Abstract
How a registered nurse and unlicensed assistive personnel partner together has implications for care delivery and, ultimately, patient outcomes. The authors summarize findings from a study that examined the characteristics of registered nurse and unlicensed assistive personnel working relationships and the care delivery practices that influence those relationships. Strategies are recommended for deploying registered nurses and unlicensed assistive personnel to promote collaboration and to improve patient care delivery.
Historically, changes in the US healthcare system have led to changes in the numbers and types of personnel who deliver direct care to patients. In response to cost-control initiatives, hospitals have increased the use of unlicensed assistive personnel (UAPs). UAPs working at the bedside with registered nurses (RNs) is increasingly common. 1 The skill mix in many hospitals has proportionally more UAPs than RNs. 2 With RNs and UAPs working together, it is important to understand the character of their working relationships, how that influences patient care delivery, and the strategies that can be deployed to improve care delivery practices.
The nursing literature contains numerous reports describing the perceptions of RNs who have worked with UAPs. Many professional nurses find it difficult to effectively communicate with UAPs, foster teamwork, and appropriately delegate responsibilities. 3,4 Concerns have been raised about the UAPs' educational backgrounds, the level of training offered in healthcare institutions, and the prevalent mistrust that exists between RNs and UAPs. 5,6
In the study conducted by Barter and colleagues, RNs reported overall dissatisfaction with UAPs' abilities to perform delegated tasks and communicate pertinent information about changes in patient status. 4 The literature suggests that RNs have difficultly working with UAPs. However, these same studies do not address the method by which RNs and UAPs are assigned together to conduct the work of patient care and the implications that poses for patient outcomes.
Few studies in the nursing literature focus on UAPs and their perceptions of working relationships with RNs. In a study of the organizational culture of acute care nursing units, Seago found that UAPs assume a thinking and behavior style of dependence and opposition. 2 This finding suggests that UAPs may believe it is necessary to be critical, resistant to authority, or demonstrate an increased need for recognition when interacting in their work environments. It is important to note that Seago also found that UAPs demonstrate a positive concern for the people they care for and have a need to do well in their caregiver role. Seago's research points to the importance of understanding the culture of a work group. However, the nursing literature fails to address UAPs' perceptions of their working environment and their relationships with RNs.
RNs' work demands in acute care settings are highly complex and stressful. RNs manage the care of multiple patients in environments where interruptions to work processes, barriers in communication, and inefficiencies in supply and resource access are the norm. 7 When a patient care unit's care delivery practices fail to foster collaboration, stress becomes the norm. Tanner and colleagues warn that when nurses work in situations where it is impossible for RNs to sufficiently know their patients to see changing relevance, recognize early warnings of clinical change, or protect patients from threats to their vulnerability, then the ground for safe and astute nursing care is undermined. 8
Barriers and distractions in the healthcare environment make it highly difficult for RNs to know the needs of patients and to make timely clinical decisions on the patients' behalves. How RNs and UAPs conduct patient care together can add to the stress of the acute care setting. Managers and administrators know that the quality of care delivered to patients can be affected by the type of working relationships that exists between RNs and UAPs. If working relationships between them are ineffective, or worse, dysfunctional, the potential for quality of nursing care to be threatened is real.
To better understand the working relationships between RNs and UAPs and the influence this has on patient care delivery, the authors' organization conducted a qualitative investigation involving focus sessions with separate groups of RNs and UAPs. Twenty-two staff (13 RNs and 9 UAPs), representing 22 of 32 patient care units in the authors' hospital, participated in the study. Subjects were asked to tell their stories of "good" and "difficult" working relationships and the care delivery practices on their units. No two subjects from either the RN or UAP group worked on the same patient care unit to ensure a broad representation of medical specialties. In addition, there were no RNs or UAPs representing intensive care units, the emergency room (ER), or labor and delivery, because the role of specialty unit UAPs differs from that of UAPs on general units.
The UAPs in the authors' organization have extensive in-house training and are equipped to perform the traditional role of nurse assistant in addition to phlebotomy. The model of care delivery in the hospital is total patient care, with each patient assigned to an RN. The findings offer valuable insight into staff relationships and the care delivery practices that affect those relationships. In addition, this study identified an important phenomenon, the ability of experienced UAPs to know patients.