, including the tensions they experienced, as they transitioned from working together as “buddies” to working more autonomously through the ONTRACC model. IE is a research approach that was developed by Canadian sociologist Dorothy Smith, which allows researchers to explore the social relations that organize people's everyday lives. Through IE, the hidden practices and activities that large social institutions, such as health authorities, professional regulatory bodies, and unions, generate in their ruling become visible. Data was collected on two orthopedic units by first observing and interviewing frontline RNs and LPNs, then interviewing others with knowledge of the ONTRACC model and/or RNs and LPNs working together. Additionally, the texts that organize the RNs and LPNs' work were collected and analyzed, including provincial nursing acts, job descriptions, and hospital policies. Nursing care delivery reform is often done to reduce costs and improve patient outcomes. This thesis explicates how the ONTRACC model met some of these institutional goals, but also subordinated the RNs and LPNs' previous knowledge of their work and scopes of practice. Keywords: institutional ethnography, intraprofessional collaboration, interprofessional collaboration, interdisciplinary, nursing, nursing care, nursing practice, oppressor/oppressed, patient care, practical nurse, registered nurse