[Sharon]

How does the CNO three-factor framework support decisions in your practice area? Provide an example of how it is used for making patient care decisions.

[Melanie]

The three-factor framework is prominent in my practice area. As mentioned before, my role is very patient centered. Working remotely and autonomously with a very large caseload my environment also a key component. I have most of the resources I need however, there are times when I need additional support or have to consult with a colleague.
My whole work day consists of non stop telephone calls with patients and teaching/educating, completing adherence checks, reporting Adverse events. Our patients are our main priority and we are expected to respond to each and every inquiry within 24 hrs.
The patients in our program/territory all suffer from the same chronic disease, they are stable and low-risk, so we RPN’s work in the same capacity as the RN’s as we all have patients who have the same condition. We cover for one another when there is an absence, so all the patients whoever they are assigned to (RPN or RN) get the same treatment and same level of care.

[Marion Catherine]

Hi Melanie, thank you for sharing how the Three Factor framework is applied in your work environment. I don’t always see how anyone individual applies this framework however, the details you provided shows that this process can become rather intuitive. I am now looking at how this framework has become so integrated that it is an intuitive process with those RN’s & RPN’s I work with.

[Marion Catherine]

The three-factor framework supports decisions in any facility where RPNs, RNs, and UCPs work alongside each other. This framework does away with the silo effect of “this is not my job” and instills an environment where “how can I support” is the mindset the facility promotes. In this way, augmented client care practices come into a clearer focus, especially where care is 24/7. If the resident feels safe and can trust the care providers, and their families are reassured that they are getting the best service for their money, and staff are supported by each other and the management team, then what could possibly go wrong?
Because the ideal is what we strive for, the reality is marked by successes & failures in the learning curve. As a facility moves from the task-oriented roles of UCPs, RPNs & RNs, the old ways will creep up unexpectedly and responding to these eruptions can be tricky. The matter at hand that stems from an outmoded practice requires a calm, patient, educational, and explanation as to why that way of thinking and working is no longer effective. That takes an awful lot of discipline for the responder as well as taking an awful lot of time and never mind the stress it puts on the interpersonal relationships between workers.
It appears that the three-factor framework is being installed without formally acknowledging this facility’s philosophy for care. Current staffing changes throughout the organizational hierarchy have addressed areas where improvements must be made to safeguard every resident. The 3-factor framework supports this process by ensuring everyone is meeting the requirements of their registered status, facility policy, and meet resident/family expectations for care. By addressing the nursing requirements that are offered at this facility, working with clients whose ageing in place perceptions may not be in line with the facility’s offerings, the working environment becomes stressed. This is understandable as change in any form or measure of complexity includes stress as a byproduct. This is where a care plan for nursing staff, and the entire intra-disciplinary team comes in real handy. Whether the 3-factor framework care plan is acknowledged and implemented by the executive management team or whether it is just something I put into place to support myself as an RPN transitioning through a change in care paradigms, the 3-factor framework supports changes in how nurses and care facilities do their job.

[Alexandra]

How the three factor frame work is used in the setting I work in does not seem to be used as there are no clear differences in the doctors office of tasks that are only for the RN’s or just the RPN’s to preform or only certain patients to be seen. I do the exact same tasks if not more than when the RN’s at the clinic do and I believe that because it is not an urgent care setting or in a hospital there are no complex patient or fragile patients to be having an RN see and not have the RPN’s see them. We see non complex patients in a pre booked appointment based office providing primary care to the community and deal with all ages for a variety of concerns but if a situation becomes urgent or complex we call an ambulance to get them to the emergency department for assessment.
The role of nursing in our setting does not have clear expectations for RN’s vs RPN’s and I am not sure if there needs to be as we function all together very well with good communication and we can all cover each others breaks or lunches without the worry of if it is tasks that the nurse is able to cover or not as we are all trained in the same tasks.

[Sadie]

While the discussion question refers to the CNO Three-Factor Framework, I understand this has now been replaced by the CNO Scope of Practice standard, which focuses on authority, context, and competence.

Although my current role is non-clinical, I previously worked as a public health nurse in a sexual health clinic. Through additional education and a medical directive, I was able to perform pelvic exams. In that situation, I had the authority to perform the activity, the competence through additional education and experience, and the professional judgment to determine when it was appropriate and safe to do so.

Another nurse working at the same organization but in a different program would not necessarily have the training and competence required to perform pelvic exams. To me, this demonstrates how the framework supports patient care decisions by helping nurses consider not only what is allowed, but also whether the activity is appropriate in that context and whether they can perform it safely.

[Author]

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