www.journalofnursingregulation.com 17 Volume 6/Issue 3 October 2015 Perceptions of Nursing Practice: Capacity for High-Quality Nursing Home Care Kirsten N. Corazzini, PhD, FGSA; Amy Vogelsmeier, PhD, RN; Eleanor S. McConnell, PhD, RN, GCNS-BC; Lisa Day, PhD, RN, CNE; Susan Kennerly, PhD, RN; Christine Mueller, PhD, RN, FAAN, FGSA; Jill T. Flanagan, MS; Karen Hawkins, BA; and Ruth A. Anderson, PhD, RN, FAAN Emerging evidence indicates that harmful nursing home resident outcomes occur because of ineffective collaboration between registered nurses (RNs) and licensed practical nurses (LPNs) during assessment, care planning, delegation, and supervision.This observational, factorial vignette survey related video vignettes of RN–LPN collaboration in nursing home care to RN perceptions of: 1) current practice in their home; and 2) preferred practice in their home (N = 444 rated vignettes of nursing practice). Current practice ranged from collaboration with few or poor-quality connections and a lack of differentiation between RN and LPN roles (low-capacity practice) to strong RN–LPN connections and clearly differentiated roles (high-capacity practice); RNs identified high-capacity practice as preferred. Interventions that bring together RNs and LPNs to learn new ways of giving care by differ- entiating roles while also strengthening connections show promise as levers for changing quality of care in nursing homes. E merging evidence indicates that harmful nursing home resident outcomes, such as medication errors, pain, and poor quality measures as well as avoidable hospitalizations result from ineffective collaboration between registered nurses (RNs) and licensed practical nurses (LPNs) (Corazzini, Anderson, Mueller, Hunt-McKinney, et al., 2013; Corazzini et al., 2015; Corazzini, Anderson, Mueller, Thorpe, & McConnell, 2013; Vogelsmeier, Scott-Cawiezell, & Pepper, 2011). This ineffective collaboration involves few or no formal or informal connections between RNs and LPNs and a blurring of their scopes of practice. As a result, RNs and LPNs interchangeably perform assessment, care planning, delegation, and supervision (Corazzini, Anderson, Mueller, Hunt-McKinney, et al., 2013). Interventions that bring together RNs and LPNs to learn new ways of giving care by differentiating roles and strengthen- ing connections show promise as levers for changing RN–LPN collaboration (Corazzini et al., 2015). In nursing homes, unit- level teams of the nursing staff at all licensure levels are the foundational clinical teams for quality of care; studies focused on these teams suggest that efforts to improve quality and care out- comes should focus on their learning capacity (Anderson et al., 2012; Estabrooks et al., 2011; Mohr, Batalden, & Barach, 2004). Distinguishing the contributions of RNs and LPNs and strength- ening the quality of RN–LPN connections foster the ability to exchange information and solve problems, integrating RN-level clinical expertise in a meaningful way. This ability to seek and share new knowledge and ideas with other members of the care team is known as reciprocal learning (Leykum et al., 2011), which has been related to the successful implementation of quality- improvement initiatives (Leykum et al., 2011; Noël, Lanham, Palmer, Leykum, & Parchman, 2013). However, acceptance of interventions targeting RN–LPN collaborations for unit-level team learning and higher quality of care requires an awareness of the differences between RN practice and LPN practice and the importance of the quality of their con- nections for achieving better resident outcomes. In foundational work to this study, RNs and LPNs in nursing homes described how they contribute to assessment, care planning, delegation, and supervision. Case study analysis comparing nursing homes yielded three general patterns of practice: ⦁ Practice with a poor capacity for RN–LPN collaboration (poor connections and blurring of RN–LPN roles) ⦁ Practice with a high capacity for RN–LPN collaboration (multiple formal and informal connections and clear distinc- tions between the scopes of practice and roles of RNs and LPNs) ⦁ Practice with a mixed capacity for RN–LPN collaboration (ele- ments of the first two patterns) (Corazzini, Anderson, Mueller, Hunt-McKinney, et al., 2013). Compared with high-capacity practice, poor- and mixed- capacity practices were associated with poorer or more inconsis- tent quality of care outcomes (Corazzini, Mueller, et al., 2013). A gap in understanding remains about how to measure these practice dimensions because the descriptive case study approach is not feasible in large-scale studies, which must rely on staff perceptions of practice. Thus, research is needed to exam- ine whether RNs can recognize their own practice patterns and whether they can determine if their practice patterns are desirable for a high quality of care.